chapter 31 infants and children. developmentalcharacteristics
TRANSCRIPT
CHAPTER 31
Infants and Children
DevelopmentalDevelopmentalCharacteristicsCharacteristics
Classification of Children
Newborns/InfantsToddlersPreschoolSchool-agedAdolescents
Birth-11-33-66-1212-18
Age (yr.): Described as:
Tolerate parental separation poorly
Exhibit minimal anxiety over presence of strangers
Accept undressing, but want to feel warm
Can track movement visually
Do not tolerate oxygen masks
Newborns and Infants (birth to 1 year)
Behavioral Traits by Age
Assessment of Children
Have a parent hold the infant during the physical exam.
Keep hands & tools warm.
Observe breathing from a distance.
Examine the head last.
If listening to lungs, do it early
(before child is upset)
Newborns and Infants (birth to 1 year)
Do not tolerate parental separation
Do not like to be touched
May perceive illness as punishment
Sensitive about modesty
Easily frightened (i.e., by needles)
Tend to be perceptive, independent
Do not tolerate masks
Toddlers (1-3 years)
Behavioral Traits by Age
Toddlers (1-3 years)
Have a parent hold the child during the physical exam.
Explain that the child was not “bad.”
If clothing is removed, replace it.
Try to examine the head last. Trunk to toe exam.
Explain what you do in advance — but use a child’s terms.
Assessment of Children
Do not tolerate parental separation
Do not like to be touched
Sensitive about modesty
May perceive illness as punishment
Tend to fear blood, pain, and permanent injury or disfigurement
Curious, communicative, cooperative
Do not tolerate masks
Preschool (3-6 years)
Behavioral Traits by Age
Preschool (3-6 years)
Have a parent hold the child during the physical exam.
If clothing is removed, replace it.
Be calm, reassuring, and respectful.
Explain what you do in advance.
Allow the child to give the history.
Avoid fastening a face mask.
Assessment of Children
Cooperative, but expect to have opinions heard
Sensitive about modesty
Tend to fear blood, pain, and permanent injury or disfigurement
School Age (6-12 years)
Behavioral Traits by Age
School Age (6-12 years)
Allow the child to give the history.
Explain as you examine.
Be calm, reassuring, and respectful.
Respect the child’s modesty.
Assessment of Children
Expect to be treated as adults.
Generally act as though indestructible.
May fear lasting disfigurement.
Variable emotional and physical development may produce some insecurity about self-image.
Adolescent (12-18 years)
Behavioral Traits by Age
Adolescent (12-18 years)
Try to respect the emerging adult, yet reassure the remaining child.
Explain as you examine.
Be calm, reassuring, and respectful.
Respect the young adult’s modesty and need for privacy. May want to be assessed away from parent/guardians/adults
Assessment of Children
AnatomicalAnatomicalDifferencesDifferences
Airway Differences between Adults and Airway Differences between Adults and ChildrenChildren
Airway Differences betweenAdults and Children (Airway)
More anterior than the adult - less head tilt needed to open the airway.
Smaller airway than adult - blocked easily by secretions or blood
Large tongue in relation to jaw size - likely to cause obstruction when child is unresponsive.
Infants prefer to breathe through their nose - nasal obstruction can cause respiratory distress.
Bigger, softer.
Infants and small children have disproportionately larger heads (until about age 4). Note the effect of padding.
Head
Airway Differences betweenAdults and Children (Breathing)
Small children are dependent upon contraction of the diaphragm to breathe
Children in respiratory distress compensate rapidly by increasing their rate of breathing and using their accessory muscles, which causes fatigue.
Increased work of breathing is demonstrated by nasal flaring and intercostal retractions.
Slow pulse (Bradycardia) is a sign of hypoxia in the pediatric patient.
Airway Differences betweenAdults and Children (Circulation)
Children compensate rapidly in shock by increasing heart rate and vasoconstricting then decompensate rapidly.
Perfusion in the child is assessed by determining the heart rate, distal pulses, mental status, capillary refill and skin color and temperature.
Hypovolemia can develop from vomiting and/ or diarrhea in children.
