31: Pediatric Emergencies

31: Pediatric Emergencies

Cognitive Objectives (1 of 3)
6-1.1 Identify the developmental considerations for the following pediatric age groups: infants, toddlers, preschool, school age, adolescent. 6-1.2 Describe the differences in anatomy and physiology between the infant, the child, and the adult patient. 6-1.3 Differentiate the response of the ill or injured infant or child (age specific) from that of an adult.

6-1.8 Identify the signs and symptoms of shock (hypoperfusion) in an infant and child patient. List common causes of seizures in the infant and child patient. Differentiate between the injury patterns in adults, infants, and children.

Summarize the indicators of possible child abuse and neglect. Describe the medical/legal responsibilities in suspected child abuse. Recognize the need for EMT-B debriefing following a difficult infant or child transport.

Affective Objectives Explain the rationale for having knowledge and skills appropriate for dealing with the infant and child patient. Attend to the feelings of the family when dealing with an ill or injured infant or child. Understand the provider’s own response (emotional) to caring for infants or children. There are no psychomotor objectives for this chapter.

Airway Differences Larger tongue relative to the mouth
Larger epiglottis Less well-developed rings of cartilage in the trachea Narrower, lower airway

Breathing Differences
Infants breathe faster than children or adults. Infants use the diaphragm when they breathe. Sustained, labored breathing may lead to respiratory failure.

Circulation Differences
The heart rate increases for illness and injury. Vasoconstriction keeps vital organs nourished. Constriction of the blood vessels can affect blood flow to the extremities.

Skeletal Differences Bones are weaker and more flexible.
They are prone to fracture with stress. Infants have two small openings in the skull called fontanels. Fontanels close by 18 months.

Growth and Development
Thoughts and behaviors of children usually grouped into stages Infancy Toddler years Preschool age School age Adolescence

Infant First year of life They respond mainly to physical stimuli.
Crying is a way of expression. They may prefer to be with caregiver. If possible, have caregiver hold the infant as you start your examination.

Toddler 1 to 3 years of age They begin to walk and explore the environment. They may resist separation from caregivers. Make any observations you can before touching a toddler. They are curious and adventuresome.

Preschool 3 to 6 years of age
They can use simple language effectively. They can understand directions. They can identify painful areas when questioned. They can understand when you explain what you are going to do using simple descriptions. They can be distracted by using toys.

School Age 6 to 12 years of age They begin to think like adults.
They can be included with the parent when taking medical history. They may be familiar with physical exam. They may be able to make choices.

Adolescent 12 to 18 years of age
They are very concerned about body image. They may have strong feelings about being observed. Respect an adolescent’s privacy. They understand pain. Explain any procedure that you are doing.

Family Matters When a child is ill or injured, you have several patients, not just one. Caregivers often need support when medical emergencies develop. Children often mimic the behavior of their caregivers. Be calm, professional, and sensitive.

Pediatric Emergencies (1 of 3)
Dehydration Vomiting and diarrhea Greater risk than adults Fever Rarely life threatening Caution if occurring with rash

Meningitis is an inflammation of the tissue that covers the spinal cord and brain. Caused by an infection If left untreated can lead to brain damage or death.

Febrile seizures Common between 6 months and 6 years Last less than 15 minutes Poisoning Signs and symptoms vary widely. Determine what substances were involved.

Physical Differences Children and adults suffer different injuries from the same type of incident. Children’s bones are less developed than an adult’s. A child’s head is larger than an adult’s, which greatly stresses the neck in deceleration injuries.

Psychological Differences
Children are not as psychologically mature. They are often injured due to their undeveloped judgment and lack of experience.

Injury Patterns: Automobile Collisions
The exact area of impact will depend on the child’s height. A car bumper dips down when stopping suddenly, causing a lower point of impact. Children often sustain high-energy injuries.

Injury Patterns: Sports Activities
Head and neck injuries can occur from high-speed collisions during contact sports. Immobilize the cervical spine. Follow local protocols for helmet removal.

Head Injuries Common injury among children
The head is larger in proportion to an adult. Nausea and vomiting are signs of pediatric head injury.

