1. © 2011 National Safety Council 21-1 PEDIATRIC PATIENTS LESSON 21

2. © 2011 National Safety Council 21-2 Introduction 5-10% of emergency responses involve children Children maybe unable to tell you what happened Because parents, family members or caretakers are often frightened and worried, communication is particularly important Size and anatomical difference make care different

3. © 2011 National Safety Council 21-3 Interacting with Infants, Children and Caretakers Prevent anxiety and panic in child and caretakers Tell child your name Say you are there to help Be especially sensitive to child’s feelings Ensure a parent or caretaker has been called

4. © 2011 National Safety Council 21-4 Interacting with Infants, Children and Caretakers (continued) Stay at child’s level, be friendly and calm Observe child for clues about how best to be reassuring Young child may be comforted by favorite toy or touch Always be honest with child and caretakers Keep patient and caretakers informed

5. © 2011 National Safety Council 21-5 Interacting with Infants, Children and Caretakers (continued) Don’t separate child from caretaker Approach slowly from a safe distance Talk with both caretaker and child Observe child and caretaker before touching child Remain calm

6. © 2011 National Safety Council 21-6 Differences in Anatomy and Physiology Infants and children are not small adults Differences from adult anatomy and physiology in most body areas

7. © 2011 National Safety Council 21-7 Head and Neck Smaller airway easily blocked Tongue relatively larger, can easily block airway When opening airway, don’t hyperextend neck Pad beneath shoulders to prevent flexion of neck Suctioning secretions from nose can improve breathing problems Head of infant or young child relatively larger and heavier “Soft spots” (fontanels) put head at greater risk

8. © 2011 National Safety Council 21-8 Chest and Abdomen Children compensate for respiratory problems or shock for short periods Compensation followed by rapid decompensation Use of accessory muscles a clear sign of breathing problem Slow pulse rate generally indicates hypoxia

9. © 2011 National Safety Council 21-9 Chest and Abdomen (continued) More susceptible to hypothermia Blood loss may be fatal More easily dehydrated (diarrhea or vomiting) Internal injuries are more likely with trauma

10. © 2011 National Safety Council 21-10 Extremities Bones easily fractured by trauma

11. © 2011 National Safety Council 21-11 Assessing Infants and Children Assessment uses same steps as for adults Correct problems threatening airway, breathing or circulation as soon as found Assessment varies based on age and nature of problem Reassess continuously until emergency care is transferred

12. © 2011 National Safety Council 21-12 Scene Size-Up Begin by observing scene Note how child and caretakers interact Gather information from caretakers Observe the environment Note location and position in which patient is found

13. © 2011 National Safety Council 21-13 General Impression: Pediatric Triangle You can often tell how ill or severely injured child is from a distance in 15-30 seconds Remember 3 key elements:  Consider child’s general appearance  Assess child’s work of breathing  Assess skin color These observations also help assess child’s mental status

14. © 2011 National Safety Council 21-14 Assess Mental Status Quality of crying or speaking Emotional state Behavior Response to caretakers How attentive child is to you

15. © 2011 National Safety Council 21-15 Possible Causes of Abnormal Findings in Triangle Assessment Respiratory distress or failure Shock Cardiopulmonary failure or arrest Other abnormal conditions

16. © 2011 National Safety Council 21-16 Primary Assessment Primary assessment follows same steps as adult

17. © 2011 National Safety Council 21-17 Responsiveness, Breathing, Circulation

18. © 2011 National Safety Council 21-18 Responsiveness Responsive if purposively moving, crying or speaking, or coughing Unless obviously responsive, tap child on shoulder and shout, “Are you OK?” or flick foot of infant Unresponsiveness is potentially life-threatening condition  summon additional EMS resources If child is responsive, assess level using AVPU scale Assess pupil size, equality and reaction to light Check whether all extremities are moving equally

