1. 32: Pediatric Assessment and Management

2. Cognitive Objectives (1 of 3)
6-1.4 Indicate various causes of respiratory emergencies.
6-1.5 Differentiate between respiratory distress and respiratory failure.
6-1.6 List steps in the management of foreign body airway obstruction.

3. Cognitive Objectives (2 of 3)
6-1.7 Summarize EMS care strategies for respiratory distress and respiratory failure.
6-1.8 Identify the signs and symptoms of shock (hypoperfusion) in the infant and child patient.
6-1.9 Describe the methods of determining end organ perfusion in the infant and child patient.
State the usual cause of cardiac arrest in infants and children versus adults.

4. Cognitive Objectives (3 of 3)
Describe the management of seizures in the infant and child patient.
Discuss the field management of the infant and child trauma patient.
• There are no affective objectives for this chapter.

5. Psychomotor Objectives (1 of 2)
Demonstrate the techniques of foreign body airway obstruction removal in the infant.
Demonstrate the techniques of foreign body airway obstruction removal in the child.
Demonstrate the assessment of the infant and child.

6. Psychomotor Objectives (2 of 2)
Demonstrate bag-valve-mask artificial ventilations for the infant.
Demonstrate bag-valve-mask artificial ventilations for the child.
Demonstrate oxygen delivery for the infant and child.

7. Additional Objectives*
Cognitive
1. Describe the steps in positioning an infant and/or child to maintain an open airway.
2. Summarize neonatal resuscitation procedures.
Affective
None
Psychomotor
3. Demonstrate the techniques necessary in neonatal resuscitation.
*These are noncurriculum objectives.

8. Pediatric Assessment and Management
Caring for sick and injured children presents special challenges.
EMT-Bs may find themselves anxious when dealing with critically ill or injured children.
Treatment is the same as that for adults in most emergency situations.

9. Take note of your surroundings.
Scene Size-up
Take note of your surroundings.
Scene assessment will supplement additional findings.
Observe:
Position of the patient
Condition of the home
Clues to child abuse

10. Begins before you touch the patient Form a general impression.
Initial Assessment
Begins before you touch the patient
Form a general impression.
Determine a chief complaint.
The Pediatric Assessment Triangle can help.

11. Pediatric Assessment Triangle
Appearance
Awake
Aware
Upright
Work of breathing
Retractions
Noises
Skin circulation

12. Assessing the ABCs Ensure airway is open and position patient.
Breathing assessment
Effort
Obstructions
Rate
Circulation assessment
Skin color, temperature, and capillary refill

13. Transport Decision
Children under 40 lb should be transported in a child safety seat, if the situation allows.
Seat should be secured to the cot or captain’s chair.
Cannot be secured to bench seat
Child may have to be transported without a seat, depending on condition.

14. Focused History and Physical Exam
Should be completed on scene unless severity requires rapid transport
Young children should be examined toe to head.
Focused exam on noncritical patients
Rapid exam on potentially critical patients

15. Vital Signs by Age Age Respirations (breaths/min) Pulse (beats/min)
Systolic Blood Pressure
(mm Hg)
Newborn: 0 to 1 mo
30 to 60
90 to 180
50 to 70
Infant: 1 mo to 1 yr
25 to 50
100 to 160
70 to 95
Toddler: 1 to 3 yr
20 to 30
90 to 150
80 to 100
Preschool age: 3 to 6 yr
20 to 25
80 to 140
School age: 6 to 12 yr
15 to 20
70 to 120
80 to 110
Adolescent: 12 to 18 yr
12 to 16
60 to 100
90 to 110
Older than 18 yr
12 to 20
90 to 140

16. Respirations
Abnormal respirations are a common sign of illness or injury.
Count respirations for 30 seconds.
In children less than 3 years, count the rise and fall of the abdomen.
Note effort of breathing.
Listen for noises.

17. Pulse In infants, feel over the brachial or femoral area.
In older children, use the carotid artery.
Count for at least 1 minute.
Note strength of the pulse.

18. Blood Pressure Use a cuff that covers two thirds of the upper arm.
If scene conditions make it difficult to measure blood pressure accurately, do not waste time trying.

19. Skin Signs Feel for temperature and moisture.
Estimate capillary refill.

20. Detailed Physical Exam and Ongoing Assessment
Status changes frequently in children.
The PAT can help with reassessment.
Repeat vital signs frequently.
If child deteriorates, repeat the initial assessment.

21. Care of the Pediatric Airway (1 of 2)
Position the airway.
Position the airway in a neutral sniffing position.
If spinal injury is suspected, use jaw-thrust maneuver to open the airway.