Blood pressure is a poor indicator of perfusion status in the pediatric patient.
AirwayAirway
Airway Opening
Position to open airway is different – head-tilt/chin-lift = do not hyperextend
Jaw thrust with spinal immobilization if trauma is suspected
Opening the Airway Opening the Airway –– Use head-tilt, Use head-tilt,chin-lift chin-lift withoutwithout hyperextension. hyperextension.
Suctioning
Ensure small enough catheter.
Do not insert too deeply.
Suction as briefly as possible – no more than 10 seconds.
Signs of Partial AirwayObstruction
Stridor, crowing, or noisy respirations
Retractions on inspiration
Pink mucous membranes and nail beds
Alert
Treating Partial Airway Obstruction
Place in position of comfort (parent’s lap okay).
Administer high-concentration oxygen.
Transport without agitating.
Signs of Complete Airway Obstruction
No crying or speech
Initial difficulty breathing that worsens
Cough becomes weak and ineffective
Altered mental status, unconsciousness
Clearing Foreign BodyObstructions
INFANTS
Back blows &chest thrusts
CHILDREN
Abdominalthrusts
Remove visible foreign body.
Attempt artificial ventilation with BVM.
Oral Airways
Adjunct, not for initial artificial ventilation
Should not have gag reflex
Use correct size.
Use tongue depressor to hold down tongue.
Insert right-side-up (not upside-down).
Oral Airway InsertionOral Airway Insertion
• Insert tongue blade to the base of the tongue
• Push down against the tongue while lifting upward
• Insert oropharyngeal airway without rotation following oropharyngeal curvature
Nasal Airways
Adjunct not for initial artificial ventilation
Use proper size.
Insertion technique same as for adult.
Do not use if facial or head trauma exists.
OxygenOxygenTherapyTherapy
Nonrebreather MaskNonrebreather Mask
Blow-By Technique
Hold tubing no more than 2 inches from face OR
Insert tubing into paper cup.
Blow-By TechniqueBlow-By Technique
Do not usestyrofoam cup.
Artificial Ventilation
Use proper size mask and bag.
If trauma involved, use jaw thrust (not head tilt).
If unable to maintain mask seal with one hand, use two.
Mouth-To-Mask VentilationMouth-To-Mask Ventilation
Artificial Ventilation
Bag-Valve-Mask Use
Squeeze bag slowly/evenly until chest rises adequately.
If under 8 years old, ventilate 20 times a minute (1 breath every 3 seconds).
If over 8 years old, ventilate 10-12 times a minute (1 breath every 5 seconds).
Provide oxygen at 100% by using an oxygen reservoir
Head
Fontanelles (soft spots) exist until about 12-18 months old.
Sunken may indicate dehydration
Bulging may indicate crying or head injury
Chest & Abdomen
Increased elasticity of chest
Primarily abdominal breathers (infants primarily nose-breathers)
Less protection than adults for internal organs
Body Surface
Larger in proportion to body mass
Increased risk of hypothermia
Burn injuries calculated differently
Techniques ofTechniques ofPediatric CarePediatric Care
Assessment
Two methods:
Pediatric Assessment Triangle (PAT)
OR
Step-by-Step assessment
Pediatric Assessment Triangle
PAT General Impression
“From the Doorway”
Observe appearance:
Mental status
Body position/Muscle tone
Observe breathing effort.
Observe circulation (skin color).
PAT “Hands-On”
Assess and treat based on doorway assessment.
Provide interventions and assess for any further concerns.
Step-by-StepStep-by-StepAssessmentAssessment
General PrinciplesChildren differ from adults, but also differ from each other depending on age
Large amount of clinical information can be obtained by observation before approaching the child:
Child often anxious and scared by presence and examination of EMT as opposed to adults who are often relieved
General PrinciplesIt is important to maintain a calm and relaxed manner when dealing with a pediatric patient
Speak softly (It is a known fact that monsters and mean people speak loudly)
Use the child’s name
Adjust your height to the child’s (Monsters are most threatening when they tower over you)
Look before you touch, and touch gently (Monsters are rough)
Tell the child what you are going to do then do it immediately
Never lie to a parent or a child or you will lose their trust
Enlist the parent’s (care giver’s) help
Attempt to keep the parent and child together
General/Initial Impression
Ensure scene safety/Take BSI precautions.
