Infants and Children

Chapter Infants and Children Twenty-Five

Chapter Pediatric respiratory emergencies Other pediatric medical emergencies Pediatric trauma Twenty-Five CORE CONCEPTS

Newborns and Infants: Birth to 1 Year

Very little anxiety from exposure to strangers. Dislike separation from parents. (Continued) Newborns and Infants

Dislike feeling of oxygen mask on face. Need warmth: Warm hands and stethoscope (Continued) Newborns and Infants

Obtain respiratory rate from a distance. If listening to lungs, do it early (before child becomes upset) . Examine head last to build confidence. Newborns and Infants

Dislike Being touched Separation from parents Removal of clothing (remove, examine, replace) Feeling of oxygen mask on face (Continued) Toddlers

Think illness/injury is punishment. Afraid of needles, pain. Examine trunk first, head last. Toddlers

Dislike Being touched Separation from parents Removal of clothing (remove, examine, replace) Feeling of oxygen mask on face (Continued) Preschoolers

Think illness/injury is punishment. Afraid of blood, pain, permanent injury. Modest. Have magical thoughts. Preschoolers

Afraid of blood and pain. Afraid of permanent injury and disfigurement. Modest. School-Age Child

Afraid of permanent injury and disfigurement. Modest. Treat as an adult. Examine in private if possible (away from adults) . Adolescent

Airway Differences between Adults and Children

Small airways are more easily blocked. Child's tongue is larger. Infants are nose breathers. Suctioning nasopharynx improves breathing significantly. (Continued) Airway Differences between Adults and Children

Put child’s head in neutral position, not hyperextended. Children can compensate (breathe faster/harder) for a while, then get worse rapidly. Airway Differences between Adults and Children

Opening the airway Use head-tilt, chin-lift procedure without hyperextension.

Ensure small enough catheter. Do not insert too deeply. Suction as briefly as possible. Suctioning

Treating Mild Airway Obstruction Place in position of comfort (parent’s lap okay). Administer high-concentration oxygen. Transport without agitating.

Severe Airway Obstruction No crying or speech Initial difficulty breathing that worsens Cough becomes weak and ineffective Altered mental status, unconsciousness

INFANTS Back blows and chest thrusts CHILDREN Abdominal thrusts Remove visible foreign body. Clearing Foreign Body Obstructions Attempt artificial ventilation with BVM.

Use correct size. Use tongue depressor to hold down tongue. Insert right side up ( not upside down ) . Oral Airways

Use proper size. Insertion technique is same as for adult. Nasal Airways

Hold tubing 2 inches from face, OR Insert tubing into paper cup. Do not use styrofoam cup. Blow-By Technique

Use proper size mask and bag. If trauma is involved, use jaw thrust (not head tilt). If unable to maintain mask seal with one hand, use two. (Continued) Artificial Ventilation

Bag-Mask Device: Squeeze bag slowly/evenly until chest rises. From birth to puberty (about 12 years old), ventilate 12–20 times a minute, each lasting 1 second. If the patient has reached puberty, ventilate 10–12 times a minute, each lasting 1 second. Use oxygen reservoir to provide 100% oxygen. Artificial Ventilation

Mental status Breathing Color Observe: Observe: Quality of cry or speech Emotional state Response to your presence Tone and body position (Continued) Assessment: General Impression

Observe: Interaction with environment and parents Normal behavior for age? Playing or moving around? Attentive? Eye contact? Recognize and respond to parents? Assessment: General Impression

As soon as you see patient, check: Mechanism of injury Surroundings Healthy or sick appearance (Continued) Approach to Evaluation

Assess respirations: Chest expansion and symmetry Effort of breathing Nasal flaring Retractions (Continued) Approach to Evaluation

Assess respirations: Crowing or noisy respirations Stridor Grunting Respiratory rate Assess perfusion: Skin color (CTC) (Continued) Approach to Evaluation

When you reach child, Breath sounds present or absent? Stridor? Wheezing? continue breathing assessment using stethoscope: (Continued) Approach to Evaluation

Assess circulation: Brachial or femoral pulse Peripheral pulses Capillary refill Blood pressure (if over age 3) Skin color, temperature, condition Approach to Evaluation

Generally start at trunk and evaluate head last. Alter order of steps to fit situation. Avoid making child more anxious. Detailed Physical Exam

P EDIATRIC RESPIRATORY EMERGENCIES

Patient ASSESSMENT Partial Airway Obstruction Signs and Symptoms Stridorous, crowing, or noisy respirations Retractions on inspiration Pink mucous membranes and nail beds Alert

Patient CARE Partial Airway Obstruction Emergency Care Steps Allow position of comfort (parent’s lap okay) . Do not lay child flat. Offer high-concentration oxygen. Transport without agitating. (Do not assess blood pressure.)