22. Care of the Pediatric Airway (2 of 2)
Positioning the airway:
Place the patient on a firm surface.
Fold a small towel under the patient’s shoulders and back.
Place tape across patient’s forehead to limit head rolling.

23. Oropharyngeal Airways
Determine the appropriately sized airway.
Place the airway next to the face to confirm correct size.
Position the airway.
Open the mouth.
Insert the airway until flange rests against lips.
Reassess airway.

24. Nasopharyngeal Airways (1 of 2)
Determine the appropriately sized airway.
Place the airway next to the face to make certain length is correct.
Position the airway.
Lubricate the airway.

25. Nasopharyngeal Airways (2 of 2)
Insert the tip into the right naris.
Carefully move the tip forward until the flange rests against the outside of the nostril.
Reassess the airway.

26. Assessing Ventilation
Observe chest rise in older children.
Observe abdominal rise and fall in younger children or infants.
Skin color indicates amount of oxygen getting to organs.

27. Oxygen Delivery Devices
Nonrebreathing mask at 10 to 15 L/min provides 90% oxygen concentration.
Blow-by technique at 6 L/min provides more than 21% oxygen concentration.
Nasal cannula at 1 to 6 L/min provides 24% to 44% oxygen concentration.

28. BVM Devices Equipment must be the right size.
BVM device at 10 to 15 L/min provides 90% oxygen concentration.
Ventilate at the proper rate and volume.
May be used by one or two rescuers

29. One-rescuer BVM VentilationD

30. Airway Obstruction Croup
A viral infection of the airway below the level of the vocal cords
Epiglottitis
Infection of the soft tissue in the area above the vocal cords
Foreign body airway obstructions

31. Signs and Symptoms Decreased or absent breath sounds Stridor
Retractions
Difficulty speaking

32. Signs of Severe Airway Obstruction
Signs and symptoms
Ineffective cough (no sound)
Inability to cry
Increasing respiratory difficulty, with stridor
Cyanosis
Loss of consciousness

33. Removing a Foreign Body Airway Obstruction (1 of 5)
In an unconscious child:
Place the child on a firm, flat surface.
Open airway using head tilt-chin lift maneuver.
Inspect the upper airway and remove any visible object.
Attempt rescue breathing.
If unsuccessful, reposition head and try again.
If ventilation is still unsuccessful begin CPR.

34. Removing a Foreign Body Airway Obstruction (2 of 5)
Place heel of one hand on lower half of sternum between the nipples.
Administer 30 chest compressions at a depth of 1/3 to 1/2 the depth of the chest.

35. Removing a Foreign Body Airway Obstruction (3 of 5)
Open airway using head tilt-chin lift maneuver. If you see the object, remove it.
Repeat process.

36. Removing a Foreign Body Airway Obstruction (4 of 5)
In a conscious child:
Kneel behind the child.
Give the child five abdominal thrusts.
Repeat the technique until object comes out.

37. Removing a Foreign Body Airway Obstruction (5 of 5)
If the child becomes unconscious, inspect the airway.
Attempt rescue breathing.
If airway remains obstructed, begin CPR.

38. Management of Airway Obstruction in Infants
Hold the infant facedown.
Deliver five back slaps.
Bring infant upright on the thigh.
Give five quick chest thrusts.
Check airway.
Repeat cycle as often as necessary.

39. Neonatal Resuscitation
Resuscitation measures include:
Positioning airway
Drying
Warming
Suctioning
Tactile stimulation

40. Neonatal Equipment

41. Additional Efforts Deliver chest compressions at 120 per minute.
Coordinate chest compressions with ventilations at a ratio of 3:1.
If meconium is present, suction infant vigorously.

42. BLS Review
Cardiac arrest in children is commonly due to respiratory arrest.
Many causes of respiratory arrest
For purposes of pediatric BLS:
Infancy ends at 1 year of age.
Childhood extends from 1 year of age to onset of puberty (12 to 14 years of age).

43. Determine Responsiveness
Gently tap on shoulder and speak loudly.
If responsive, place in position of comfort.
If you find an unresponsive child when you are not on duty:
Provide BLS for about 2 minutes.
Then call EMS system.

44. Airway Airway may be obstructed by tongue.
Use head tilt-chin lift technique or jaw-thrust maneuver to open the airway.
Jaw-thrust maneuver is safer if possibility of neck injury exists.

45. Breathing Look, listen, and feel. Provide rescue breathing if needed.
Perform Sellick maneuver to prevent gastric distention.

46. Circulation
Assess circulation after airway is open and two rescue breaths have been given.
Check for pulses.
Evaluate for other signs of circulation.
Take at least 5 seconds but not more than 10 seconds trying to find a pulse.
If infant or child is not breathing, the pulse is often too slow or absent. CPR will be required.