Begin actively observing the child from the doorway
Much of the assessment can be performed prior to touching (thereby upsetting the child)
General/Initial Impression
Ensure scene safety/Take BSI precautions.
Begin actively observing the child from the doorway
Pay particular attention to Mental status
Skin Color
Effort of breathing
General Impression
The well versus sick child versus very sick
Mental Status
How is the child interacting with environment and parents (including eye contact)
What is the child’s behavior?
What is the child’s response to the EMT?
Tone/body position
Flaccid?
Is the child able to maintain an upright position?
Tripod Positioning?
General Impression
The well versus sick child versus very sick
Color
Pink?
Pale?
Cyanosis?
Respiratory rate and effort
What is the respiratory rate?
Is the chest rising and falling normally?
How much effort is the child making just to breathe?
Is the breathing noisy?
Primary Assessment
Detection of life threatening problems and treatment
Responsiveness
Stabilize cervical spine
Establish unresponsiveness
Primary Assessment
Airway
Is the child speaking or does the child have a vigorous cry? If not then position head
Trauma - Neutral with jaw thrust
Medical - Sniffing or Sniff Plus
OPA insertion as necessary
Primary Assessment
Airway cont’d…
Is stridor (indicates upper airway obstruction) or other evidence of upper airway obstruction present ?
Foreign body - FBAO procedure as per AHA guidelines
Swelling due to disease - Possibly croup or epiglottitis
Serious medical emergency
Do not agitate child
Maintain position of comfort
If necessary assist ventilations with a BVM
Primary Assessment
Airway cont’d…
Is gurgling / snoring present?
Excessive secretions require suctioning
Obstruction with the tongue requires repositioning of the head or insertion of OPA / NPA as indicated
Initial Assessment
Assess breathing:
What is the respiratory rate ?
Is chest rise adequate ?
What is the respiratory effort ?
Increased work of breathing
Retractions
Nasal flaring
What are the breath sounds ?
Listen at mid-axillary line for equality and abnormal breath sounds
Initial AssessmentAssess breathing cont’d…:
Is oxygenation / ventilation adequate ?
Cyanosis - Central versus peripheral
Altered Mental State
If oxygenation is inadequate provide supplemental oxygen
Non-Rebreather Mask (if tolerated) with 10-15 LPM flow rate
Blow-by Oxygen with oxygen tubing at 6 LPM flow rate
If ventilations are inadequate provide assisted ventilations
BVM with a reservoir
Are there signs of trauma to the chest ?
Seal holes
Stabilize fractures
Initial AssessmentAssess circulation:
Assess the rate and quality of peripheral pulses
Diminished or absent peripheral pulses indicates compensated shock especially in the presence of a strong central pulse.
Absence of central pulses (femoral or in children older than one year brachial) indicates decompensated shock
Absence of carotid pulse (brachial in infants) indicates cardiac arrest
Assess capillary refill
Normal is less than 2 seconds
Delayed (2-4 seconds) is seen with compensated shock
Absent (greater than 4 seconds) is seen with decompensated shock
Initial AssessmentAssess circulation:
Assess skin color and temperature
Pale and/or cool skin can indicate shock
Is shock present ? If present is it compensated or decompensated
Is their signs / symptoms of internal and/or external bleeding ?
Blood pressure is difficult to measure in pediatric patients and is of limited value
Support circulation as necessary
Control bleeding
Elevate the legs in the absence of trauma
Maintain body temperature
Initial AssessmentAssess disability:
Altered mental status is indicative of hypoxia or hypoperfusion
Assess the level of consciousness
Mental status evaluation is dependent on the patient’s age
AVPU scale
Assess pupils and ability to move all four extremities
If collar has not been applied and is indicated, apply a rigid extrication collar
Initial AssessmentExpose:
Attempt to locate all injuries
Maintain body temperature
CUPS Decision – Use pediatric CUPS status
Identify Priority Patients
Poor general impression
Unresponsive
Airway compromise
Inadequate breathing
Shock
Uncontrolled bleeding
Focused History
Child may be only source.
