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BLS Management of the Peds Patient By
Daniel B. Green II, NREMT-P, CCP
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Objectives
Review developmental milestones of children
Use the pediatric assessment triangle to assess pediatric patients
Discuss modifications to patient assessment based on age
Review common pediatric illnessess and treatments
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Pediatric Development
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Pediatric Development
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Age and Weight
Important to be able to estimate ages and weights for pediatric patients
Affects treatment decisions, particularly for AED and CPR
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Age and Weight
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Age and Weight
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Developmental Characteristics
Children have different behaviors at different ages
Tailor your assessment
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Newborns and InfantsBirth to 1 Year
Do not like cold Do not like separation from
primary caregivers Let parent or caregiver
hold child during assessment
Ask caregiver to expose areas for examination
Warm stethoscope bell before placing on child
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Newborns and InfantsBirth to 1 Year
Ask caregiver to comfort crying child Try distraction: pen or toy Check fontanels
Bulging indicates possible increased intracranial pressure
Sunken may indicate dehydration
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Toddlers 1–3 Years
Sense of independence but unable to communicate complex ideas
Do not like strangers or separation from parents
Require assuranceMay consider illness or separation from family
as punishment
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Toddlers 1–3 Years
Place bell of stethoscope under shirt, rather than taking off clothing
Consider demonstrating procedure such as chest auscultation on stuffed toy before using on child
May not tolerate oxygen mask Use blow-by oxygen
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Preschoolers 3–6 Years
More developed concrete thinking skills Ask for their version of events and feelings Frightened of potential pain, blood, injury Reassure, provide simple explanations Allow parent or caregiver to remain Protect modesty
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School Aged Children6–12 Years
Have basic idea of body and its functions
Very literal Aware of and afraid of
dying, pain, deformity, permanent injury
Use reassurance and include them in discussions of care
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Adolescents 12–18 Years
More thorough understanding of A&P
Able to process and express complex ideas
Good risk takers, poor judges of consequence
Sense of immortality Speak respectfully Protect privacy
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The Pediatric Airway
HeadProportionally larger and heavier than body
TongueLarger in proportion to lower jawFalls back, occluding airway
TracheaThinner, more elasticMay close off with hyperextension
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Breathing
Infants breath primarily through noseNose may be blocked with secretions
Infant and child have higher respiratory rate Abdominal breathers
Tire quickly when stressed
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Pediatric Assessment Triangle
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Pediatric Assessment
Elements of the pediatric assessment triangleAppearance and environmentWork of breathingCirculation
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Appearance and Environment
Key questions Is scene safe? Is there an obvious
mechanism of injury? Is environment safe for
a child? Is child active and
attentive? Can child make eye
contact, respond to parent’s voice?
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Work of Breathing
Look for symmetrical chest movement Note respiratory rate Primary causes of cardiac arrest in children
are respiratory disorders
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Abnormal Findings
Stridor Harsh, high pitched sound during inhalation or
exhalation Indicates partial upper airway obstruction
Retraction of chest wall muscles Muscles pulling in between ribs, above sternum with
inspiration Nasal flaring
Extended opening or flaring of nostrils Wheezing
High pitched sounds created by air moving through narrowed air passages in lungs
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Assessing Circulation
Central perfusion Supply of oxygen to
and removal of wastes from central circulation
Asses with brachial and femoral pulse checks
Check capillary refill Assess skin
temperature, color, and moisture
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Assessing Circulation
BP difficult to obtain below 3 years of age Rely on mental status,
quality of pulses, and capillary refill
Children 3 Ensure right size BP
cuff Be aware of variation of
vital signs with age
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Compensating/Decompensating
Children will compensate for poor respirations and circulation
However, decompensation may develop quickly
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Respiratory Emergencies in Infants and Children
Respiratory distress Respiratory failure Respiratory arrest Airway management Airway adjuncts Oxygen therapy Assisted artificial ventilations Shock
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Respiratory Distress
Most common cause in pediatric patients is asthma
Also includesChronic lung diseaseAirway obstructionCongenital heart diseaseForeign body aspirationChest wall trauma
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Definitions
Respiratory distressAbnormal physiologic process that prevents
adequate gas exchange Respiratory failure
Inability of respirations to maintain adequate oxygenation and ventilation
Respiratory arrestAbsence of breathing
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Upper Airway Obstruction
Partial obstructionStridor on inspiration
Complete obstructionNo crying, no speaking, no coughingCyanosis
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Lower Airway Obstruction
Wheezing Prolonged, labored exhalations Rapid respiratory rate No stridor
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Signs of Respiratory Distress in Children
Altered mental status Flared nostrils Pale or cyanotic lips or
mouth Noisy respirations
(stridor, grunting, gasping, wheezing)
Respiratory rate greater than 60
Retractions Use of abdominal
muscles for breathing (see-saw breathing)
Poor peripheral perfusion
Decreased heart rate
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Signs of Respiratory Failure
Decreased mental status
Poor eye contact No response to verbal
stimuli
Pale, cyanotic skin Delayed capillary refill,
weak pulses Fatigue, floppy, head
bobbing
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Continuing Respiratory Failure
Without immediate intervention, child will continue to deteriorate
Respiratory rate 10/min Unresponsive, limp Decreasing heart rate Eventual respiratory and cardiac arrest
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Airway Management
Airway is primary concern for children
