1. Silver Cross EMS System July 2011 2 nd Trimester CME PEDIATRICS “Things to know, appreciate and think about when caring for kids” Presenter: Leslie Livett RN MS Provena Saint Joseph Medical Center

2. Objectives Differentiate anatomic and physiologic differences in children vs. adults Describe how to systematically access a pediatric patient Identify general treatment techniques specific to pediatric patients and their families Describe the assessment and emergency management of specific illnesses and injuries

3. Illness and Injury Prevention Pediatric chain of survival – To assess, support, restore effective ventilation and circulation to child in respiratory arrest Prevention of illness/injury Early CPR Early EMS activation Early, effective advanced life support

4. APPROACH TO PEDIATRIC ASSESSMENT Prioritize! Find and treat the life threats Initiate interventions for non life threatening conditions Management depends on appropriate triage and assessment

5. Anatomic and Physiological Considerations Trachea Chest wall Intercostal muscles Decreased oxygen reserves Increased risk of head injury Higher incidence of multiple organ failure Breath sounds Prone to temperature extremes Larger body surface area Pliabilty of bones Less protection of abdominal organs Circulating blood volume

6. Developmental Challenges Understanding the differences and developmental stages leads to better triage/treatment decisions

7. Less than 1 year Homicide leading cause of all injury deaths (intentional and unintentional) For unintentional injuries causing death, suffocation leads the list Most common age for child abuse

8. Toddlers and Preschoolers (1-4 years) – I’ll Do it myself School Age (5-9years) – Injury and death due to motor vehicle/occupant, motor vehicle/pedestrian, fires and burns,drowning and homicides Middle School Age/Preadolescent (10- 14 years) – Risk takers/invincibility – Injury and death due to motor vehicle/occupant, motor vehicle/pedestrian, homicide, drowning, motorcycle/moped, bike, unintentional firearms.

9. Adolescents – Invincibility, hormonal changes – Deaths due to motor vehicle/occupant, homicide, suicide, drowning pedestrian, motorcycle or moped, ATV, followed by unintentional firearm injuries

10. Assessment of the Ill/Injured Child Initial assessment – First impression Younger children need different approach than older children Pediatric assessment triangle (PAT)

11. Assessment of the Ill/Injured Child Pediatric Assessment Triangle

12. Assessment of the Ill/Injured Child Physical examination – Urgent problems, provide initial care for life-threatening conditions, rapid transport

13. – ABC’s----- The Pediatric Way » Assessment and resuscitation are the same as with adults!

14. PRIMARY SURVEY Airway – Inspection – Position – Signs/ Symptoms partial airway obstruction – Management – Non invasive access options – Intubation

15. BREATHING Assess ventilations Listen to breath sounds Causes and treatment – Hypoventilation Management

16. CIRCULATION CV assessment – Heart rate – Pulses Capillary refill/ peripheral pulses – Blood pressure – IV/IO Indirect CV assessment – End organ perfusion Hemorrhage Management

17. DISABILITY Unique considerations – Fontanelles/cranial sutures – Response to the environment Assessment – AVPU – GCS – Consistency is key

18. EXPOSURE Management

19. SECONDARY SURVEY History – Purpose – Historians – SAMPLE Vital Signs – Pulse – Blood pressure

20. Assessment of the Ill/Injured Child Reassessment – Continually monitor Respiratory effort Color Mental status Pulse oximetry Vital signs

21. Specific Pathophysiology, Assessment, and Management – Croup Description and definition – Viral respiratory infection, affects upper respiratory tract – Below glottis most common – Swollen, inflamed mucosa – Hoarseness, inspiratory stridor, barking cough

22. Specific Pathophysiology, Assessment, and Management Croup Epidemiology and demographics – Most common cause of upper airway obstruction in pediatrics – Affects children 6 months to 6 years, peaks at age 2 – Parainfluenza viruses most often in fall, RSV in midwinter, spring – Person-to-person spread – 2- to 4-day incubation period

23. Specific Pathophysiology, Assessment, and Management – Croup History – Upper respiratory infection 2-3 days/spasmodic – Night Physical examination – Increased respiratory rate, elevated temperature – Loud stridor, hoarse voice, barking cough – Nasal flaring – Retractions

