1. Dr. Miada Mahmoud Rady Pediatric emergencies

2. Introduction  Children differ from adults in their anatomy, physiology, and emotions and experience a range of illnesses and injuries that varies across the pediatric age span.  So paramedic approach to pediatric patients must be based on their age and accommodate their unique developmental and social issues.

3. Why paramedic cases represent challenge ?! 1.Children perceive their illness or injury differently than adults. 2.Young children may not be able to report what is bothering them. 3.Fear or pain may slow down assessment. 4.Stressed or frightened parents and caregivers may also pose challenges.

4. Pediatric Age Categories 1.Newborns and infants: birth to 1 year 2.Toddlers: 1–3 years 3.Preschool: 3–6 years 4.School age: 6–12 years 5.Adolescent: 12–18 years

5. Neonate and Infant 1.Neonatal period: first month. 2.Infancy: first 12 months.

6. Assessment of neonates and infants 1.Keep child warm and warm your hands and stethoscope. 2.Support a young infant’s head and neck. 3.infants will be calmest in a parent’s arms. 4.If child is quiet, listen to heart and lungs first. 5.Try to quiet crying baby as much as possible

7. Toddler  Ages 1 to 3.

8. Toddler  Use the Pediatric Assessment Triangle (PAT) to assess the child ( measure the child’s interactions with the caregiver, vocalizations, and mobility ).  Strategies for examination: 1.Examine on parent’s lap and have a parent assist if possible. 2.Get down to the child’s level and be flexible.

10. Preschool-Age Child  Ages 3 to 5  Becoming verbal and active  Respect modesty.  Let child participate.  Set limits on behavior if the child acts out.

11. School-Age Child (Middle Childhood)  Ages 6 to 12.  Greater understanding may increase fear.  By age 8, anatomy and physiology is similar to adults.  Explain steps in simple language.

12. Adolescence 1.Ages 13 to 17 2.With respect to CPR, once secondary sexual characteristics have developed, treat as an adult. 3.Address and reassure patient. 4.Offer as much control as appropriate.

13. Pediatric Anatomy, Physiology, and Pathophysiology

14. The head  Child head is larger relative to the rest of his body and larger than adult head ( till age of 4 ) : 1.Larger surface area  more heat loss  so the head must be covered. 2.children often fall head first  suspect head injury whenever there is a serious MOI. 3.proportionally larger occiput  Take care when positioning the airway

15.  During infancy, the anterior and posterior fontanelles are open  Bulging suggests increased intracranial pressure and sunken fontanelles suggest dehydration.

18. The neck and airway 1.Children have short neck  can be difficult to feel carotid pulse or see jugular veins. 2. air way is smaller than the adult and tongue occupies larger space  More prone to obstruction. 3.During the first few months of life, infants are obligate nose breathers  Nasal obstruction with mucus can result in significant respiratory distress 4.Epiglottis is long and floppy  difficult to see vocal cords during intubation.

20. The Respiratory System 1. Smaller tidal volume, double metabolic oxygen demand. 2. Smaller functional residual capacity. 3. Faster breathing. 4. Infants use diaphragm during inspiration. 5. Experience muscle fatigue quicker. 6. Highly susceptible to hypoxia.

21. Cardiovascular system 1.Children rely mainly on pulse rate to maintain adequate cardiac output and compensate for decreased oxygenation. 2.Children have limited but vigorous cardiac reserves. 3.Injured children can maintain blood pressure for longer periods than adults, even though they are in shock (hypoperfusion). 4.Proportionally larger circulating blood volume compared with adults.

22. Cardiovascular System 1.A larger proportional volume of fluid/blood loss is needed to cause shock. 2.Hypotension is warning sign of imminent cardiac arrest. 3.Suspect shock if tachycardia is present. 4.Bradycardia usually indicates severe hypoxia. 5.Monitor the pediatric patient carefully for the development of hypotension.