19. © 2011 National Safety Council 21-19 Breathing While assessing for responsiveness, look for normal breathing Child who can speak, cough or make other sounds is breathing and has heartbeat Reflex gasping (agonal respirations) is not normal breathing Lack of breathing may be caused by cardiac arrest, an obstructed airway or other causes If patient is not breathing normally, quickly check for pulse

20. © 2011 National Safety Council 21-20 Breathing (continued) If breathing, assess breathing adequacy:  Respiratory rate  Chest expansion and symmetry of movement

21. © 2011 National Safety Council 21-21 Breathing (continued) If breathing, assess breathing adequacy:  Effort of breathing: nasal flaring, retractions, grunting  Abnormal sounds: stridor, crowing

22. © 2011 National Safety Council 21-22 Circulation If not breathing, check pulse for <10 seconds Use femoral or carotid pulse in a child or brachial pulse in an infant If no pulse, start CPR and use AED

23. © 2011 National Safety Council 21-23 Circulation (continued) Assess pulse rate and strength Assess skin color, temperature and condition Reduced circulation indicated by: -Pale, ashen or cyanotic skin color -Cool, clammy skin -Capillary refill time ≥2 seconds Begin CPR if the pulse is less than 60 beats/minute Assess for signs of shock and treat

24. © 2011 National Safety Council 21-24 Check for Severe Bleeding Decompensation can occur quickly in an infant or child with blood loss Control external bleeding immediately with direct pressure

25. © 2011 National Safety Council 21-25 History Communicate at level with child Gather SAMPLE information from caretakers Pay particular attention to signs and symptoms and their duration: -Fever -Activity level -Recent eating and drinking and urine output -Vomiting, diarrhea or abdominal pain

26. © 2011 National Safety Council 21-26 Vital Signs Vital signs of infants and children are normally different from adults Changes may occur quickly in infants and children, especially with decompensation Falling blood pressure is a late sign of shock

27. © 2011 National Safety Council 21-27 Normal Vital Signs PatientNormal Respiratory Rate at Rest Normal Pulse Rate at Rest Normal Blood Pressure (systolic/diastolic) Infant30 - 40100 - 16070-100 / 56-70 Child20 - 3070 - 13070-120 / 50-80 Adult12 - 2060 - 100118-140 / 60-90

28. © 2011 National Safety Council 21-28 Physical Examination Maintain spinal immobilization in trauma or unresponsive patient Support head when moving infant Expose skin to look for injuries, but promptly cover child to prevent hypothermia; cover infant’s head Assess anterior fontanel on top of skull Examine from toe to head

29. © 2011 National Safety Council 21-29 Physical Examination (continued) Especially assess: The head for bruising or swelling The ears for drainage suggestive of trauma or infection The mouth for loose teeth, identifiable odors and bleeding The neck for abnormal bruising The chest and back for bruise, injuries and rashes Extremities for deformities, swelling and pain on movement

30. © 2011 National Safety Council 21-30 Airway Management Opening airway Suctioning Using airway adjuncts

31. © 2011 National Safety Council 21-31 Opening the Airway of Pediatric Patients Be careful not to hyperextend neck when using head tilt  chin lift to open airway of infant Put folded towel under back and shoulders for better positioning of airway Look inside mouth of an unresponsive infant for obstructing object Use jaw thrust technique for trauma patients Suction airway if needed

32. © 2011 National Safety Council 21-32 Suctioning Using gauze pad sweep mouth or suction Don’t insert tip of rigid catheter deeper than base of tongue For newborn, don’t suction longer than 3-5 seconds at a time With an older infant or child, don’t suction longer than 10 seconds at a time

33. © 2011 National Safety Council 21-33 Airway Adjuncts Use oral airway if no gag reflex Remove airway if child gags, coughs, etc. Oral airway not for initial ventilations Device keeps airway open Select proper size Nasal airways are not usually inserted in children by EMRs

34. © 2011 National Safety Council 21-34 Oral Airway Insertion Insert oral airway in upright position – do not rotate 180 degrees as for adult Open child’s mouth Use tongue blade to press base of tongue down Insert airway in upright (anatomic) position If tongue blade not available, use index finger to press base of tongue down