Use simple yes/no questions.
Use parents/guardians for information if possible.
Detailed Physical Exam
Generally, start at trunk and evaluate head last.
Alter order of steps to fit situation.
Avoid making child more anxious.
Ongoing Assessment
Reassess interventions.
Reassess ABCs.
Reassess vital signs.
Continuous reassessment is key!
NewbornNewbornAssessment andAssessment and
ManagementManagement
Newborn Assessment/ManagementImportance:
Newborn resuscitation needs to be provided immediately following delivery which is most likely to be provided by the first responder
Parents most likely will not have the skills or a good hold of the situation to perform the necessary skills
Newborn AssessmentRespiratory Effort
What is the respiratory rate?
Respiratory Effort
Are there retractions, nasal flaring, chest wall movement, etc…
Skin Color
Peripheral cyanosis is normal in the newborn
Central or persistent cyanosis is worrisome
Newborn AssessmentPerfusion
Heart rate
Assess by palpating umbilical cord or listening with stethoscope for heartbeat
Skin Color
Muscle Tone
The newborn should have a normal grasp and movement of all extremities
Newborn ManagementWarm and Dry
All newborns require warming and drying, this alone may stimulate breathing
Suctioning
All newborns require suctioning of the mouth and nose
Suctioning will stimulate the newborn to breathe
Always suction the mouth before the nose to prevent aspiration
Tactile Stimulation
After warming, drying and suctioning if the newborn has a poor or absent respiratory effort they may need to be stimulated
Tactile stimulation is accomplished by either rubbing the back or flicking the soles of the newborn
Blow-by Oxygen/Assisted VentilationsMost newborns do not require supplemental oxygen or assisted ventilations
Blow-by oxygen should be provided for the newborn who has either central cyanosis or prolonged peripheral cyanosis AND a normal respiratory effort and a heart rate above 100
If the indications for blow-by oxygen resolve the blow-by oxygen should be gradually withdrawn
Assisted ventilations should be provided to any newborn with either:
Heart rate below 100
Absent or poor respiratory effort despite warming, drying, suctioning and stimulating the newborn
Cyanosis which has not improved with blow-by oxygen
If the newborns indications for assisted ventilations resolve ventilations should be stopped and blow-by oxygen provided
Chest Compressions
Rarely does a newborn require chest compressions
If the newborn’s heart rate is either below 80 and not improving despite warming, drying, tactile stimulation and 30 seconds of BVM ventilation, begin, chest compressions
Common Medical Common Medical ProblemsProblems
Airway ObstructionsPartial Airway Obstruction – infant or child who is alert and sitting
Stridor, crowing, or noisy
Retractions on inspiration
Pink
Good peripheral perfusion
Still alert, not unconscious
Emergency medical care
Allow position of comfort, assist younger child to sit up, do not lay down. May sit on parents lap.
Offer oxygen
Transport
Do not agitate child
Limited exam. Do not assess blood pressure.
Airway Obstructions
Complete Airway Obstruction and altered mental status or cyanosis and partial obstruction
No crying or speaking and cyanosis.
Child's cough becomes ineffective
Increased respiratory difficulty accompanied by stridor
Victim loses consciousness
Altered mental status
Clear airway.
Infant foreign body procedures
Child foreign body procedures
Attempt artificial ventilations with a bag-valve-mask and good seal.