23. The Nervous System 1. Neural tissue and vasculature are fragile and brain, spinal cord is not as well protected  takes less force to cause brain and spinal cord injuries and brain injuries are frequently more devastating. 2. Pediatric brain requires nearly twice the blood flow  makes even minor injuries significant and Increases risk of hypoxia

24. The Abdomen and Pelvis 1.Organs are situated more anteriorly ( less bony protection ) and are relatively large also liver and spleen extend below rib cage  so insignificant forces can cause serious internal injury. 2.Kidneys are also more vulnerable to injury as it is more mobile and Less well supported.

25. Musculoskeletal system 1.Bones of growing children are weaker than their ligaments and tendons  makes fractures more common than sprains. 2.Joint dislocations without associated fractures are not common. 3.Growth plate fractures can be seen with low-energy MOIs and may be lacking the degree of tenderness, swelling, and bruising usually associated with a broken bone. 4.Immobilize all sprains or strains, and suspect fractures.

26. Respiratory Emergencies 1.Frequently encountered and so early identification and intervention are critical. 2.Respiratory failure and arrest precede majority of cardiopulmonary arrests. 3.Use PAT to determine severity before touching the patient ( Distress, failure, or arrest ).

27. Respiratory distress  Respiratory distress means increased work of breathing to maintain oxygenation and/or ventilation.  Classified as mild, moderate, or severe.  Signs of respiratory distress : 1. Retractions (suprasternal, intercostal, subcostal). 2. Abdominal breathing. 3. Nasal flaring. 4. Grunting.

28. Respiratory failure  Condition in which patient can no longer compensate by increased work of breathing so hypoxia and/or carbon dioxide retention occur.  Signs may include: 1.Decreased or absent retractions due to respiratory muscle fatigue. 2.Altered mental status due to inadequate brain oxygenation. 3.Abnormally low respiratory rate.

29. Respiratory arrest  Condition in which the patient is not breathing spontaneously.  Administer immediate bag-mask ventilation with supplemental oxygen to prevent cardiopulmonary arrest.  Resuscitation of a child is often successful.

30. Assessment A.Using PAT before touching patient : 1.Appearance : gives an idea about brain oxygenation and ventilation i.e. sleepy child is mostly hypoxic child. 2.Assess the work of breathing via Patient’s position of comfort Presence or absence of retractions Grunting or flaring

31. A patient who prefers to sit upright, in the sniffing position, or to use arms for support is trying to optimize breathing mechanics ( indicates respiratory distress ). Deep retractions indicates the use of accessory muscles. 3.Look for pallor or cyanosis: provides information on adequacy of oxygenation.

32. Assessment B.Assess the airway:  Listen for stridor in awake patients.  Check for obstruction in obtunded patients. C.Assess breathing:  Determine respiratory rate.  Listen for air entry and abnormal breath sounds.  Check pulse oximetry.

33. Foreign Body Aspiration or Obstruction  Infants and toddlers have a high risk of foreign body aspiration.  Signs of mild obstruction: 1.Awake 2.Stridor 3.Increased work of breathing 4.Good color  Signs of severe obstruction 1.Cyanotic. 2.Unconscious.

34. Foreign Body Aspiration or Obstruction 1.For removing a foreign body from responsive infants  Deliver five back slaps and five chest thrusts.

37. 2.Removing a foreign body in unresponsive infant : a.look inside the mouth and If you see the object, remove it. b.If not, start CPR c.assess for a pulse If there is no pulse, or the pulse rate is less than 60 beats/min, begin CPR

40. Removing a foreign body in children 1.If the child is responsive  use abdominal thrust maneuver ( the Heimlich maneuver) 2.If the child becomes unresponsive:  Position supine and start chest compression.  Open airway, if you see the object remove it, and if not attempt ventilation.  If unable to relieve sever obstruction  proceed with laryngoscopy and removal with Magill forceps.