35. © 2011 National Safety Council 21-35 Respiratory Emergencies

36. © 2011 National Safety Council 21-36 Respiratory Emergencies Airway obstructions Respiratory distress and arrest Respiratory infections Asthma

37. © 2011 National Safety Council 21-37 Signs and Symptoms of Mild Airway Obstructions Infant or child is alert and sitting Hear stridor, crowing, noisy breathing Retractions on inspiration Skin pink with good peripheral perfusion Strong pulse

38. © 2011 National Safety Council 21-38 Emergency Care for Mild Airway Obstructions Allow child to assume position of comfort Assist a younger child to sit up, not lie down Do not agitate child Encourage continued coughing to dislodge object Follow local protocol for oxygen administration

39. © 2011 National Safety Council 21-39 Signs and Symptoms of Severe Airway Obstructions No crying or speaking Weak and ineffective cough Cyanosis Cough that becomes ineffective Increased respiratory difficulty and stridor Altered mental status; unresponsiveness

40. © 2011 National Safety Council 21-40 Emergency Care for Severe Airway Obstructions Attempt to clear airway (finger sweep and suctioning) Use alternating back blows (slaps) and chest compressions in responsive infant Use abdominal thrusts in responsive child Give CPR to unresponsive infant or child

41. © 2011 National Safety Council 21-41 Emergency Care for Severe Airway Obstructions (continued) Check for object in mouth before giving a breath Remove any object you see Never perform blind finger sweep Attempt artificial ventilations with mouth-to-mask technique

42. © 2011 National Safety Council 21-42 Respiratory Distress and Arrest Respiratory distress is difficulty breathing Respiratory distress frequently leads to respiratory arrest

43. © 2011 National Safety Council 21-43 Signs and Symptoms of Respiratory Distress Gasping, speaking in shortened sentences Respiratory rate 60 breaths/minute in infants  30-40 breaths/minute in children Nasal flaring Intercostal, supraclavicular, subcostal retractions Stridor, grunting or noisy breathing Cyanosis, or pale or ashen skin Altered mental status

44. © 2011 National Safety Council 21-44 Emergency Care for Respiratory Distress Perform standard patient care Allow child to assume position of comfort Ensure appropriate position of head and neck Follow local protocol for oxygen administration

45. © 2011 National Safety Council 21-45 Blow-by Oxygen Responsive infant or child may resist mask on face Use blow-by oxygen delivery technique Have caretaker hold mask about 2 inches from face

46. © 2011 National Safety Council 21-46 Signs and Symptoms of Respiratory Arrest Breathing rate: -<20 breaths/minute in an infant -<10 breaths/minute in a child Limp muscle tone Unresponsiveness Slow or absent pulse Weak or absent distal pulses Cyanosis

47. © 2011 National Safety Council 21-47 Emergency Care for Respiratory Arrest Perform standard patient care Provide ventilations by mouth or mask Follow local protocol for oxygen administration Monitor pulse and provide CPR if needed

48. © 2011 National Safety Council 21-48 Respiratory Infections Common in childhood Range from minor to life threatening May affect upper or lower airways Result from infection, foreign bodies, allergic conditions

49. © 2011 National Safety Council 21-49 Signs and Symptoms of Respiratory Problems Rapid breathing Noisy breathing Retractions Mental status changes

50. © 2011 National Safety Council 21-50 Croup Viral infection of upper/lower airway More frequently occurs in winter months and in evening More common in younger children Often preceded by being ill 1-2 days with or without fever Generally not life-threatening

51. © 2011 National Safety Council 21-51 Signs and Symptoms of Croup Hoarseness Stridor “Barking” cough Difficulty breathing

52. © 2011 National Safety Council 21-52 Emergency Care for Croup Perform standard patient care Difficult to distinguish from life-threatening epiglottitis If croup persistent, child should see physician Give care for respiratory distress Follow local protocol for humidified oxygen