Respiratory Emergencies
Common causes are:
Aspiration of foreign objects
Respiratory diseases and infections
Near drowning or electrocution
Poisonings
SIDS
Respiratory Emergencies
Upper Airway Obstruction
Stridor on inspiration
Lower Airway Disease Wheezing and breathing effort on exhalation
Rapid breathing without stridor
Know respiratory rates for age
Complete Airway Obstruction
No crying
No speaking
Cyanosis is present
No couging
Respiratory Assessment
Check respiratory rate
Rate can be affected by many factors such as fear, fever and age
Initial response to respiratory distress is an increased respiratory rate, followed by a drop in the respiratory rate as the child fatigues
Assess respiratory effort
Chest rise
Retractions
Nasal flaring
Respiratory AssessmentAuscultate breath sounds
Should be performed at the mid-axillary line
Sounds on inspiration usually indicate upper airway problems while sounds with expiration usually represent lower airway problems
Look for asymmetry
Wheezes are a sign of small airway narrowing and reduced air flow
Inspect and palpate the chest
Are there any visible signs of trauma
Assess Skin Color
Central or peripheral cyanosis
Respiratory Distress
Recognize signs of increased effort or breathing – needs a NRB maskEarly respiratory distress is indicated by any of the following:
Nasal flaring
Intercostal Retractions (neck muscles), supraclavicular (above clavicles), subcostal retractions (below ribs)
Stridor
Neck and abdominal muscles – retractions
Audible wheezing
Grunting
Respiratory DistressThe presence of signs and symptoms of early respiratory distress and any of the following
Rate >60
Cyanosis
Decreased muscle tone
Severe use of accessory muscles
Poor peripheral perfusion and color
Altered mental status
Alert, irritable, anxious
Grunting
Signs of Respiratory DistressSigns of Respiratory Distress
Respiratory Arrest/FailureNeeds assisted BVM assisted ventilations. Use the
patients as medical control (i.e. any pediatric patient who will tolerate a BVM needs a BVM)
Difficulty with breathing
Increased respiratory effort at sternal notch
Breathing rate less than 10 per minute
Retractions
Head bobbing
Grunting
Severe accessory muscle use
Absent or shallow chest wall motion
Respiratory Arrest/Failure
Needs assisted BVM assisted ventilations. Use the patients as medical control (i.e. any pediatric patient who will tolerate a BVM needs a BVM)
Difficulty with breathing cont’d…
Limp muscle tone
Decreased muscle tone or poor muscle tone (e.g. unable to maintain sitting position in infant > 4 months)
Change in Mental Status
Sleepy
Intermittently combative
Agitated
Unresponsive to voice or touch
Unconscious
Respiratory Arrest/Failure
Needs assisted BVM assisted ventilations. Use the patients as medical control (i.e. any pediatric patient who will tolerate a BVM needs a BVM)
Difficulty with breathing cont’d…
Slower, absent heart rate
Difficulty with color/perfusion
Central cyanosis
Marked tachycardia or bradycardia
Poor peripheral perfusion
Weak or absent distal pulses.
Respiratory ailments are the primary cause of cardiac arrest, not due to trauma
Respiratory Emergencies
Maintain the airway
Provide high-concentration oxygen to all children with resp. emergencies
Provide oxygen and assist ventilations if respiratory distress is severe:
Altered mental status
Cyanosis not improving with oxygen
Poor muscle tone
Respiratory failure
Respiratory arrest – apply oxygen and ventilate wit BVM
Viral inflammation of trachea & larynx
Usually affects ages 6 months to 4 years
Onset typically at night
Seal-like barking cough
Signs of respiratory distress
Croup
Place in position of comfort.
Administer high-concentration oxygen.
Cool air may provide relief.
Transport.
Treatment of Croup
A life-threatening emergency!
Bacterial inflammation of epiglottis
Usually affects ages 3 to 7
Sudden onset of high fever
Epiglottitis
Continued…
A life-threatening emergency!
Tripod positioning
Painful swallowing & respiratory distress
Epiglottitis
Place in position of comfort.
Administer high-concentration oxygen.
Transport immediately.
Do not increase child’s anxiety.
Do not place anything in patient’s mouth.
Treatment of Epiglottitis
Seizures
Seizures in children who have chronic seizure are rarely life-threatening. However, seizures, including febrile, should be considered life- threatening by the EMT-B
May be brief or prolonged
Assess for presence of injuries which may have occurred during the seizures
Seizures
Fever
Infection
Poisoning
Hypoglycemia
Trauma
Hypoxia
Idiopathic (Unknown Cause)
Causes
Assessing Seizures
History of Seizures:
Has child had seizures before?
If yes, is this the child’s normal seizure pattern?
Anti-seizure medication taken?