41. Anaphylaxis  Definition : Potentially life-threatening allergic reaction triggered by exposure to an antigen.  Onset of symptoms occurs immediately.  Delayed effects may occur after 8 hours so patient transport is crucial even if they are asymptomatic

42. Clinical presentation 1.Skin rash ( hives ) 2.Respiratory distress ( stridor, wheezy chest ) 3.Circulatory compromise ( hypotension, shock ) 4.Swelling of tongue, oral mucosa and puffy eye lids 5.Cardiorespiratory failure in sever cases

44. Management 1.Address ABCS. 2.Ensure patent air way 3.High flow oxygen. 4.I.V fluids via large bore cannula 5.Vasopressors in case of shock.

45. 6.Pharmacological therapy  Epinephrine ( gold standard and main line ).  Diphenhydramine  Corticosteroids  Inhaled beta 2 agonist. 7.Rapid transport to appropriate facility.

49. Croup  Definition : inflammation of the upper airway, mostly viral.  Clinical presentation : a.Audible stridor with activity or agitation b.Barky cough c.Mild respiratory distress and normal skin color.

50.  Management: a.Position of comfort and avoid agitating the child. b.Nebulized epinephrine c.Assisted ventilation with bag-mask ventilation d.Rapid transport.

52. Epiglotittis Definition : Inflammation of the supraglottic structures Classic presentation: a.Sick, anxious; sitting in sniffing position b.Drooling. c.Increased work of breathing and pallor or cyanosis

53. Management : Epiglotittis is major emergency, it could be fatal a.Symptoms progress rapidly so rapid transport is crucial b.Bag – mask ventilation may be necessary c.Be prepared with endotracheal intubation.

55. Bacterial Tracheitis Definition : Bacterial infection of soft tissues of trachea Clinical presentation: –Cough, stridor, respiratory distress –History of preceding viral infection Management : Keep patient as calm and comfortable as possible.

56. Asthma  Definition : disease of small airway characterized by : a.Bronchospasm b.Increased mucous production c.Airway hyper reactivity leading to hypoxia.  Triggering factor : Smoke, dust, common cold and upper respiratory infection.

57.  Clinical presentation : 1.Cough 2.Wheezy chest 3.Signs of respiratory distress.  Management : 1.O2 via mask. 2.Inhaled bronchodilator and or Inhaled corticosteroids.

59. Bronchiolitis  Definition : Inflammation or swelling of small airways in lower respiratory tract due to viral infection.  Clinical presentation : 1.Mild to moderate retractions 2.Tachypnea 3.Diffuse wheezing and crackles 4.Mild hypoxia

61. Complication  Complication : respiratory failure.  Signs of impending respiratory failure : 1.Sleepy. 2.Severe retractions 3.Diminished breath sounds 4.Moderate to severe hypoxia

62.  Risk factors for respiratory failure : 1.First months of life 2.Prematurity 3.Lung disease 4.Congenital heart disease 5.Immunodeficiency

63. Management  Mainly supportive : 1.Position of comfort 2.Supplemental oxygen 3.Inhaled albuterol or Nebulized racemic epinephrine may be given for moderate to severe respiratory distress.

64. Cardiopulmonary Arrest  Mostly associated with respiratory failure and arrest  Manifestation : hypoxia and bradycardia  Child must be ventilated early with sever hypoxia or bradycardia.  Survival rate is bad.

65. Shock  Definition : Inadequate delivery of oxygen and nutrients to tissues to meet metabolic demand  classification : A.Etiological : 1. Hypovolemic 2. Distributive 3. Cardiogenic

66. B.Clinical classification :  Compensated : Body is able to maintain adequate perfusion to vital organs.  Decompensated : State of inadequate perfusion. C.Signs : 1.Hypotension 2.Poor peripheral perfusion 3.Hypotension ( late signs and sever sign )

67. Hypovolemic shock  Most common type in infant and children.  Due to volume loss e.g. hemorrhage, diarrhea and vomiting.  Signs : a.Lethargic b.Pale, mottled, or cyanotic c.Dehydration.

68. Management 1.Position of comfort 2.Supplemental oxygen 3.Keep the child warm. 4.Direct pressure to stop external bleeding 5.Volume replacement

69. Distributive Shock  Due to sever vasodilatation  Occurs in children with sepsis and anaphylactic shock  Fever is main symptoms in case of sepsis.