Chest Injuries Most chest injuries in children result from blunt trauma. Children have soft, flexible ribs. The absence of obvious external trauma does not exclude the likelihood of serious internal injuries.

Abdominal Injuries Abdominal injuries are very common in children.
Children compensate for blood loss better than adults but go into shock more quickly. Watch for: Weak, rapid pulse Cold, clammy skin Poor capillary refill

Injuries to the Extremities
Children’s bones bend more easily than adults’ bones. Incomplete fractures can occur. Do not use adult immobilization devices on children unless the child is large enough.

Pneumatic Antishock Garments (PASG)
Rarely used for treating children When to use a PASG: Obvious lower extremity trauma Pelvic instability Clear signs and symptoms of decompensated shock Should only be used if it fits properly Should never inflate the abdominal compartment

Burns Most common burns involve exposure to hot substances.
Suspect internal injuries from chemical ingestion when burns are present around lips and mouth. Infection is a common problem with burns. Consider the possibility of child abuse.

Submersion Injury Drowning or near drowning
Second most common cause of unintentional death of children in the United States Assessment and reassessment of ABCs are critical. Consider the need for C-spine protection.

Child Abuse Child abuse refers to any improper or excessive action that injures or harms a child or infant. This includes physical abuse, sexual abuse, neglect, and emotional abuse. More than 2 million cases are reported annually. Be aware of signs of child abuse and report suspicions to authorities.

Signs of Child Abuse

Questions Regarding Signs of Abuse (1 of 4)
Is the injury typical for the child’s developmental stage? Is reported method of injury consistent with injuries? Is the caregiver behaving appropriately? Is there evidence of drinking or drug abuse?

Was there a delay in seeking care for the child? Is there a good relationship between child and caregiver? Does the child have multiple injuries at various stages of healing? Does the child have any unusual marks or bruises?

Does the child have several types of injuries? Does the child have burns on the hands or feet involving a glove distribution? Is there an unexplained decreased level of consciousness?

Is the child clean and an appropriate weight? Is there any rectal or vaginal bleeding? What does the home look like? Clean or dirty? Warm or cold? Is there food?

Emergency Medical Care
EMT-Bs must report all suspected cases of child abuse. Most states have special forms for reporting. You do not have to prove that abuse occurred.

Sexual Abuse Children of any age or either sex can be victims.
Limit examination. Do not allow child to wash, urinate, or defecate. Maintain professional composure. Transport.

Sudden Infant Death Syndrome (SIDS)
Several known risk factors: Mother younger than 20 years old Mother smoked during pregnancy Low birth weight

Tasks at Scene Assess and manage the patient.
Communicate with and support the family. Assess the scene.

Assessment and Management
Assess ABCs and provide interventions as necessary. If child shows signs of postmortem changes, call medical control. If there is no evidence of postmortem changes, begin CPR immediately.

Communication and Support
The death of a child is very stressful for the family. Provide support in whatever ways you can. Use the infant’s name. If possible, allow the family time with the infant.

Scene Assessment Carefully inspect the environment, following local protocols. Concentrate on: Signs of illness General condition of the house Family interaction Site where infant was discovered

Apparent Life-Threatening Event
Infant found not breathing, cyanotic, and unresponsive but resumes breathing with stimulation Complete careful assessment. Transport immediately. Pay strict attention to airway management.

Death of a Child (1 of 2) Be prepared to support the family.
Family may insist on resuscitation efforts. Introduce yourself to the child’s caregivers. Do not speculate on the cause of death.

Death of a Child (2 of 2) Allow the family to see the child and say good-bye. Be prepared to answer questions posed by caregivers. Seek professional help for yourself if you notice signs of posttraumatic stress.

Children With Special Needs
Children born prematurely who have associated lung problems Small children or infants with congenital heart disease Children with neurologic diseases Children with chronic diseases or with functions that have been altered since birth

Tracheostomy Tube

Artificial Ventilators
Provide respirations for children unable to breathe on their own. If ventilator malfunctions, remove child from the ventilator and begin ventilations with a BVM device. Ventilate during transport.

Central IV Lines

Gastrostomy Tubes Food can back up the esophagus into the lungs.
Have suction readily available. Give supplemental oxygen if the patient has difficulty breathing.