Any fever?
Treatment of Seizures
Assure patency of airway.
Position patient on side if no possibility of cervical spine trauma. Protect from injury.
Have suction ready.
Provide oxygen and if in respiratory arrest or severe respiratory distress, assure airway position and patency and ventilate with BVM.
Transport. Although brief seizures are not harmful, there may be a more dangerous underlying condition.
Seizures
Can be caused by head injury
Inadequate breathing and/or altered mental status may occur following a seizure.
Hypoglycemia
Poisoning
Post-seizure
Infection
Head trauma
Hypoxia
Shock
Causes
Altered Mental Status
Emergency Care ofAltered Mental Status
Establish airway.
Administer high-concentration oxygen.
Be prepared to artificially ventilate and suction as needed.
Consider spinal precautions.
Transport.
Poisonings
Common reason for infant and child ambulance calls
Identify suspected container through adequate history. Bring container to receiving facility if possible.
Emergency medical care
Responsive patient
Contact medical control.
Provide oxygen.
Transport.
Continue to monitor patient - may become unresponsive.
Poisonings
Emergency medical care cont’d…
Unresponsive patient
Assure patency of airway.
Be prepared to artificially ventilate.
Provide oxygen if indicated.
Call medical control.
Transport.
Rule out trauma, trauma can cause altered mental status.
Fever
Common reason for infant or child ambulance call
Many causes – rarely life-threatening. A severe cause is meningitis
Fever with a rash is a potentially serious consideration
Transport and be prepared for seizures.
Diarrhea and dehydration
Trauma
Vomiting
Blood loss – The loss of any amount of blood in an infant or child can be life-threatening
Infants = 50ml
Infection
Abdominal injuries
Common
Causes
Shock (Hypoperfusion)
Blood VolumeBlood Volume
Allergic reactions
Poisoning
Cardiac problems
UncommonCauses
Shock (Hypoperfusion)
Assessment of Shock
Different than for adults
Blood pressure hard to measure and unreliable, especially true when < 3 years old, don't even obtain BP measurement
Key assessment is peripheral perfusion and mental status
Be aware that shock in a child can rapidly deteriorate
Diminished or absent peripheral pulses indicates compensated shock especially in the presence of a strong central pulse.
Signs and Symptoms of Shock
Compensated Shock
Altered Mental Status
Rapid pulse (tachycardia)
Cool extremities
Weak/absent peripheral pulses
Delayed capillary refill
Continued…
Decompensated Shock
Weak or impalpable central pulses
Extensive cyanosis of all extremities
Absence of tears even when crying
Systolic BP less than 70mmHg
Signs and Symptoms of Shock
Signs of Shock
TreatingTreatingShockShock
1. Assure airway/oxygen
2. Provide supplemental oxygen
3. Be prepared to artificially ventilate
4. Manage bleeding if present
5. Immobilize the patient as indicated
6. Elevate legs if no indication of trauma
7. Keep warm
8. Transport.
***Rapid transport form infant/child with secondary exam en route***
Emergency Care forNear Drowning
Artificial ventilation is top priority
Consider possibility of trauma
Consider possibility of hypothermia
Consider possible ingestion, especially alcohol
Protect airway, suction if necessary
Secondary drowning syndrome - Deterioration after breathing normally from minutes to hours after event. All near drowning victims should be transported to the hospital.
Sudden Infant DeathSyndrome (SIDS)
Key Term
Sudden death without identifiable cause Sudden death without identifiable cause in infant < 1 year old. Cause is not well in infant < 1 year old. Cause is not well understood. Most common time of understood. Most common time of discovery is early morning.discovery is early morning.
Emergency Care of SIDS
Resuscitate if indicated - unless rigor mortis is present.
Parents will be in agony from emotional distress, remorse and imagined guilt.
Avoid comments that blame parents.
TraumaTrauma
In the United States, injuries kill more children and infants than any other cause of death.