53. © 2011 National Safety Council 21-53 Epiglottitis Rare, life-threatening infection of epiglottis Epiglottis swells and airway completely obstructed Occurs more frequently in children older than 4

54. © 2011 National Safety Council 21-54 Signs and Symptoms of Epiglottitis Child appears ill and frightened High fever Child is sitting up to breathe Saliva may drool from the child’s mouth

55. © 2011 National Safety Council 21-55 Emergency Care for Epiglottitis Perform standard patient care Don’t examine mouth or place OPA Allow child to remain in comfortable position Give care for respiratory distress Follow local protocol for oxygen administration Ensure immediate transport

56. © 2011 National Safety Council 21-56 Bronchiolitis Common cause of respiratory distress in young children Also called respiratory syncytial virus Viral infection of smaller airways causing respiratory distress and occasional hypoxia

57. © 2011 National Safety Council 21-57 Signs and Symptoms of Bronchiolitis Fever Nasal congestion Increased work of breathing with retractions and use of accessory muscles Markedly abnormal lung sounds with crackles and wheezes together May be cyanotic

58. © 2011 National Safety Council 21-58 Emergency Care for Bronchiolitis Perform standard patient care Give care for respiratory distress Follow local protocol for humidified oxygen If patient has asthma medication inhaler, follow local protocol

59. © 2011 National Safety Council 21-59 Asthma Common medical problem in children Causes periodic attacks of difficulty breathing Results from an abnormal spasm of lower airways Attacks range from minor to life threatening

60. © 2011 National Safety Council 21-60 Signs and Symptoms of Asthma Attack Difficulty breathing, rapid irregular breathing Coughing, wheezing Exhaustion In severe attack: - Altered mental status - Cyanosis

61. © 2011 National Safety Council 21-61 Emergency Care for Asthma Attack Perform standard patient care Give care for respiratory distress Follow local protocol for humidified oxygen If patient has asthma medication inhaler, follow local protocol to assist

62. © 2011 National Safety Council 21-62 Shock

63. © 2011 National Safety Council 21-63 Shock Commonly occurs from bleeding, traumatic injury, and fluid loss from prolonged vomiting or diarrhea May occur rapidly in infants and quickly become life-threatening May be delayed in children  who then suddenly decompensate Common cause of cardiac arrest in infants and children

64. © 2011 National Safety Council 21-64 Signs and Symptoms of Shock Rapid (early) or slow (late) weak pulse or absent pulse Unequal central and peripheral pulses Poor skin perfusion, delayed capillary refill Cool, clammy, pale skin Rapid respiratory rate (early shock) Altered mental status

65. © 2011 National Safety Council 21-65 Emergency Care for Shock Perform standard patient care Control any bleeding Follow local protocol for oxygen administration Monitor pulse carefully and provide CPR if needed Raise legs if spinal or traumatic injury is not suspected Keep patient warm but not overheated Monitor vital signs frequently while awaiting EMS

66. © 2011 National Safety Council 21-66 Seizures

67. © 2011 National Safety Council 21-67 Causes of Seizures High fever Epilepsy Infections Head injuries Poisoning Low oxygen levels Low blood sugar Other causes

68. © 2011 National Safety Council 21-68 Seizures Potentially life-threatening You don’t need to know cause to give care Febrile seizures common in children <5 years Most will be over by the time you arrive at scene After a seizure (except a febrile seizure), child appears sleepy and confused

69. © 2011 National Safety Council 21-69 Assessing Seizures Perform standard assessment Assess for injuries that may occur Gather the history from caretakers: -Has child had prior seizure(s)? -Is this child’s usual seizure pattern? How long did it last? -Does child take seizure medication? -Could child have ingested any other medication or potential toxins?