70. Management  Supportive and rapid transport : 1.Address ABCS 2.High flow oxygen 3.Fluids via large bore cannula 4.Vasopressors in sever shock

71. Cardiogenic shock  Shock due to pump failure ( heart failure )  Occurs in children with underlying heart disease : 1.Congestive heart failure. 2.Cardiomyopathy. 3.Sever arrhythmias.

72. Clinical presentation 1.Listless or lethargic 2.Increased work of breathing 3.Impaired circulation 4.Skin pale, mottled, or cyanotic 5.Sweating with feeding

73. Sure signs of cardiogenic shock 1.Increased work of breathing 2.Drop in oxygen saturation 3.Worsening perfusion ……………………………………All after a fluid bolus

74. Management 1.Position of comfort 2.Supplemental oxygen 3.Transport to facility which offer pediatric critical care. 4.No fluid should be given with sure diagnosis of cardiogenic shock

75. Bradysrhythmias Pulse rate is lower than normal for age. Often secondary to hypoxia in children Initial treatment: 1.Airway management 2.Supplemental oxygen 3.Assisted ventilation as needed.

76. Bradysrhythmias 4.Initiate electronic cardiac monitoring. 5.If child is asymptomatic, no further treatment is indicated in the field. 6.If the child exhibits symptoms of poor perfusion : Begin chest compressions. Attempt IV or IO access.

77. Tachydysrhythmias Pulse rate is higher than normal for age. Assessment should include pulse rate monitoring and an ECG or rhythm strip.

78. Cyanotic Disease 1.Hypoplastic left heart syndrome (HLHS) 2.Tricuspid atresia 3.Transposition of the great arteries (TGA) 4.Tetralogy of Fallot (TOF) 5.Total anomalous pulmonary vascular return. 6.Truncus arteriosus

80. Cyanotic Disease Presents in neonatal period with: 1.Increasing respiratory distress 2.Poor perfusion 3.Cyanosis 4.Cardiovascular collapse if unrecognized Emergency management includes Cardiorespiratory support and monitoring.

82. Noncyanotic Disease Examples include: 1.Atrial septal defects (ASDs) 2.Ventricular septal defects (VSDs) 3.Patent ductus arteriosus (PDA) Clinical presentation varies.

83. Coarctation of the aorta Definition : a discrete narrowing of the thoracic aorta. Major clinical finding: 1. Difference in systolic blood pressure between upper and lower extremities. 2.Most older infants and children remain asymptomatic.

86. Congestive Heart Failure Definition : failure of the heart to meet metabolic demands at normal physiologic venous pressures. Signs and symptoms : 1.Infants : Tachypnea, retractions, grunting and interrupted feeding. 2.Children: Profuse sweating, increased work of breathing during feedings. 3.Older children: Tachycardia, crackles

88. Congestive Heart Failure Initial management 1.Assessment of ABCs 2.Place the patient in semisetting position 3.Provide oxygen. 4.Diuretics in consultation with a cardiologist

91. Myocarditis Definition : Condition caused inflammation of the heart muscle that results in myocardial dysfunction and eventually can lead to heart failure Mostly caused by viral infections

92. Myocarditis clinical presentation Present with CHF signs and symptoms: 1.Dyspnea at rest 2.Syncope 3.Tachycardia 4.Hepatomegaly 5.Galloping heart or new murmur

93. Myocarditis 1.Transport on Cardiorespiratory monitors. 2.Obtain vascular access. 3.Patients will often need inotropic support. 4.Apply oxygen during transport.

94. Altered LOC and Mental Status

95. General lines of management 1.Assess and support airway and breathing. 2.Establish vascular access and if hypoglycemic, give glucose. 3.Transport all patients expeditiously. 4.Assess for increased ICP.