Trauma – General Considerations
Most pediatric trauma is blunt trauma and arises from falls and motor vehicle accidents
Blunt trauma has less overt signs and has a later deterioration than penetrating trauma, therefore rely on the mechanism in the absence of overt signs and / or symptoms of serious trauma
Children have relatively large liver and spleen and have poor muscle protection of these organs making them extremely susceptible to injury
Trauma – General Considerations
Head trauma is more prevalent in children because of the larger head to body ratio when compared with adults
Infants can lose enough blood in their head to develop decompensated shock
Pediatric head injury patients usually die from airway and ventilatory problems and not the actual head injury. As such control the airway and ventilation
Pelvic fractures can cause enough blood loss in the pediatric shock to cause hypovolemic shock
What may seem like a small blood loss may be relatively extensive when compared to the child’s smaller blood volume
Blunt TraumaMost Common Type of Injury
Pattern of Injury will be different from adults:
Motor vehicle crashes:
Unrestrained passenger (head and neck injuries)
Restrained passenger (abdominal and lower spine injuries)
Blunt Trauma
Motor vehicle impacts:
Struck while riding bicycle (head, abdominal, spinal injuries)
Pedestrian struck by vehicle (abdominal injury with internal bleeding, possible painful, swollen, deformed thigh, head injury)
Blunt Trauma
Falls from height, diving into shallow water
Head and neck injuries
Burns
Sports injuries – head and neck
Child abuse
Blunt TraumaSpecific Types of Injuries
HeadThe single most important maneuver is to assure an open airway by means of the modified jaw thrust combined with a neutral head position.
Children are likely to sustain head injury along with internal injuries. Signs and symptoms of shock (hypoperfusion) with a head injury should cause you to be suspicious of other possible injuries.
Respiratory arrest is common secondary to head injuries and may occur during transport.
Blunt TraumaSpecific Types of Injuries
Head cont’d…Common signs and symptoms are nausea and vomiting.
Most common cause of hypoxia in the unconscious head injury patient is the tongue obstructing the airway. Jaw-thrust is critically important.
Do not use sandbags to stabilize the head because the weight on child's head may cause injury if the board needs to be turned for emesis.
Blunt TraumaSpecific Types of Injuries
Pediatric Cervical Spinal Stabilization and Immobilization
Manual stabilization
Initially provide manual stabilization while maintaining an adequate airway
Cervical Collars
Initially assure that the head is in a neutral position
Choose a collar of appropriate size based on manufacturers recommendations
Towels can be used in place of a cervical collar for infants that do not fit in the available collars.
Blunt TraumaSpecific Types of Injuries
Spinal Immobilization
Immobilization of pediatric patients should account for their anatomical differences
Children are shorter than adults - use backboards which have strap holes at multiple locations or use a short backboard.
Children are narrower than adults - it may be necessary to pad along the sides to insure a snug fit of the straps.
Small children have a large occiput - pad under the upper torso to insure neutral alignment of the cervical spine.
Blunt TraumaSpecific Types of Injuries
Spinal Immobilization cont’d…
Assure that a cervical collar is in place prior to moving patient to the backboard.
Place a child on the backboard using standard patient moves for a spinal injury patient
Secure the chest, pelvis and knees and then the head
Chest
Children have very soft pliable ribs
There may be significant injuries without external signs
Blunt TraumaSpecific Types of Injuries
Abdomen
More common site of injury in children than adults
Often a source of hidden injury
Always consider abdominal injury in the multiple trauma patient who is deteriorating without external signs
Air in stomach can distend abdomen and interfere with artificial ventilation efforts
Blunt TraumaSpecific Types of Injuries
Blunt TraumaSpecific Types of Injuries
Extremities
Managed in the same manner as adults
TraumaOther Considerations
Burns
Cover with sterile dressing (non-adherent, if possible, sterile sheets may be used).
Follow local protocol with regard to transport to burn center.
Emergency Care of Trauma
Maintain an adequate airway while manually stabilizing the cervical spine
Assure airway position and patency. Use modified jaw thrust.
Suction as necessary with large bore suction catheter.
Provide oxygen.
Assist ventilations for severe respiratory distress and ventilate with a bag-valve-mask for respiratory arrest.
Support circulation
Provide spinal immobilization.
Transport immediately.