70. © 2011 National Safety Council 21-70 Signs and Symptoms of Seizures Altered mental status Muscle twitching, convulsions, rigid extremities May be brief or prolonged Loss of bowel and bladder control

71. © 2011 National Safety Council 21-71 Emergency Care for Seizures Perform standard patient care Place patient on floor and protect patient from environment Loosen any constricting clothing, remove eyeglasses Ask bystanders (except caretakers) to leave Ensure airway remains open Never restrain patient Don’t put anything in mouth

72. © 2011 National Safety Council 21-72 Emergency Care for Seizures (continued) If patient is bluish, ensure airway is open and give ventilations After seizure, place an unresponsive patient in recovery position Be prepared to suction to maintain airway Follow local protocol for oxygen administration Report assessment findings to additional EMS personnel

73. © 2011 National Safety Council 21-73 Altered Mental Status

74. © 2011 National Safety Council 21-74 Causes of Altered Mental Status Low blood sugar Poisoning Seizures Infection Head trauma Any condition that causes decreased oxygen levels

75. © 2011 National Safety Council 21-75 Assessing Altered Mental Status Perform standard assessment Ask caretakers about any history of diabetes, seizures or recent trauma Monitor patient’s vital signs

76. © 2011 National Safety Council 21-76 Signs and Symptoms of Altered Mental Status in an Infant or Child Drowsiness Confusion, agitation Behavior described as unusual by caretakers

77. © 2011 National Safety Council 21-77 Emergency Care for Altered Mental Status Perform standard patient care Place unresponsive patient in recovery position (if no trauma suspected) Follow local protocol for oxygen administration

78. © 2011 National Safety Council 21-78 Sudden Infant Death Syndrome

79. © 2011 National Safety Council 21-79 Sudden Infant Death Syndrome Sudden Infant Death Syndrome (SIDS) is the unexpected, sudden death of a normal, healthy infant during sleep Causes not well understood Leading cause of death between 1 week and 1 year of age in United States Peak incidence occurs at 2-4 months of age

80. © 2011 National Safety Council 21-80 Sudden Infant Death Syndrome (continued) More common during winter months and in males Not due to external suffocation from blankets or pillows Not related to child abuse or vomiting and aspiration of stomach contents

81. © 2011 National Safety Council 21-81 Assessing SIDS Perform standard assessment Complete primary assessment and care for life-threatening conditions If infant is still alive, take history and perform secondary assessment In addition, ask caretakers about circumstances: -When was infant put to bed? -When was infant last seen? -What position was infant in when found? -How did infant look when found? -Was there anything unusual in environment? -Infant’s general health recently?

82. © 2011 National Safety Council 21-82 Signs and Symptoms of SIDS Cardiac and respiratory arrest Skin cyanotic or mottled Most commonly discovered in early morning

83. © 2011 National Safety Council 21-83 Emergency Care for SIDS Perform standard patient care Take body substance isolation precautions Try to resuscitate infant unless the body is stiff Lividity is normal, not sign of abuse Comfort, calm and reassure caretakers Avoid any comments that might suggest blame to caretakers

84. © 2011 National Safety Council 21-84 Trauma

85. © 2011 National Safety Council 21-85 Trauma Common emergency in childhood Leading cause of death in children Blunt trauma causes the most injuries Pattern of injury may be different from that in adults

86. © 2011 National Safety Council 21-86 Common Causes of Trauma Motor vehicle crashes -Unrestrained infants and children have head/neck injuries -Restrained infants and children have abdominal and lower spine injuries -Infant and booster seats often improperly fastened

87. © 2011 National Safety Council 21-87 Common Causes of Trauma (continued) Being struck by a vehicle while riding a bicycle Being struck by a vehicle while walking Falls from a height or diving into shallow water Burns Sports injuries to head and neck Child abuse and neglect

88. © 2011 National Safety Council 21-88 Common Types of Injury Anatomical differences make certain types of injury more likely Head injuries Abdominal injuries Extremity injuries Burns

89. © 2011 National Safety Council 21-89 Assessing Trauma Perform standard assessment Examine responsive child from toe to head Suspect certain types of injuries based on MOI Smaller amounts of blood loss can result in shock; signs of shock may occur later