96. Seizures Definition : Abnormal movements that result from abnormal electrical discharges in the brain. Causes : 1.Trauma 2.Metabolic disturbances 3.Ingestion 4.Infection

97. Seizures Types of seizures : A.Generalized seizures : involve the entire brain. B.Partial seizures : involve only part of the brain. 1.Simple partial seizures: no loss of consciousness 2.Complex partial seizures: loss of consciousness

98. Febrile convulsion To diagnose febrile convulsions the following condition must be present in child : I.Feverish II.Between 6 months and 6 years of age III.Have no other identifiable cause. IV.Positive family history is highly suggestive.

100. Types of febrile seizers  Simple febrile seizures: Brief, generalized tonic-clinic seizures occurring without underlying neurologic abnormalities  Complex febrile seizures: Longer, focal or occur with baseline developmental or neurologic abnormality

102. Assessment of patient with seizers The following must be covered in history taking : 1.Prior seizures 2.Anticonvulsant medications 3.Recent illness, injury, or suspected ingestion of toxic substance. 4.Duration of seizure activity 5.Character of the seizure

103. Management : 1.Provide 100% supplemental oxygen; bag-mask ventilation as indicated for hypoventilation. 2.Measure serum glucose; treat hypoglycemia. 3.Consider administering a benzodiazepine. 4.If seizures do not stop, a second-line agent is necessary e.g. Phenobarbital,Phenytoin and Fosphenytoin

104. Meningitis Definition : inflammation of the meninges. Causative organism : many, commonest is meningococci ( responsible for epidemic form). Method of transmission : 1.Direct contact with infected nasopharyngeal secretion. 2.Droplet infection.

105. Assessment Clinical presentation include: 1.Fever 2.Headache 3.Neck stiffness 4.Skin rash 5.Kernig sign 6.Brudzinski sign 7.seizures

108. Meningitis 1.Perform a glucose check. 2.Provide lifesaving interventions as needed, and transport quickly. 3.Patient may need oxygen, airway management, and ventilation support. 4.Infection control measure must be properly followed

109. Hydrocephalus Definition : accumulation of CSF that results from impaired circulation and absorption of cerebrospinal fluid (CSF) Leading to enlargement of ventricles and increased ICP Clinical presentation : symptoms of increased ICP Treatment : Cerebral shunt often used to decrease ICP 1.Ventriculoperitoneal (VP) shunts 2.Ventriculoatrial (VA) shunts

112. Management 1.Address ABCS 2.Rapid transport

113. Ventricular shunts  Used to drain excess cerebrospinal fluid.  Two types : 1.Ventriculoperitoneal (VP) shunts. 2.Ventriculoatrial (VA) shunts.  Complication : infection and obstruction.  Management of complicated shunt: 1.Manage ABCS 2.Rapid transport

114. Head trauma  Common in children ( large sized head)  Even children who appear normal, may have significant intracranial injury  Children with head trauma, should be evaluated for signs of abuse.

116. Closed head trauma 1.Epidural hematoma :  Hemorrhage into space between the dura and skull.  Almost exclusively caused by trauma. 2.Subdural hematoma :  Hemorrhage into space between dura and arachnoid membranes  Suspect abuse until proven otherwise.

119. Assessment of pediatric trauma case 1.Begin with a thorough scene size-up. 2.Use PAT to form a general impression. 3.If findings are grossly abnormal, move to ABCs and initiate life support interventions: a.Circulation : Any trauma patient should be considered to be at risk for developing shock, so continuously assess circulation, the only sign for shock might be tachycardia.

120. Primary assessment Identify and manage life threats Form a general impression Address ABC TRANSPORT DECISION

121. b.Breathing : Pneumothorax may be present with penetrating trauma of the chest or upper abdomen. Signs : Tachycardia,Jugular vein distention and Pulsus paradoxus Treatment : Perform needle decompression. 4.Once ABCs are stabilized, continue assessment of disability with AVPU.

122. 5.Place a cervical collar, and immobilize on a long backboard as indicated. 6.Perform rapid exam to identify all injuries. 7.Cover the child with blankets. 8.Treat any fractures.