Patient ASSESSMENT Complete Airway Obstruction Signs and Symptoms No crying or speech Initial breathing difficulty that worsens Cough becomes weak and ineffective Altered mental status, unconsciousness

Patient CARE Complete Airway Obstruction Emergency Care Steps Clear airway with infant/child foreign body procedures. Attempt artificial ventilation with BVM. Assure good seal between mask and face.

Upper airway obstruction Stridor on inspiration Lower airway disease Wheezing and respiratory effort on exhalation OR rapid breathing without stridor Respiratory Emergencies

Tell new EMT-Bs that pediatric care experts emphasize that the priority of children in respiratory distress is “AAA,” not just “ABC.” In other words, if you manage the patient’s airway and oxygenate, circulation improvement will follow! P RECEPTOR P EARL

Patient ASSESSMENT Early Respiratory Distress Signs and Symptoms Nasal flaring Retractions Between ribs (intercostal) Above clavicles (supraclavicular) Below ribs (subcostal) (Continued)

Patient ASSESSMENT Early Respiratory Distress Signs and Symptoms Stridor Retractions of neck, abdominal muscles Audible wheezing Grunting (Continued)

Patient ASSESSMENT Early Respiratory Distress Signs and Symptoms Respiratory rate > 60/minute Cyanosis Decreased muscle tone Excessive use of accessory muscles

Patient ASSESSMENT Respiratory Distress Signs and Symptoms Poor peripheral perfusion Altered mental status Grunting

Patient ASSESSMENT Respiratory Arrest Signs and Symptoms Respiratory rate < 10/minute Little or no muscle tone Unconsciousness Slow/absent heart rate Weak/absent pulse

Patient CARE Respiratory Emergencies Emergency Care Steps Administer high-concentration oxygen. Ventilate if respiratory distress is severe: Altered mental status Cyanosis not improving with oxygen Poor muscle tone Respiratory failure Respiratory arrest

Trauma In the United States, injuries kill more children and infants than any other cause of death.

Unrestrained passenger head and neck injuries Restrained passenger abdominal and lower spine injuries (Continued) Blunt Trauma (Most Common Type of Injury) Motor vehicle crashes

Motor vehicle crashes Struck while riding bicycle (head, spine, abdominal injuries) Pedestrian struck by vehicle (abdominal, femur, head injuries) (Continued) Blunt Trauma

Falls from height Head and neck injuries Diving into shallow water Head and neck injuries Burns Sports injuries Child abuse Blunt Trauma

Head Airway maintenance is critical. Head injury is common. Can result in respiratory arrest. Nausea and vomiting are common. (Continued) Blunt Trauma Specific Types of Injurie s

Children’s ribs are less rigid than adults’ ribs. Result in injury to internal organs without external wounds. (Continued) Blunt Trauma Specific Types of Injuries Chest

Abdomen More commonly injured in children than adults. May be subtle and difficult to detect. Under stress, children swallow air (may cause gastric distention, impede breathing) . (Continued) Blunt Trauma Specific Types of Injuries

Extremities Managed the same as adults Blunt Trauma Specific Types of Injuries

Use only if: Child fits in garment. Trauma occurs with hypoperfusion and pelvic instability. Do not inflate abdominal compartment. Trauma Other Considerations (Continued) Pneumatic Antishock Garment

Burns Cover with sterile dressing (sterile sheet works well) . Follow local protocol with regard to transport to burn center. Trauma Other Considerations

Patient CARE Trauma Emergency Care Steps Establish and maintain airway with jaw thrust. Suction and ventilate as needed. Provide high-concentration oxygen. Immobilize spine. Transport.

Diarrhea, vomiting, dehydration Trauma and blood loss Infection Abdominal injuries Causes Allergic reactions Poisoning Cardiac problems Uncommon Causes Shock (Hypoperfusion)

Tell new EMT-Bs that one way to remember how little blood children have is to envision that an infant’s total blood volume would fill only a soda can and a school age child’s a six-pack. P RECEPTOR P EARL

Patient ASSESSMENT Shock (Hypoperfusion) Signs and Symptoms Rapid breathing Pale, cool, clammy skin Weak/absent peripheral pulses Delayed capillary refill (Continued)

Patient ASSESSMENT Shock (Hypoperfusion) Signs and Symptoms Decreased urine output Inspect diaper/ask parents when last changed. Changes in mental status Lack of tears when crying

Signs of Shock (Hypoperfusion)

Patient CARE Shock (Hypoperfusion) Emergency Care Steps Assure airway and give high-concentration oxygen. Ventilate as needed. Control bleeding. Elevate legs. Keep warm. Transport promptly.

Patient CARE Near Drowning (submersion) Emergency Care Steps Ventilation is top priority. Consider possibilities of trauma, hypothermia, and drug ingestion (especially alcohol in teenagers) . Transport. (Some patients deteriorate minutes/hours later.)