Shunts Tubes that drain excess fluid from around brain
If shunt becomes clogged, changes in mental status may occur. If a shunt malfunctions, the patient may go into respiratory arrest.

Review How does a child’s anatomy differ from an adult’s anatomy?
A. The child’s trachea is more rigid B. The tongue is proportionately smaller C. The epiglottis is less floppy in a child D. The child’s head is proportionately larger

Review Answer: D Rationale: There are several important anatomic differences between children and adults. A child’s head—specifically the occiput—is proportionately larger. Their tongue and epiglottis are also proportionately larger, and the epiglottis is floppier and more omega-shaped. The child’s airway is narrower at all levels, and the trachea is less rigid and easily collapsible.

Review How does a child’s anatomy differ from an adult’s anatomy?
The child’s trachea is more rigid Rationale: A child’s trachea is less rigid, narrower, and more anterior than an adult’s. B. The tongue is proportionately smaller Rationale: A child’s tongue is proportionally larger than an adult’s. C. The epiglottis is less floppy in a child Rationale: A child’s epiglottis is floppier and shaped differently than an adult’s. D. The child’s head is proportionately larger Rationale: Correct answer

Review 2. When assessing a conscious and alert 9-year-old child, you should: A. isolate the child from his or her parent. B. allow the child to answer your questions. C. obtain all of your information from the parent. D. avoid placing yourself below the child’s eye level.

Review Answer: B Rationale: A 9-year-old child is capable of answering questions. By allowing a child to answer your questions, you can gain his or her trust and build a good rapport, which facilitates further assessment and treatment. Do not isolate the child from his or her parent, yet do not allow the parent to do all the talking, unless the child is unable to communicate. When assessing any patient, you should place yourself at or slightly below the patient’s eye level. This position is less intimidating and helps to minimize patient anxiety.

Review 2. When assessing a conscious and alert 9-year-old child, you should: isolate the child from his or her parent. Rationale: Do not isolate a child from his or her parents. B. allow the child to answer your questions. Rationale: Correct answer C. obtain all of your information from the parent. Rationale: Some information from parents is useful, but allow the child to speak. D. avoid placing yourself below the child’s eye level. Rationale: Never tower over a child, instead maintain yourself at/or below eye level.

Review 3. You are called to a residence for a child in respiratory distress. The child, a 3-year-old boy, is ventilator-dependent and has a tracheostomy tube. He is tachypneic and you hear gurgling sounds in the tube. You should: A. remove the ventilator from the tracheostomy tube and suction the tube. B. reposition the child’s airway and reassess his respiratory rate and effort. C. turn off the mechanical ventilator and apply oxygen via nonrebreathing mask. D. remove the tracheostomy tube and ventilate the child with a bag-mask device.

Review Answer: A Rationale: Secretions often accumulate in or around a tracheostomy tube, resulting in partial or complete obstruction. A gurgling sound from the tube indicates this and can lead to hypoxia if not corrected. Proper treatment involves detaching the ventilator, suctioning the tracheostomy tube, reattaching the ventilator, and reassessing the patient. If the child’s condition has not improved, ventilate him with a bag-mask device attached to the tube, resuction the tube if needed, and transport at once.

Review (1 of 2) 3. You are called to a residence for a child in respiratory distress. The child, a 3-year-old boy, is ventilator-dependent and has a tracheostomy tube. He is tachypneic and you hear gurgling sounds in the tube. You should: remove the ventilator from the tracheostomy tube and suction the tube. Rationale: Correct answer B. reposition the child’s airway and reassess his respiratory rate and effort. Rationale: The child’s airway is maintained by a rigid tube, repositioning it will not facilitate a better airway.

Review (2 of 2) 3. You are called to a residence for a child in respiratory distress. The child, a 3-year-old boy, is ventilator-dependent and has a tracheostomy tube. He is tachypneic and you hear gurgling sounds in the tube. You should: C. turn off the mechanical ventilator and apply oxygen via nonrebreathing mask. Rationale: If suctioning is not helpful, the mechanical ventilator can be disconnected. However, ventilations must be continued by using a bag-mask connected to 100% oxygen. D. remove the tracheostomy tube and ventilate the child with a bag-mask device. Rationale: Never remove a tracheotomy tube, doing so may eliminate the only route for the patient to receive oxygen and may induce trauma or create additional obstructions.