124. Transport Considerations  Some traumas are load-and-go because of severe injuries and unstable condition  Perform lifesaving steps on scene or en route and transfer quickly.  All trauma victims with suspected spinal injury require spinal stabilization ( use only appropriate collar size).

125. History Taking and Secondary Assessment  If patient is stable: 1.Obtain additional history 2.Perform a more thorough physical exam. 3.Look for bruises, abrasions, other subtle signs of injury that may have been missed.

126. Hyperglycemia and diabetes  Type 1 diabetes or juvenile diabetes  Symptoms of diabetes include : polyuria, polydepsia, polyphagia and unexplained weight loss.  Complication : untreated hypoglycemia can lead to 1.Dehydration 2.Acid base disorders 3.Diabetic ketoacidosis

128. Assessment  History taking may reveal : 1.Missed insulin dose. 2.Greater proportion of food was eaten. 3.Insulin pump malfunctioned. 4.Ask about the following during assessment :  Urine out put, mental status, insulin pump function, compliance with treatment, last glucose check and last insulin take)

129. Management of hyperglycemia 1.Ensure patent airway and administer 100% oxygen. 2.Assisted ventilation may be needed 3.Obtain an I.V access and start isotonic fluid administration 4.Avoid rapid fluid administration as it may lead to brain edema and brain stem herniaition 5.Monitor vital signs closely. 6.If patient reports worsening of a headache or mental status deteriorates : Discontinue fluids, assess and treat for increased ICP.

130. Hypoglycemia  Normal blood glucose levels: 80 to 120 mg/dl.  Hypoglycemia : low blood glucose level ( ＜ 80mg/dl ).  Clinical presentation : 1.Sweating. 2.Tremors. 3.Tachycardia and palpitation. 4.Hunger and weakness. 5.Finally confusion and coma.

131.  Complication : brain damage if prolonged, due to low glucose reserve.  Management : 1.Maintain patent airway and give high flow oxygen. 2.Give glucose :  Orally if the child is completely alert and able to swallow.  I.V if child is confused  I.M glucagon if an I.V access cannot be obtained. 3.Monitor vital signs closely.

133. Sickle cell disease Definition : Autosomal recessive disorders, caused by abnormal adult hemoglobin, abnormal hemoglobin is known as hemoglobin S. Pathophysiology : abnormal shape of the RBCS make them more liable for destruction and they can easily obstruct small blood vessels. Present with ischemia and painful crises.

135. Sickle Cell Disease (SCD) Infants may present with: 1.Fussiness 2.Irritability 3.Crying 4.Poor feeding 5.Nonspecific findings Older children may report: 1.Pain in specific locations, including joints, back, and chest.

136. Sickle Cell Disease (SCD)  Priapism: Caused by sickling of cells within the penis characterized by painful sustained erection and can lead to damage of penile tissues.  Treatment includes: 1.Gentle hydration 2.Supplemental oxygen 3.Anti-inflammatory medications and narcotics 4.Transport.

137. Thrombocytopenia  Abnormally low number of platelets ( normal platelet count: 150,000 to 450,000/ul ).  Bleeding is proportional to the degree of thrombocytopenia.  Causes include: 1.Infections,cancers. 2.Rheumatologic diseases. 3.Inherited conditions, Medications and chemotherapy drugs.

138. Treatment : 1.Treating the underlying cause if present. 2.Transfusing platelets if bleeding cannot be controlled. 3.Transport for consultation with a hematologist.

139. Von Willebrand Disease  Most common heritable disorder of coagulation caused by Decreased or abnormal production of Von Willebrand factor  Presentation can mimic hemophilia A.  Presentation : range from mild (nosebleeds) to severe uncontrolled bleeding tendencies.  Treatment : control bleeding and transport to a hospital with hematology services.

140. Leukemia/Lymphoma Management consideration: 1.Patients are often immunocompromized secondary to the leukemic cells overtaking the bone marrow 2.Patients need antibiotics at the first sign of illness. 3.Fluid therapy should be aggressive in pediatric patients who are tachycardic.