Child AbuseChild Abuse and Neglectand Neglect
Abuse
Key Term
Improper or excessive action so as to injure or cause harm
Neglect
Key Term
Giving insufficient attention or respect to someone who has a claim to that attention
EMT–B must be aware of condition in order to recognize it.
Physical abuse and neglect are the two forms of child abuse EMT–B is most likely to suspect.
Signs of Abuse
Multiple bruises in various stages of healing
Injury inconsistent with mechanism described
Repeated calls to the same address
Continued…
Fresh burns
Parents seem inappropriately unconcerned
Conflicting stories
Fear on the part of the child to discuss how the injury occurred
Signs of Abuse
Lack of adult supervision
Child appears malnourished
Unsafe living environment
Untreated chronic illness (i.e. asthmatic with no medications)
Signs of Neglect
Handling Abuse and Neglect
CNS injuries are most lethal.
Shaken baby syndrome
Do not accuse anyone in the field.
Accusation and confrontation delays transportation
Bring objective information to the receiving facility
Handling Abuse and Neglect
Required Reporting
Follow state laws and local regulations.
Document objective information (what you SEE and HEAR, NOT what you THINK).
Infants and ChildrenInfants and Childrenwithwith
Special NeedsSpecial Needs
Children with Special Needs
This can include many different types of children:
Premature babies with lung disease
Babies and Children with heart disease
Infants and children with neurologic disease
Children with chronic disease or altered function from birth
Technologically DependentChildren (“High-Tech Kids”)
Tracheostomy tube
Central intravenous lines
Gastrostomy tubes
Shunts
Tracheostomy TubeComplications
Obstruction
Bleeding
Air leak
Dislodged tube
Infection
Tracheostomy Tube
Managing the Tracheostomy Tube
Maintain open airway.
Suction.
Maintain a position of comfort.
Transport.
Home Artificial Ventilation
Parents are usuallyfamiliar withequipment.
Home Artificial Ventilation
Assure airway.
Artificially ventilate with high-concentration oxygen.
Transport.
Central Intravenous Lines
IVs that are placed near the
heart for long term use
Complications
Cracked line
Infection
Clotting off
Bleeding
Care of Central IntravenousLines
If bleeding is present, apply pressure.
Transport.
Tube placed directly into stomach for feeding. Comes in many shapes. These patients usually cannot be fed by mouth.
Gastrostomy Tubes
Key Term
Managing GastrostomyTubes
Assure adequate airway.
Have suction available.
If a diabetic patient, be alert for altered mental status. Infant will become hypoglycemic quickly if they cannot be fed.
Provide high-concentration oxygen.
Transport patient sitting or lying on right side with head elevated.
Shunt
Key Term
Device running from brain to abdomen to drain excess cerebrospinal fluid. Will find reservoir on side of skull.
Managing Shunts
Prone to respiratory arrest
Manage airway.
Assure adequate artificial ventilation.
Transport.
Family ResponseFamily Response
A child cannot be cared for in isolation from the family; therefore, you have multiple patients.
Family Response
Striving for calm, supportive interaction with family will result in improved ability to deal with the child.
Calm parents = calm child; Agitated parents = agitated child.
Anxiety arises from concern over child’s pain; fear for child’s well-being
Worsened by state of helplessness
Family Response
Parent may respond with anger/hysteria toward EMT–B.
Parents should remain part of the care unless child is not aware or medical conditions require separation.
Parents should be instructed to calm child; can maintain position of comfort and/or hold oxygen.
Parents may not have medical training, but they are experts on what is normal or abnormal for their children and what will have a calming effect.
ProviderProviderResponseResponse
Anxiety from lack of experience with treating children as well as fear of failure.
Skills can be learned and applied to children.
Stress from identifying patient with their own children.
Provider should realize that much of what they learned about adults applies to children; they need to remember the differences.
Provider Response
Infrequent encounters with sick children; advance preparation is important (practice with equipment and examining children).
Encounters with sick or injured children may result in adverse emotional response by the EMT-B.
Critical Incident Stress Management (CISM) programs have been helpful in assisting EMS personnel to manage their normal response to these stressful situations.
Provider Response