Review 4. Which of the following indicators of perfusion is more reliable in small children than in adults? A. Skin color B. Heart rate C. Capillary refill D. Respiratory rate

Review Answer: C Rationale: Capillary refill time (CRT) is an excellent indicator of perfusion in children younger than 6 years of age. It is less reliable in older children and adults. There are certain factors, however, that can affect CRT, such as cold temperatures and peripheral vasoconstriction.

Review 4. Which of the following indicators of perfusion is more reliable in small children than in adults? Skin color Rationale: Skin color may indicate hypoxia, hyperthermia, hypothermia, jaundice, and possibly shock. B. Heart rate Rationale: Heart rate changes are a compensatory mechanism and can be due to hypoxia, shock, etc. C. Capillary refill Rationale: Correct answer D. Respiratory rate Rationale: Respiratory rates are driven by hypoxia and the need to increase the concentration of oxygen in the blood.

Review 5. The purpose of a shunt is to:
A. minimize pressure within the skull. B. reroute blood away from the lungs. C. instill food directly into the stomach. D. drain excess fluid from the peritoneum.

Review Answer: A Rationale: A ventriculoperitoneal (VP) shunt—simply called a “shunt”—is a tube that extends from the ventricles (cavities) of the brain to the peritoneal cavity. VP shunts are used to drain excess fluid from the brain, thus preventing increased pressure within the skull.

Review 5. The purpose of a shunt is to:
minimize pressure within the skull. Rationale: Correct answer B. reroute blood away from the lungs. Rationale: The shunt is connected from the brain to the abdomen. C. instill food directly into the stomach. Rationale: The shunt drains excess cerebrospinal fluid from the brain. D. drain excess fluid from the peritoneum.

Review 6. A frantic mother calls EMS because the ventilator that her child is dependent upon is malfunctioning and she fears that it will stop working altogether. The EMT-B should: A. call for an ALS unit to perform endotracheal intubation on the child. B. detach the ventilator from the tube and ventilate the child with a bag-mask device. C. attempt to repair the ventilator and monitor the child for signs of increased hypoxia. D. remove the tracheostomy tube and provide assisted breathing with a pocket mask.

Review Answer: B Rationale: If a mechanical ventilator malfunctions, simply detach the ventilator from the tracheostomy tube, attach a bag-mask device to the tube, and resume ventilations. Do not attempt to “repair” the ventilator; there are many types of mechanical ventilators and most EMTs are not familiar with them. If the tracheostomy tube is severely obstructed despite suctioning, it may be necessary to remove the tube and ventilate over the stoma with a pocket mask. However, the issue here is with the ventilator, not the tracheostomy tube.

Review (1 of 2) 6. A frantic mother calls EMS because the ventilator that her child is dependent upon is malfunctioning and she fears that it will stop working altogether. The EMT-B should: call for an ALS unit to perform endotracheal intubation on the child. Rationale: This option may be necessary if assisted ventilations using a bag-mask are ineffective, which is not the case here. B. detach the ventilator from the tube and ventilate the child with a bag-mask device. Rationale: Correct answer

Review (2 of 2) 6. A frantic mother calls EMS because the ventilator that her child is dependent upon is malfunctioning and she fears that it will stop working altogether. The EMT-B should: C. attempt to repair the ventilator and monitor the child for signs of increased hypoxia. Rationale: Do not attempt to “repair” the ventilator. There are many types of mechanical ventilators and most EMTs are not familiar with all of them. D. remove the tracheostomy tube and provide assisted breathing with a pocket mask. Rationale: The problem is a ventilator malfunction — not a tracheostomy tube issue or obstruction.

Review 7. When assessing and monitoring an infant’s heart rate, it is important to remember that: A. as hypoxia worsens, the infant’s heart rate significantly increases. B. the heart rate is the primary compensatory mechanism against hypoxia. C. the infant’s heart rate can only reach a maximum of 170 beats/min. D. the primary site to assess the infant’s pulse is at the radial artery.