141. Leukemia/Lymphoma 1.Consider tumor lysis syndrome (TLS). – Condition that can occur after treatment of certain cancers. – Can lead to acute renal injury and failure – If suspected, institute rapid fluid therapy and transport rapidly.

143. Toxicologic Emergencies Toxic exposures account for a significant number of pediatric emergencies. 1.Ingestion 2.Inhalation 3.Injection 4.Application

144. Assessment of Toxicologic Emergencies 1.Evaluation follows standard assessment sequence. 2.Attend to ABCs as indicated. 3.Treat documented hypoglycemia. 4.If child is stable, obtain additional history and perform secondary assessment.

145. Assessment of Toxicologic Emergencies 5.Look for toxidromes by assessing: A.Mental status B.Pupillary changes C.Skin CTC D.Gastrointestinal activity E.Abnormal odors 6.Reassess frequently.

146. 5.Reduce absorption by decontamination. 6.Enhance elimination 7.Provide an antidote.

147. Methods of decontamination With skin exposure, remove all clothing and wash skin. With ocular exposure, wash out the eyes. 3.For ingested toxins, reduce gastric absorption by : a.Dilution b.Gastric lavage c.Activated charcoal d.Syrup of ipecac is not recommended.

148. Decontamination For substances that are renally excreted : diuresis may be beneficial. Dialysis is required for some overdoses: 1.Salicylates 2.Lithium 3.Methyl alcohol 4.Ethylene glycol 5.Barbiturates

149. Decontamination If inhaled, assess respiratory status : – Bronchodilators may be needed for bronchial irritation and bronchospasm. – Monitoring of oxygen saturations and intubation may be necessary.

150. Enhanced Elimination Cathartics are sometimes combined with activated charcoal. – Work by speeding up elimination. – Not recommended for young children. Additional options include whole bowel irrigation and urinary alkalinization.

151. Antidotes Can be lifesaving Available for only a few poisonings Reverse or block effects of ingested toxins Dose depends on child’s weight.

152. Psychiatric emergency approach 1.Safety is your first priority. 2.Approach the child calmly, and explain you are there to help. 3.Address patient directly. 4.Answer questions honestly. 5.Some children must be mechanically restrained,so carefully document the reason.

153. Psychiatric emergency approach 6.PAT will give you a general impression of mental status and cardiovascular stability. 7.Assessment is based on observation and history. 8.Treat problems or injuries with standard protocols

154. Fever Emergencies Record temperature. Life-threatening signs may include: –Respiratory distress –Seizures –Petechial or purpuric rash –Bulging fontanelles in an infant

155. Fever Emergencies 1.History taking and secondary assessment will help determine the underlying cause and severity of illness. 2.Perform on scene if child is stable. 3.Perform en route if seriously ill.

156. Fever Emergencies May require little intervention : 1.Support ABCs. 2.Provide temperature control : consider acetaminophen or ibuprofen. 3.Transport to an appropriate medical facility.

157. Child Abuse and Neglect Child abuse : Any improper or excessive action that injures or harms a child or infant Types of child abuse 1.Physical abuse 2.Sexual abuse 3.Emotional abuse 4.Neglect

158. Risk Factors for Abuse Risk factors for abuse: 1.Younger children 2.Children who require extra attention 3.Lower socioeconomic status 4.Divorce, financial problems, and illness 5.Drug and alcohol abuse 6.Domestic violence in the home

159. Suspecting Abuse or Neglect If you suspect abuse, trust your instincts. Look for “red flags” that could suggest maltreatment. ( table 27)

160. Red flags of child abuse 1.Inconsistency of the injury with child developmental age. 2.History inconsistent with the injury. 3.Inappropriate parental concern. 4.Delay in seeking care and injuries of different age. 5.Lack of supervision 6.Unusual injury pattern 7.Suspicious circumstances and environmental clues

161. Assessment and Management of Abuse and Neglect 1.Carefully document what you see regarding : a.Child’s environment b.Condition of home c.Interactions among caregivers, child and EMS crew. 2.Prehospital personnel are legally obligated to report suspicion of abuse.