24. Specific Pathophysiology, Assessment, and Management – Croup Therapeutic intervention – Keep warm, comfortable – Assess for FBAO via history only – O 2 saturation above 95% – Nebulized saline per medical direction – Respiratory failure, arrest

25. Specific Pathophysiology, Assessment, and Management Respiratory compromise – Epiglottis Description and definition – Bacterial infection of upper airway – Complete airway obstruction, death within hours – History, observe from distance

26. Specific Pathophysiology, Assessment, and Management

27. Respiratory compromise – Epiglottis Epidemiology and demographics – 3-7 years old – Decreased from HiB virus in children – Adolescents, adults increasing – No seasonal preference

28. Specific Pathophysiology, Assessment, and Management – Epiglottis Physical examination – Acutely ill appearance – Prefer sitting up, leaning forward, mouth open – Difficulty swallowing, sore throat, drooling – Muffled voice – Shallow breathing – Stridor late, near-complete airway obstruction – Increased respirations, pulse, temp

29. Specific Pathophysiology, Assessment, and Management – Epiglottis Therapeutic intervention – Close observation, frequent reassessment – Position of comfort – Do not examine oropharynx – Do not administer anything by mouth – Administer high concentration O 2 – Assist breathing with 100% O 2 – Total obstruction, ventilate with high pressure

30. Specific Pathophysiology, Assessment, and Management

31. – Asthma and reactive airway disease Description and definition – Reversible obstructive airway disease – Chronic inflammation – Hyperreactive airways – Bronchospasm episodes

32. Specific Pathophysiology, Assessment, and Management – Asthma and reactive airway disease Etiology – Triggered by allergen, air pollution, exercise, cold air, infection – Both larger and smaller airways – Ineffective ventilation, hypoxemia – Air trapping, inadequate ventilation, hypoxemia, hypercapnia, respiratory acidosis

33. Specific Pathophysiology, Assessment, and Management – Asthma and reactive airway disease Risk factors – Personal, family history – Passive cigarette smoke – Male gender – Maternal history – Viral respiratory infection – Smaller airways in early life – Low birth weight

34. Specific Pathophysiology, Assessment, and Management – Asthma and reactive airway disease History – Recurrent respiratory symptoms – Exercise – Viral infections – House dust mites, molds, smoke, pollen – Weather changes – Strong emotional depression – Airborne chemicals

35. Specific Pathophysiology, Assessment, and Management – Asthma and reactive airway disease Signs/symptoms – Wheezing – Dry cough – Chest tightness, shortness of breath – Retractions – Tachypnea – Poor air entry – Prolonged expiratory phase

36. Specific Pathophysiology, Assessment, and Management – Asthma and reactive airway disease Therapeutic intervention – Position of comfort – O 2, saturation >95% – Assist with bag-mask at 100% O 2 – Cardiac monitor – Bronchodilators – Epinephrine – ET intubation

38. Specific Pathophysiology, Assessment, and Management Shock – Perfusion Circulation of blood through organ, part of body Delivers O 2, nutrients to cells Removes waste products Inadequate circulation of blood through organ

39. Specific Pathophysiology, Assessment, and Management – Initially subtle signs Compensated shock signs/symptoms – Irritability/anxiety – Tachycardia, tachypnea – Weak peripheral pulses, full central pulses – Delayed capillary refill – Cool, pale extremities – Systolic BP within normal limits – Decreased urinary output

40. Specific Pathophysiology, Assessment, and Management Decompensated shock signs/symptoms – Lethargy, altered mental status – Marked tachycardia/bradycardia – Absent peripheral pulses, weak central pulses – Markedly delayed capillary refill – Cool, pale, dusky, mottled extremities – Hypotension – Markedly decreased urinary output – Cardiac arrest imminent

41. Specific Pathophysiology, Assessment, and Management – Shock severity Hypotension – Differentiates compensated from decompensated – Late sign of cardiac compromise