Modify head tilt/chin lift to maintain neutral position
Avoid hyperextension or flexion
Consider placing towel under body to maintain neutral airway position
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Suctioning Secretions and Vomit
Use bulb-type suction device for suctioning nose and mouth of infant
For larger children, use thin flexible plastic catheter
Use rigid catheter for removing thick secretions and vomit
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Principles of Suctioning
Administer oxygen prior to suctioning
Suction for maximum of 5 seconds at a time
Do not touch the back of the throat May slow heart rate
and cause soft-tissue damage
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Partial Airway Obstruction
Alert Noisy respirations Increased work of
breathing Retractions around
ribs and sternum Pink mucous
membranes Good peripheral
pulses
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Managing Partial Airway Obstruction
Place child in position of comfort
Likely sitting up Calm child Allow child to sit with
parent or caregiver Provide oxygen by
mask or blow-by technique
Let child or caregiver hold oxygen device
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Management of Airway Obstruction
Intervene if following signs are notedAbsence of speaking or crying Ineffective coughAltered mental statusRespiratory arrest
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Children Under 1 Year of Age
If ventilation is ineffective or impossible, clear airway 5 back blows 5 chest thrusts If object is visible,
remove Continue until effective
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Children Over 1 Year of Age
If ventilation is ineffective or impossible, clear airwayPerform chest compressionsDo not perform blind finger sweeps
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Shock
Causes in childrenVomitingDiarrhea InfectionTraumaBlood loss
Less commonAllergic reactionsPoisoning
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Cardiac Causes of Shock
Very rare in children Occasionally may have child with
congenital or chronic heart disease
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Signs and Symptoms of Shock
Rapid heart rate Rapid respiratory rate Cool extremities Pale skin, dry mucous
membranes Delayed capillary fill
time
Weak central pulse Weak or absent distal
pulse Decreased response
to environment “Floppy” muscle tone
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Questions to Ask Caregiver
Has child been vomiting or had diarrhea? How many wet diapers in the past
24 hours?
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Management of Shock in Children
Child showing signs of shock is very sick Children tend to compensate well, then
decompensate quickly
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Emergency Care for Shock
BSI and scene safety Ensure adequate ABCs Control obvious bleeding Administer high flow
oxygen Keep patient warm Elevate legs, if possible Expedite transport/call for
ALS backup
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Trauma in Children
Leading cause of death in infants and children Head injuriesChest injuriesAbdominal injuries Injuries to the extremitiesBurn injuries
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Common Mechanisms of Injury
Motor vehicle crash Motor vehicle versus bicycle Pedestrian versus motor vehicle Fall from height Diving into shallow water Others
Burns, sports injuries, child abuse
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Motor Vehicle Crashes
Most common cause of blunt trauma Unrestrained child
Injuries to head and neck Restrained child
Abdominal and lower spine injuries
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Motor Vehicle versus Bicycle
Injuries to Head Spine Abdominal injuries
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Pedestrian versus Motor Vehicle
Bumper hits abdomen or upper legs Child thrown and lands on head With toddlers, bump will impact head and
neck Often associated with abdominal, head,
upper leg, pelvic injuries
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Head Injuries
Use modified jaw-thrust Tongue obstruction in supine patient most
common cause of hypoxiaDeveloping respiratory failure and arrest
Watch forNausea, vomitingSecondary injuries
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Chest Injuries
Children's ribs are more pliableWill bend further before breaking
May be significant internal bleeding without obvious external signs of injury
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Abdominal Injuries
More common in children than adults Abdominal muscles are weaker than in
adults Internal organs are less securely anchored Suspect abdominal injury in child who is
deteriorating without outward signs of injury Be aware of gastric distension when
providing assisted ventilations
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Injuries to the Extremities
Isolated limb injuries more frequent in pediatric population
Rarely life-threatening Use of PASG prohibited in children Ensure you know local protocols
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Burn Injuries
Impaired skin integrity and exposure increase risk of hypothermia
Know Rule of 9s for infants and children
Heads are larger relative to body
Cover with sterile nonstick gauze
Transport to burn center
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Emergency Medical Care
BSI, scene survey Maintain cervical
stabilization Use modified jaw-thrust Suction if necessary Provide oxygen Assist respirations as
required Secure to backboard Transport to appropriate
facility
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Seizures
Causes Infection Poisoning Hypoglycemia Hypoxia Head trauma
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Febrile Seizures
Most common cause of seizures in infants and children
Usually associated with viral illness
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Assessment of Seizure Patient
Ask caregiverHow many seizures child has hadHow long seizures lastedWhat part of the body was convulsingRecent history of fever or chronic seizure
disorderWhat medications child takes
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Emergency Care for Seizures
Protect cervical spine as necessary
Ensure patent airway Provide oxygen Suction, assist
respirations, if required
Transport to appropriate facility
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Poisoning
Common cause is accidental ingestion
Look for substance and container at scene
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Emergency Care for Poisoning
If responsiveContact medical directionAdminister oxygen and transport
If unresponsiveMaintain patent airwaySuction and assist ventilations as necessaryContact medical directionAdminister oxygen and transport
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Fever
Seldom life-threatening on its own Causes usually infectious
e.g., meningitis Transport and be alert for seizures
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The Last Word
Keys are airway, breathing, and oxygenation
Cardiac events in children are almost always preceded by an obstructed airway or inadequate respirations
EMS providers often intimidated by pediatric calls
Practice your skills when working with children
Remain calm and supportive