2Cognitive 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.
3Cognitive Objectives (2 of 3) 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.
4Cognitive Objectives (3 of 3) 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.
5Affective ObjectivesExplain 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.
6Airway Differences Larger tongue relative to the mouth Larger epiglottisLess well-developed rings of cartilage in the tracheaNarrower, lower airway
7Breathing Differences Infants breathe faster than children or adults.Infants use the diaphragm when they breathe.Sustained, labored breathing may lead to respiratory failure.
8Circulation 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.
9Skeletal 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.
10Growth and Development Thoughts and behaviors of children usually grouped into stagesInfancyToddler yearsPreschool ageSchool ageAdolescence
11Infant 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.
12Toddler1 to 3 years of ageThey 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.
13Preschool 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.
14School 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.
15Adolescent 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.
16Family MattersWhen 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.
17Pediatric Emergencies (1 of 3) DehydrationVomiting and diarrheaGreater risk than adultsFeverRarely life threateningCaution if occurring with rash
18Pediatric Emergencies (2 of 3) Meningitis is an inflammation of the tissue that covers the spinal cord and brain.Caused by an infectionIf left untreated can lead to brain damage or death.
19Pediatric Emergencies (3 of 3) Febrile seizuresCommon between 6 months and 6 yearsLast less than 15 minutesPoisoningSigns and symptoms vary widely.Determine what substances were involved.
20Physical DifferencesChildren 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.
21Psychological Differences Children are not as psychologically mature.They are often injured due to their undeveloped judgment and lack of experience.
22Injury 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.
23Injury 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.
24Head Injuries Common injury among children The head is larger in proportion to an adult.Nausea and vomiting are signs of pediatric head injury.
25Chest InjuriesMost 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.
26Abdominal 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 pulseCold, clammy skinPoor capillary refill
27Injuries 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.
28Pneumatic Antishock Garments (PASG) Rarely used for treating childrenWhen to use a PASG:Obvious lower extremity traumaPelvic instabilityClear signs and symptoms of decompensated shockShould only be used if it fits properlyShould never inflate the abdominal compartment
29Burns 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.
30Submersion Injury Drowning or near drowning Second most common cause of unintentional death of children in the United StatesAssessment and reassessment of ABCs are critical.Consider the need for C-spine protection.
31Child AbuseChild 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.
33Questions 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?
34Questions Regarding Signs of Abuse (2 of 4) 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?
35Questions Regarding Signs of Abuse (3 of 4) 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?
36Questions Regarding Signs of Abuse (4 of 4) 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?
37Emergency 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.
38Sexual 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.
39Sudden Infant Death Syndrome (SIDS) Several known risk factors:Mother younger than 20 years oldMother smoked during pregnancyLow birth weight
40Tasks at Scene Assess and manage the patient. Communicate with and support the family.Assess the scene.
41Assessment 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.
42Communication 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.
43Scene AssessmentCarefully inspect the environment, following local protocols.Concentrate on:Signs of illnessGeneral condition of the houseFamily interactionSite where infant was discovered
44Apparent Life-Threatening Event Infant found not breathing, cyanotic, and unresponsive but resumes breathing with stimulationComplete careful assessment.Transport immediately.Pay strict attention to airway management.
45Death 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.
46Death 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.
47Children With Special Needs Children born prematurely who have associated lung problemsSmall children or infants with congenital heart diseaseChildren with neurologic diseasesChildren with chronic diseases or with functions that have been altered since birth
49Artificial 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.
51Gastrostomy Tubes Food can back up the esophagus into the lungs. Have suction readily available.Give supplemental oxygen if the patient has difficulty breathing.
52Shunts 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.
53Review How does a child’s anatomy differ from an adult’s anatomy? A. The child’s trachea is more rigidB. The tongue is proportionately smallerC. The epiglottis is less floppy in a childD. The child’s head is proportionately larger
54ReviewAnswer: DRationale: 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.
55Review How does a child’s anatomy differ from an adult’s anatomy? The child’s trachea is more rigidRationale: A child’s trachea is less rigid, narrower, and more anterior than an adult’s.B. The tongue is proportionately smallerRationale: A child’s tongue is proportionally larger than an adult’s.C. The epiglottis is less floppy in a childRationale: A child’s epiglottis is floppier and shaped differently than an adult’s.D. The child’s head is proportionately largerRationale: Correct answer
56Review2. 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.
57ReviewAnswer: BRationale: 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.
58Review2. 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 answerC. 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.
59Review3. 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.
60ReviewAnswer: ARationale: 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.
61Review (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 answerB. 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.
62Review (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.
63Review4. Which of the following indicators of perfusion is more reliable in small children than in adults?A. Skin colorB. Heart rateC. Capillary refillD. Respiratory rate
64ReviewAnswer: CRationale: 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.
65Review4. Which of the following indicators of perfusion is more reliable in small children than in adults?Skin colorRationale: Skin color may indicate hypoxia, hyperthermia, hypothermia, jaundice, and possibly shock.B. Heart rateRationale: Heart rate changes are a compensatory mechanism and can be due to hypoxia, shock, etc.C. Capillary refillRationale: Correct answerD. Respiratory rateRationale: Respiratory rates are driven by hypoxia and the need to increase the concentration of oxygen in the blood.
66Review 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.
67ReviewAnswer: ARationale: 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.
68Review 5. The purpose of a shunt is to: minimize pressure within the skull.Rationale: Correct answerB. 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.
69Review6. 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.
70ReviewAnswer: BRationale: 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.
71Review (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
72Review (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.
73Review7. 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.
74ReviewAnswer: BRationale: 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.
75Review7. 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 answerC. 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).
76Review8. 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 ageC. Febrile seizures are rarely associated with tonic-clonic activity, but last for more than 15 minutesD. Febrile seizures usually last less than 15 minutes and often do not have a postictal phase
77ReviewAnswer: DRationale: 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.
78Review (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 ageRationale: Most febrile seizures occur in children between the ages of 6 months and 6 years.
79Review (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 minutesRationale: Febrile seizures last less than 15 minutes.D. Febrile seizures usually last less than 15 minutes and often do not have a postictal phaseRationale: Correct answer
80Review9. When a small child falls from a significant height, his or her ______ MOST often strikes the ground first.A. headB. backC. feetD. side
81ReviewAnswer: ARationale: 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.
82Review9. When a small child falls from a significant height, his or her ______ MOST often strikes the ground first.HeadRationale: Correct answerB. BackRationale: The head is heavier and gravity tends to tilt the head in a downward direction.C. FeetRationale: Adults will attempt to land feet first.D. Side
83Review10. 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.
84ReviewAnswer: ARationale: 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.
85Review10. 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 answerB. 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.