162. Assessment and Management of Abuse and Neglect 3.Involve police early to secure the scene. 4.Approach emergency department staff with concerns. 5.Be aware of local regulations. 6.Focus on assessment and management. 7.Be aware of history inconsistent with type of injury and multiple burises

163. Mimics of Abuse Definitions : Situation in which it is difficult to distinguish some normal skin findings from inflicted injuries. Example :

164. Examples of mimics of Abuse 1.Medical conditions can mimic bruises e.g. Purpura and Petechiae 2.Exposure to sun can cause reactions with certain medications or fruits. 3.Mongolian spots may be mistaken for bruises. 4.Certain cultural customs produce skin markings e.g. Coining and Cupping

165. Mimics of Abuse

166. Sudden Infant Death Syndrome Definition : sudden and unexpected death of an infant younger than 1 year for whom a thorough autopsy fails to demonstrate an adequate cause of death.

168. Causes Exact cause is unknown several theories are proposed : 1. Developmental abnormality especially of the brain 2.Sleep patterns e.g. sleep on stomach, on soft surface or with the parents. 3.Respiratory problems.

169. Sudden Infant Death Syndrome Risk factors include: 1.Prematurity; low birth weight 2.Young maternal age 3.Sleeping prone or with soft, bulky blankets 4.Exposure to tobacco smoke

171. Assessment and Management of SIDS 1.Be alert to other potential causes of death. 2.Decision to start or stop resuscitative efforts should be guided by local protocols 3.Thorough scene size-up and history are important.

172. Apparent Life-Threatening Event Definition : episode during which an infant: 1.Becomes pale or cyanotic 2.Chokes, gags, or has an apneic spell, or 3.Loses muscle tone Causes: range from benign to serious diagnoses.

173. Apparent Life-Threatening Event management ( ALTE) 1.Provide life support with signs of cardiorespiratory compromise or altered mental status. 2.Transport all infants with a history of ALTE.

174. Assessment and Management of Burns Burns suggestive of abuse : are burns where the mechanism or pattern observed does not match history or child’s capabilities Management : 1.Remove burning clothing support ABCs. 2.Give 100% supplemental oxygen.

175. Management of Burns 3.Clean burned areas minimally. 4.Avoid lotions or ointments. 5.Cover burn and patient as needed. 6.Analgesia is a critical part of management. 7.Transport to an appropriate medical facility.

176. Children with Special Health Care Needs Definition : they are children with physical, developmental, and learning disabilities. Examples : children with tracheostomy tubes, those on artificial ventilation and gastrostomy.

177. Tracheostomy Tubes and Artificial Ventilators Tracheostomy : It means surgical creation of a stoma through which a tracheostomy tube can be placed for long-term ventilatory needs.

178. Dealing with child with Tracheostomy Tubes and Artificial Ventilators 1.Caregivers are a source of valuable information so allow them to participate. 2.Most common problem: obstruction of tube with secretions 3.Child may breathe spontaneously with room air or depend on a home ventilator and supplemental oxygen. 4.With respiratory distress, assess tube position and suction tube. 5.If child does not improve, you may need to remove and replace the tube.

179. Gastrostomy Tubes Definition : surgically placed directly into the stomach to provide nutrition or medications Management : usually includes supportive care and transport.

180. Central Venous Catheters Function : usually inserted for long-term IV access for medications or nutrition Placed into large central veins e.g. jugular vein Complications : include infections, obstruction, and dislodged or broken catheters.

181. Assessment and Management of Children With Special Health Care Needs 1.Follow standard assessment sequence. 2.Ask parent questions to establish baseline neurologic function and physiologic status. 3.Meet child at his or her developmental level. 4.Work with parents to restore child to his or her own physiologic baseline.

182. Transport of Children With Special Health Care Needs 1.Transport to the child’s medical home. 2.If this is not possible, take along any medical records and assistive devices. 3.Most important, take the caregiver!