Abuse Improper or excessive action so as to injure or cause harm Neglect Giving insufficient attention or respect to someone who has a claim to that attention K EY TERMS

Physical abuse and neglect are forms of child abuse EMT-B is most likely to suspect. EMT-B must be aware of condition in order to recognize it.

Tell new EMT-Bs that the ED physician is required to report cases of child abuse. Therefore, they should complete the PCR with factual information that they observed about the child’s home environment, the condition of the home, the reaction of the parents or other caretakers, the child’s hygiene, and general interaction of all family members involved, and call it to the attention of the physician. P RECEPTOR P EARL

Patient ASSESSMENT Abuse Signs and Symptoms Multiple bruises in different stages of healing Injury inconsistent with mechanism described Repeated calls to same address (Continued)

Patient ASSESSMENT Abuse Signs and Symptoms Fresh burns Apparent lack of enough concern in parents Conflicting stories Child’s hesitancy to describe how injury occurred

Patient ASSESSMENT Neglect Signs and Symptoms Lack of adult supervision Apparent malnourishment Unsafe living environment Untreated chronic illness

Head injuries are most lethal (shaken baby syndrome) . Do not accuse anyone in the field. (Continued) Handling Abuse and Neglect

Required reporting Follow state laws and local regulations. Document objective information: what you SEE and HEAR, not what you merely THINK . Handling Abuse and Neglect

P EDIATRIC MEDICAL EMERGENCIES

Seizures Rarely life-threatening in children, but EMT-B should take seriously. May be brief or prolonged. May cause injuries.

Fever Infection Poisoning Hypoglycemia Trauma Hypoxia Idiopathic Causes (unknown cause) Seizures

Patient ASSESSMENT Child after Seizure Signs and Symptoms Has child had seizures before? If yes, was this typical seizure? Was antiseizure medication taken?

Patient CARE Seizures Emergency Care Steps Establish airway. Position on left side if no spine trauma. Have suction ready. Give oxygen. Ventilate if respiratory distress/arrest. Transport.

Hypoglycemia Poisoning Postseizure Infection Head trauma Hypoxia Shock Causes Altered Mental Status

Patient CARE Altered Mental Status Emergency Care Steps Establish airway. Ventilate and suction as needed. Transport.

Patient CARE Poisoning: Responsive Patient Emergency Care Steps Contact medical direction. Give activated charcoal as directed. Administer oxygen. Transport and monitor patient.

Patient CARE Poisoning: Unresponsive Patient Emergency Care Steps Rule out trauma. Establish airway. Administer oxygen; ventilate as needed. Contact medical direction. Transport.

Fever Many things can cause fever. Meningitis is one of worst. May appear as fever with rash. Transport. Be prepared for seizures.

Sudden Infant Death Syndrome (SIDS) Sudden death occurs without identifiable cause in infant < 1 year old. Cause is not well understood. Most common time of discovery is early morning.

Patient CARE SIDS Emergency Care Steps Try to resuscitate unless rigor mortis is present. Avoid comments that blame parents. Expect parents to feel remorse and guilt.

I NFANTS AND CHILDREN WITH SPECIAL NEEDS

Premature babies with lung disease Heart disease Neurologic disease Chronic disease or altered function since birth Children with Special Needs

Technologically Dependent Children (“High-Tech Kids”) Tracheostomy tube Central intravenous lines Gastrostomy tubes Shunts

Obstruction Bleeding Air leak Dislodged tube Infection Tracheostomy Tube Complications

Patient CARE Tracheostomy Tube Emergency Care Steps Maintain open airway. Suction. Maintain position of comfort. Transport.

Parents are usually very familiar with equipment. Home Artificial Ventilation

Patient CARE Home Artificial Ventilation Emergency Care Steps Assure airway. Artificially ventilate with high-concentration oxygen. Transport.

IVs that are very long Tip in vein near heart Complications Cracked line Infection Clotting off Bleeding Central Intravenous Lines

Patient CARE Central Intravenous Lines Emergency Care Steps If bleeding, apply pressure. Transport.

Shunt Tube running from brain to abdomen to drain excess cerebrospinal fluid Gastrostomy Tube Tube placed directly into the stomach for a child who cannot be fed by mouth K EY TERMS

Patient CARE Shunt Emergency Care Steps Assure airway and ventilate as needed. Transport.

Patient CARE Gastrostomy Tube Emergency Care Steps Assure patent airway. Suction as needed. Provide high-concentration oxygen. Transport patient sitting or lying on right side with head elevated.

1. Describe two characteristics of a typical child in each of the five age groups. 2. Describe the management of pediatric respiratory distress. 3. How do children compensate for blood loss compared to an adult? 4. What are some indications of child abuse? R EVIEW QUESTIONS

Infants and Children

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