42. Specific Pathophysiology, Assessment, and Management Shock – Hypovolemic shock Small blood volume, hemodynamic compromise Loss of blood, plasma, fluids, electrolytes, endocrine disorders Major blood loss causes

43. Specific Pathophysiology, Assessment, and Management Shock – Hypovolemic shock Signs/symptoms – Compensated, decompensated shock – Internal, external bleeding – Poor skin turgor – Decreased saliva/tears – Sunken fontanelle

44. Specific Pathophysiology, Assessment, and Management Shock – Hypovolemic shock Therapeutic interventions – Trauma suspected, cervical spine stabilization – Open airway with jaw thrust without head tilt – O 2 – Effective oxygenation, breathing – Pulse oximeter – O 2 saturation >95%

45. Specific Pathophysiology, Assessment, and Management – Hypovolemic shock Therapeutic interventions – Absent pulse/circulation, chest compressions – Cardiac monitor – IV access/IO access – Isotonic crystalloid bolus, 20 mL/kg per medical direction – Check glucose level – Maintain normal body temperature

46. Specific Pathophysiology, Assessment, and Management – Hypovolemic shock Anaphylactic shock – Substance exposure previously sensitized – Histamine released – Signs/symptoms – Causes – O 2, effective ventilation, oxygenation – Pulse oximeter – Saturation >95% – Absent pulse, heart rate <60 beats/min

47. Specific Pathophysiology, Assessment, and Management – Hypovolemic shock Anaphylactic shock – Cardiac monitor – Epinephrine intramuscularly/subcutaneously per medical direction – Bronchodilator, antihistamine, steroid – Vascular access – Monitor for work of breathing, crackles – Glucose level

48. Specific Pathophysiology, Assessment, and Management Hypovolemic shock Neurogenic shock – Cardiac monitor – IV, IO needle if necessary – 20-mL/kg fluid per medical direction – Monitor work of breathing, crackles – Maintain normal body temperature – Hypothermia – Glucose level

51. Specific Pathophysiology, Assessment, and Management Seizures – Altered mental status Causes – Hypoxia – Head trauma – Seizures – infection – Hypoglycemia – Drug/alcohol ingestion

52. Specific Pathophysiology, Assessment, and Management Seizures – Temporary change in behavior/consciousness, abnormal electrical activity – Partial seizures Simple Complex Generalized

53. Specific Pathophysiology, Assessment, and Management Seizures – Status epilepticus Repeated seizures without full recovery of responsiveness between seizures Life threatening Febrile seizure

54. Specific Pathophysiology, Assessment, and Management Seizures – Causes Head trauma Toxins Hypoxia Fever Hypoglycemia Infection Metabolic disorders Brain tumor/abscess Vascular disorders Cardiac dysrhythmias Genetic, hereditary factors

56. Specific Pathophysiology, Assessment, and Management Hypoglycemia – Description and definition Metabolically stressed Prolonged, irreversible brain damage Alcohol intoxication – Etiology Too much insulin, not eaten, overexercised, physical/emotional stress

57. Specific Pathophysiology, Assessment, and Management Hypoglycemia Signs/symptoms – Normal/decreased responsiveness, pale, diaphoretic – Normal/increased breath rate – Tachycardia, normal/delayed capillary refill, cool/pale/clammy skin – Rapid onset, headache – Normal breath odor, tremors, staring, inability to concentrate, uncoordination, irritability

58. Specific Pathophysiology, Assessment, and Management Hypoglycemia – Therapeutic intervention ABCs IV access Dextrose, glucagon per medical direction Recheck vital signs often Recheck blood glucose level 10 minutes after therapy

59. Specific Pathophysiology, Assessment, and Management Hyperglycemia – Description and definition Excess glucose in blood Dehydration, ketoacidosis – Etiology Blood glucose level too high Not enough insulin Eaten too much Emotional stress

60. Specific Pathophysiology, Assessment, and Management Hyperglycemia – Epidemiology and demographics Excessive food intake containing sugar Insufficient insulin dosage Infection, surgery, emotional stress Polydipsia, polyuria, polyphagia