90. © 2011 National Safety Council 21-90 Emergency Care for Trauma Perform standard patient care Use jaw thrust to open airway -Use head tilt–chin lift if unsuccessful Suction airway as needed Manually stabilize head and neck

91. © 2011 National Safety Council 21-91 Emergency Care for Trauma (continued) Manually stabilize extremity injuries Treat shock Maintain normal body temperature (hypothermia more likely in shock in children) Follow local protocol for oxygen administration Ensure transport as soon as possible

92. © 2011 National Safety Council 21-92 Child Abuse and Neglect

93. © 2011 National Safety Council 21-93 Suspected Child Abuse and Neglect Abuse: an intentional improper and excessive action injuring or causing harm May include psychological or emotional abuse and sexual abuse Neglect: failing to provide basic needs

94. © 2011 National Safety Council 21-94 Who is Abused? Any child, although some are more likely to be abused Child abuser can come from any geographic, religious, ethnic, occupational, educational or socioeconomic group Abuser is usually a caretaker or someone in role of parent Most abusers of children were themselves abused as children

95. © 2011 National Safety Council 21-95 Signs and Symptoms of Abuse Multiple bruises or burns in various stages of healing Injury inconsistent with MOI described by caretakers Bite marks

96. © 2011 National Safety Council 21-96 Signs and Symptoms of Abuse (continued) Suspicious patterns of injury or marks on skin: -Cigarette burns -Whip marks -Hand prints -Injuries to genitals, inner thighs or buttocks -Rope burns

97. © 2011 National Safety Council 21-97 Signs and Symptoms of Abuse (continued) Repeated calls to same address Unusual burns -Scalding -A glove or dip pattern -Burns inconsistent with history presented -Untreated burns Caretakers inappropriately unconcerned Caretakers with uncontrollable anger

98. © 2011 National Safety Council 21-98 Signs and Symptoms of Abuse (continued) Conflicting stories Child fearful to discuss how injury occurred Child’s obvious fear of caretaker Obvious or suspected fractures in child younger than 2 More injuries than are usually seen at same age Injuries scattered on many areas of the body

99. © 2011 National Safety Council 21-99 Signs and Symptoms of Neglect Lack of adult supervision Child appears malnourished Clothing inappropriate for environment Unsafe living environment Signs of drug or alcohol abuse Untreated chronic illness (asthmatic with no medications) Untreated soft-tissue injuries Delayed call for help

100. © 2011 National Safety Council 21-100 Assessing Suspected Abuse or Neglect Perform standard assessment Obtain as much information as possible Document all information on patient report

101. © 2011 National Safety Council 21-101 Emergency Care When Abuse is Suspected Perform standard patient care Don’t accuse caretakers in the field Treat patient’s injuries appropriately Protect child from further abuse, if necessary Report objective information to EMS unit

102. © 2011 National Safety Council 21-102 Emergency Care When Abuse is Suspected (continued) Save evidence of physical or sexual abuse File a report as required by state law and local protocol: -Remain objective -Report what you see and hear -Do not comment on what you think Maintain confidentiality about the call

103. © 2011 National Safety Council 21-103 Shaken Baby Syndrome Pattern of injury resulting when caretaker shakes infant Also occurs in young children Infant may have severe internal injuries, including brain or spinal injuries Infant may be unresponsive or experiencing seizures

104. © 2011 National Safety Council 21-104 Emergency Care for Shaken Baby Syndrome Perform standard patient care Manually stabilize the head and neck Follow local protocol for oxygen administration Ensure transport as soon as possible

105. © 2011 National Safety Council 21-105 Emergency Medical Responder Stress Death or serious injury can cause strong emotional reactions and stress Stress is likely in instances of serious child abuse or neglect Providing care while family members or caretakers are very emotional is stressful

106. © 2011 National Safety Council 21-106 Emergency Medical Responder Stress (continued) Don’t react personally to others’ emotions or behavior Realize that many patients may die regardless of care provided Talk with family and friends Seek professional help CISM programs are available