Review Answer: B Rationale: Infant’s and small children rely heavily on their heart rates to maintain adequate oxygenation and perfusion. As they are compensating, heart rates of 200 beats/min or higher are not uncommon. As hypoxia worsens, however, their heart rate will begin to fall; this is an ominous signs and indicates impending cardiopulmonary arrest. An infant’s heart rate should be assessed at the brachial artery.

Review 7. When assessing and monitoring an infant’s heart rate, it is important to remember that: as hypoxia worsens, the infant’s heart rate significantly increases. Rationale: Continued hypoxia will cause bradycardia. B. the heart rate is the primary compensatory mechanism against hypoxia. Rationale: Correct answer C. the infant’s heart rate can only reach a maximum of 170 beats/min. Rationale: Infant heart rates can exceed 200 beats/min. D. the primary site to assess the infant’s pulse is at the radial artery. Rationale: The primary site for palpating an infant’s pulse is the brachial artery (in the upper arm).

Review 8. Which of the following statements regarding febrile seizures is correct? A. Febrile seizures usually indicate a serious underlying condition, such as meningitis. B. Most febrile seizures occur in children between the ages of 2 months and 2 years of age C. Febrile seizures are rarely associated with tonic-clonic activity, but last for more than 15 minutes D. Febrile seizures usually last less than 15 minutes and often do not have a postictal phase

Review Answer: D Rationale: Febrile seizures are the most common seizures in children; they are common in children between the ages of 6 months and 6 years of age. Most pediatric seizures are due to fever alone—hence the name “febrile” seizure. However, seizures and fever may indicate a more serious underlying condition, such as meningitis. Febrile seizures are characterized by generalized tonic-clonic activity and last less than 15 minutes; if a postictal phase occurs, it is generally very short.

Review (1 of 2) 8. Which of the following statements regarding febrile seizures is correct? Febrile seizures usually indicate a serious underlying condition, such as meningitis. Rationale: Most febrile seizures are caused by fever, but a fever and seizures may be an indication of a serious underlying condition. B. Most febrile seizures occur in children between the ages of 2 months and 2 years of age Rationale: Most febrile seizures occur in children between the ages of 6 months and 6 years.

Review (2 of 2) 8. Which of the following statements regarding febrile seizures is correct? C. Febrile seizures are rarely associated with tonic-clonic activity, but last for more than 15 minutes Rationale: Febrile seizures last less than 15 minutes. D. Febrile seizures usually last less than 15 minutes and often do not have a postictal phase Rationale: Correct answer

Review 9. When a small child falls from a significant height, his or her ______ MOST often strikes the ground first. A. head B. back C. feet D. side

Review Answer: A Rationale: Compared to adults, children have proportionately larger heads. When they fall from a significant height, gravity usually takes them head first. This is why head trauma is the most common cause of traumatic death in children.

Review 9. When a small child falls from a significant height, his or her ______ MOST often strikes the ground first. Head Rationale: Correct answer B. Back Rationale: The head is heavier and gravity tends to tilt the head in a downward direction. C. Feet Rationale: Adults will attempt to land feet first. D. Side

Review 10. When using the mnemonic CHILD ABUSE to assess a child for signs of abuse, you should recall that the “D” stand for: A. delay in care. B. divorced parents. C. dirty appearance. D. disorganized speech.

Review Answer: A Rationale: The mnemonic CHILD ABUSE stands for Consistency of the injury with the child’s developmental age, History inconsistent with the injury, Inappropriate parental concerns, Lack of supervision, Delay in seeking care, Affect, Bruises of varying stages, Unusual injury patterns, Suspicious circumstances, and Environmental clues. A delay in care may happen when the parent or caregiver does not want the abuse noted by other people.

Review 10. When using the mnemonic CHILD ABUSE to assess a child for signs of abuse, you should recall that the “D” stand for: delay in care. Rationale: Correct answer B. divorced parents. Rationale: Divorce may put the child at greater risk, but does not indicate the child is being abused. C. dirty appearance. Rationale: This is something providers should be aware of. A potential for abuse exists, but this does not indicate that the child is being abused. D. disorganized speech. Rationale: This may indicate a learning disability or handicap.

31: Pediatric Emergencies

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