61. Specific Pathophysiology, Assessment, and Management Hyperglycemia – Physical examination Slight respiratory rate increase Kussmaul respirations Tachycardia BP decrease Poor skin turgor, dry mucous membrane, sunken fontanelle Abdominal tenderness, distention

62. Specific Pathophysiology, Assessment, and Management Hyperglycemia Therapeutic intervention Open airway, suction, O 2 Cardiac monitor, pulse oximeter Check glucose level Dehydration, IV access, 20-mL/kg bolus normal saline per medical direction

63. Specific Pathophysiology, Assessment, and Management Meningitis – Description and definition Inflammation of meninges Infection spread quickly Brain becomes swollen, covered with pus Newborns Older children

64. Specific Pathophysiology, Assessment, and Management Meningitis – History Sudden or gradual onset Recent ear/upper respiratory infection, fever Apnea, respiratory distress in neonates Vomiting, headache, poor feeding, photophobia AMS, lethargy, irritability

65. Meningitis Signs/Symptoms – Fever, chills – Tachycardia, tachypnea – Cough, sore throat – Nasal congestion – Malaise – Cool/clammy skin – Petechiae – Respiratory distress – Poor feeding – Vomiting, diarrhea – Dehydration – Shock – Purpura – Seizures – Severe headaches – Irritability – Stiff neck – Bulging fontanelle

66. Meningitis-Therapeutic Invervention PPE ABCs, Supportive care Seizure monitoring IV, O2, monitor Pulse oximeter IV fluid bolus Reassess

67. Specific Pathophysiology, Assessment, and Management Meningitis – Physical examination – Differential diagnosis – Therapeutic interventions – Patient and family education

68. Let’s take 5 Audrey will find a film for your viewing pleasure. Remember the audio will come from your computer, not the phone Grab a pop and see you in a few minutes.

69. Pediatric Trauma!

70. EPIDEMIOLOGY FOR TRAUMA Injury every 4 seconds, death every 6 minutes Mortality rates higher here than any other country One million hospitalizations/year 25 million ED visits

71. Incidence 250,000 children suffer head injuries each year 50% of injury related deaths are head injury Falls < 2 years and child abuse < 1 year

72. Key Concepts to Remember Brain Sensitivity Brain Perfusion CPP 3 Components of the box

73. Categories of Injury Coup Contrecoup

74. Causes of Brain Injury Primary – Direct insult at the time of the injury – Results in dysfunction to skull, scalp, neurons, axons and blood vessels Secondary or Tertiary (indirect) injury – Results of metabolic events precipitated by the trauma

75. Glasgow Coma Scale Standard for reliability. Influences treatment, transport and transfer decisions – GCS 3-7 severe injury – GCS 8-12 moderate injury – GCS 13-15 mild injury

78. In the child look for headache, stiff neck, photophobia, cranial nerve involvement, posturing or Cushing’s triad Bradycardia: Systolic hypertension Bradycardia Irregular breathing pattern This is a late finding.

79. Assessment History is important Must recognize brain injury Must recognize signs and symptoms of increasing ICP

80. General Management of Head/Brain Injuries Maintain airway and ventilation – The brain does not tolerate hypoxia – Tube if you need to – Make sure suction is available!!!! Elevate head of bed 30 degrees Prevent hypotension Avoid Glucose Treat seizures

81. – Use the GCS for serial comparisons! – A GCS that falls 2 points suggests significant deterioration!

82. Pediatric Spinal Inury

83. Pediatric Trauma Specific injuries – Spinal trauma Spinal nerve injury without vertebrae injury <8 years, C1 and C2 injury >8 years, C5-C7 injury

84. Pediatric Trauma Spinal trauma Signs – Neck/back pain – Movement pain of neck/back – Posterior neck/midline back pain on palpation – Spinal column deformity – Neck/back muscle guarding/splinting – Priapism – Neurogenic shock signs – Paralysis, paresis, numbness, arm/leg tingling – Diaphragmatic breathing

85. Pediatric Trauma Spinal trauma management ABCs Spinal stabilization indications – Mechanisms of injury involving blunt trauma – MOI with rapid, forceful head movement – AMS with trauma, drowning history – Neurological deficit in arms/legs – Helmet damage – Tenderness/deformity in cervical, thoracic, lumbar region