47. Infant CPR (1 of 2) Place infant on firm surface and maintain airway.
Place two fingers in the middle of the sternum.
Use two fingers to compress the chest 1/3 to 1/2 the depth of the chest at a rate of 100/min.

48. Infant CPR (2 of 2)
Allow sternum to return briefly to its normal position between compressions.
Coordinate rapid compressions and ventilations in a 30:2 ratio.
Reassess the infant for return of breathing and pulse after every 2 minutes of CPR.

49. Child CPR (1 of 2)
Place child on firm surface and maintain airway with one hand.
Place heel of other hand over lower half of the sternum.
Avoid the xiphoid process.
Compress chest 1/3 to 1/2 the depth of the chest at a rate of 100/min.

50. Child CPR (2 of 2)
Coordinate compressions with ventilations in a 30:2 ratio for one rescuer, 15:2 for two rescuers, pausing for ventilations.
Reassess for breathing and pulse after every 2 minutes of CPR.
If the child resumes effective breathing, place child in recovery position.

51. AED Use in Children (1 of 2)
Can be safely used in children older than 1 year of age
Use pediatric-sized pads and a dose-attenuating system for children 1-8 years old.
If not available, use adult AED.
AED is not indicated for use in infants less than 1 year of age.

52. AED Use in Children (2 of 2)
AED should be applied to children over 1 year of age after the first 2 minutes of CPR.
After 2 minutes of CPR, AED is used to deliver shocks in the same manner as with an adult patient.

53. Trauma (1 of 2)
© Jones and Bartlett Publishers. Courtesy of MIEMSS.
Extremity injuries in children are generally managed in the same manner as those in adults.

54. Trauma (2 of 2)
Be alert for airway problems on all children with traumatic injuries.
Give supplemental oxygen to all children with possible:
Head injuries
Chest injuries
Abdominal injuries
Shock
If ventilation is required, provide at 20 breaths/min.

55. Immobilization
Any child with a head or back injury should be immobilized.
Young children may need padding beneath their torso.
Children may need padding along the sides of the backboard.

56. Immobilization in a Child Safety Seat
Assess child for injuries and seat for visible damage.
If child is injured or seat is damaged, remove child to another transport device
Apply padding around child to minimize movement.
Move seat to ambulance and secure according to the manufacturer’s instructions.

57. Removing a Child from a Child Safety Seat
Remove both the child and the seat from the vehicle.
Place immobilization device behind the child.
Slide child into place on device.

58. Signs and Symptoms of Respiratory Emergencies
Nasal flaring
Grunting respirations
Use of accessory muscles
Retractions of rib cage
Tripod position in older children

59. Emergency Care
Provide supplemental oxygen in the most comfortable manner.
Place child in position of comfort.
This may be in caregiver’s lap.
If patient is in respiratory failure, begin assisted ventilation immediately.
Continue to provide supplemental oxygen.

60. Shock
Circulatory system is unable to deliver sufficient blood to organs.
Many different causes
Patients may have increased heart rate, respirations, and pale or mottled skin.
Children do not show decreased blood pressure until shock is severe.

61. Assessing Circulation
Pulse: Above 160 beats/min suggests shock
Skin signs: Assess temperature and moisture
Capillary refill: Is it delayed?
Color: Is skin pink, pale, ashen, or mottled?

62. Emergency Medical Care for Shock
Ensure airway.
Give supplemental oxygen.
Provide immediate transport.
Continue monitoring vital signs en route.
Contact ALS for backup as needed.

63. Seizures May present in several different ways
A postictal period of extreme fatigue or unresponsiveness usually follows seizure.
Be alert to presence of medications, poisons, and possible abuse.

64. Febrile Seizures
Febrile seizures are most common in children from 6 months to 6 years.
Febrile seizures are caused by fever.
Generally last less than 15 minutes
Assess ABCs and begin cooling measures.
Provide prompt transport.

65. Emergency Medical Care of Seizures (1 of 2)
Perform initial assessment, focusing on the ABCs.
Securing and protecting the airway is the priority.
Place patient in the recovery position.
Be ready to suction.

66. Emergency Medical Care of Seizures (2 of 2)
Deliver oxygen by mask, blow-by, or nasal cannula.
Begin BVM ventilation if no signs of improvement.
Call ALS for backup if appropriate.

67. Dehydration
Determine if child is vomiting or has diarrhea and for how long.
“How many wet diapers has the child had during the day?” (6 to 10 is normal)
“What fluids are the child taking?”
“What was the child’s weight before the symptoms started?”
“Has the child been normally active?”

68. Emergency Medical Care for Dehydration
Assess the ABCs.
Obtain baseline vital signs.
ALS backup may be needed for IV administration.