86. Pediatric Trauma Spinal trauma management Spinal stabilization – Head, neck in neutral in-line position – Rigid cervical collar – Logroll onto rigid board – Secure around chest, pelvis, legs – Secure head first – Safety seat can be used – Cravat around head – Pad all open areas

87. Pediatric Trauma – Chest trauma High mortality rate Most common – Pulmonary contusion, laceration – Pneumothorax, hemothorax – Rib/sternal fractures – Cardiac injury – Diaphragm injury – Major blood vessel injury

88. Pediatric Trauma Chest trauma Rib fracture, significant force – Left lower, spleen injury – Right lower, liver injury – Multiple, inadequate breathing, pneumonia – Flail chest, life-threatening – Pulmonary contusion easily missed – Tension pneumo, immediate threat to life – Massive hemothorax, rare – Hypovolemia, jugular venous distention absent – Bradycardia, arrest imminent

89. Pediatric Trauma Abdominal and pelvic trauma Abdominal wall thin, organs closer to skin MVCs most common with blunt trauma Spleen most frequent injury Liver, lethal hemorrhage Kidney injury

90. Pediatric Trauma – Abdominal and pelvic trauma General management – ABCs – Palpate one quadrant at a time – Hypovolemia/shock, fluids – Pelvic injury, hemorrhage – Rapid transport

91. Pediatric Trauma – Extremity trauma Greenstick fracture – Splinters in pieces, remains connected – Growth plate injury – Bilateral femur fractures – Child abuse

92. Pediatric Trauma – Extremity trauma General management – ABCs – Control bleeding – Splint – Immobilize joint above and below the injury – Pulses, motor function, sensation before/after splinting – Hypovolemia/shock, IV fluids – Transport

93. Pediatric Trauma Special considerations – Airway control In-line stabilization in a neutral position 100% O 2, trauma Open airway, suction, jaw thrust without head/tilt Assist ineffective breathing Intubation, inadequate airway Needle cricothyroidectomy rarely indicated

94. Pediatric Trauma Immobilization Rigid c-collar Towel, blanket roll Child safety seat Vest-type device, short wooden backboard Pediatric immobilization device Long backboard Straps, cravats Tape Padding Do not flex neck

95. Pediatric Trauma – Fluid management Large-bore IV in large peripheral vein Or IO access 20 mL/kg fluid bolus per medical direction Reassess vital signs Repeat if there is no improvement Rapid transport

96. Child Abuse – Maltreatment Physical abuse, neglect Emotional abuse, neglect Sexual abuse – Neglect Failure to provide for basic needs Physical Educational Emotional

97. Child Abuse – Physical abuse Inflicting of nonaccidental injury – Emotional abuse Conveyance that child is worthless

98. Child Abuse Red Flags – Burns – Fractures – Hair loss – Suspicious stories – Bruising

99. Call DCFS We are mandated reporters by law We must call DCFS if we suspect child abuse or neglect. – 1-800-25-Abuse Doesn’t matter if nurse, doctor, cops or neighbors are calling too. The law says if you see it, you call.

100. – Trauma Prevention – Learning by example – Safety should be part of the daily routine – Remember, Trauma is leading cause of death and disability in children and adolescents – Changes in products or environment » Education » Products » Environment » Legislation

101. COMMUNICATION TIPS Provide reassurance Always talk with children of all ages Remember the family

102. And the # 1 Thing To Remember About “Little People” is.... AIRWAY MANAGEMENT! Just Like Adults

103. Some Quick System Notes Next month is a trimester testing month, so get those study guides completed! In September, CME will focus on new SMO’s, which have been approved and will be released in 2012. The new SMO’s have lots of fun additions for BLS providers!

104. Thank You for your Attention References: Comprehensive Pediatric emergency Care (Aehlert) Mosby’s Paramedic Care Journal of Trauma Nursing, “The Trauma Top 10”, October 2009, Noreen Felich, RN Please refer any further questions to Audrey at afinkel@silvercross.org and she will get them answered for you! afinkel@silvercross.org