Section 7: Special Populations

Pediatric Outdoor Emergency Care Chapter 30 Pediatric Outdoor Emergency Care

Objectives Differentiate the response of the ill or injured infant or child (age specific) from that of an adult. Discuss the field management of the child trauma patient. Demonstrate an assessment of an infant, toddler, and school-aged child. Demonstrate oxygen delivery for the infant and child. Demonstrate the techniques of foreign body airway obstruction removal in a child.

Airway Differences Larger tongue relative to the mouth Less well-developed rings of cartilage in the trachea Head tilt-chin lift may occlude the airway.

Breathing Differences Infants breathe faster than children or adults. Infants depend on diaphragm use when they breathe. Sustained, labored breathing may lead to respiratory failure.

Circulation Differences The heart rate increases during illness and injury. Vasoconstriction keeps vital organs nourished, ie, pale skin may mean decreased perfusion. Constriction of the blood vessels can affect blood flow to the extremities.

Skeletal Differences Growth plates exist at the ends of long bones. Bones are weaker and more flexible. Bones are prone to fracture with stress. Infants have two small openings in the skull called fontanels. Fontanels close by age 18 months.

Growth and Development Thoughts and behaviors of children are usually grouped into stages: Infancy Toddler years Preschool age School age Adolescence

Infant Infancy is the first year of life. Infants respond mainly to physical stimuli. Crying is the infant’s main avenue of expression. Infants may prefer to be with their caregiver. If possible, have the caregiver hold the infant as you start your examination.

Toddler 1 to 3 years of age Begin to walk and explore the environment May resist separation from caregivers Make any observations you can before touching a toddler. They are curious and adventuresome.

Preschool-Age Child 3 to 6 years of age Use simple language effectively Understand directions Identify painful areas when questioned Understand what you are going to do from simple descriptions Can be distracted with toys

School-Age Child 6 to 12 years of age Begin to think like adults Can be included with the parent when taking medical history May be familiar with physical exam May be able to make choices

The Adolescent 12 to 18 years of age Very concerned about body image May have strong feelings about being observed Need respect for privacy Understand pain Explain any procedure that you are doing.

Approach to Assessment Approach at eye level. Note appearance and activity level. Note “work-of-breathing” (WOB). Determine responsiveness with AVPU. Grade behavior at the stage of development level, ie, toddler, infant. Maintain normal body temperature.

Helpful Hints Remain calm and appear confident. You are caring for a whole family. Honesty is important. Inform caregiver and child often. Keep the family together. Provide hope and reassurance to all.

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

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.

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.

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.

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.

BVM Devices Equipment must be the right size. Ventilate at the proper rate and volume. A BVM device may be used by one or two rescuers.

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.

Airway Obstruction Croup An infection of the airway below the level of the vocal cords, caused by a virus Epiglottitis Infection of the soft tissue in the area above the vocal cords

Signs and Symptoms Decreased or absent breath sounds Stridor Wheezing Rales

Signs of Complete Airway Obstruction Ineffective cough (no sound) Inability to cry or speak Increasing respiratory difficulty, with stridor Cyanosis Loss of responsiveness

Removing a Foreign Body Airway Obstruction (1 of 5) In an unconscious child: Place the child on a firm, flat surface. Inspect the upper airway and remove any visible object. Attempt rescue breathing. If ventilation is unsuccessful after two attempts, position your hands on the abdomen.

Removing a Foreign Body Airway Obstruction (2 of 5) Give five abdominal thrusts. Open airway again to try and see object. Only try to remove object if you see it.

Removing a Foreign Body Airway Obstruction (3 of 5) Attempt rescue breathing. If unsuccessful, reposition head and try again. Repeat abdominal thrusts if obstruction persists.

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.

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

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

Vital Signs by Age

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

Vital Signs: 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.

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

Vital Signs: Skin Feel for temperature and moisture. Estimate capillary refill.

Signs and Symptoms of Respiratory Emergencies Nasal flaring Grunting respirations Wheezing, stridor, or abnormal sounds Use of accessory muscles Retractions of rib cage Tripod position in older children

Respiratory Emergencies Croup: viral infection that responds well to hydration Epiglottitis: bacterial infection on the decline due to HIB vaccine Asthma: common, and treated with inhalers, rarely epinephrine Bronchiolitis, bronchitis, and pneumonia: infections of lung and lung passages

Airway Be alert for airway problems in all children with trauma. Unconscious children breathing on their own are at risk for airway obstruction. Use jaw-thrust maneuver when necessary. Keep suction available.

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 ventilations immediately. Continue to provide supplemental oxygen.

Breathing Give supplemental oxygen to all children with possible: Head injuries Chest injuries Abdominal injuries Shock Use properly sized equipment.

Seizures Result of disorganized electrical activity in the brain Types of seizures Generalized (grand mal) seizures Partial seizures Absence (petit mal) seizures Usually followed by a postical period Status epilepticus—a continuous seizure or multiple seizures without a return to consciousness for 30 minutes or more.

Febrile Seizures Febrile seizures are most common in children from 6 months to 6 years. Febrile seizures are caused by fever. They last less than 15 minutes, with tonic-clonic activity. Postictal period may or may not follow. Assess ABCs and begin cooling measures. Arrange for prompt transport.

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.

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

Altered Level of Responsiveness The first step in treatment is to assess the ABCs and provide proper care. Use the AVPU scale. Obtain a brief history from caregivers. After initial assessment, secure airway. Support patient’s vital functions. Arrange for prompt transport.

Common Causes A E I O U T I P S Alcohol Epilepsy, endocrine, or electrolyte imbalance Insulin or hypoglycemia Opiates or other drugs Uremia Trauma or temperature Infection Psychogenic or poison Shock, stroke, or shunt obstruction

Poisoning Poisoning is common in children. Care will be based on how awake and alert the child appears. Focus on the ABCs. Do not administer syrup of ipecac unless directed by medical control. Collect poison containers and vomitus. Arrange for prompt transport. Child’s condition could change at any time.

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

Assessing Circulation Pulse: greater than 160 beats/min suggests shock Skin signs: assess temperature and moisture Capillary refill: is it delayed or are the fingers just cold? Color: is skin pink, pale, ashen, or blue?

Emergency Medical Care for Shock Ensure airway. Support ventilations with supplemental oxygen. Control bleeding. Elevate feet and maintain body temperature. Arrange for immediate transport. Monitor vital signs. Arrange for ALS backup as needed. Ensure that caregiver accompanies patient.

Dehydration Determine if child is vomiting and/or has diarrhea and for how long. Watch for clues: Dry lips and gums Fewer wet diapers Shrunken eyes Irritable or sleepy Poor skin turgor Cool, clammy skin

Other Emergencies Hyperthermia: watch for overdressing and infants left in vehicles Hypothermia: newborns are especially susceptible Sepsis: usually follows a history of upper respiratory infection Sports-related injuries: seen in activities with high speed or contact

Head Injuries Nausea and vomiting are common signs and symptoms. The most important step is to ensure the airway is open. Respiratory arrest can occur; be prepared. Avoid hyperventilating the patient until normal ventilations with a BVM device have been established for a few minutes.

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.

Chest Injuries Most chest injuries in children result from blunt trauma. Children have soft, flexible ribs. The absence of obvious trauma does not exclude the likelihood of serious internal injuries.

Abdominal Injuries Abdominal injuries are very common in children. Children compensate for blood loss better than adults but go into shock more quickly. Children involved in trauma tend to swallow air, creating stomach distention.

Injuries to the Extremities A child’s bones bend more easily than an adult’s. Incomplete fractures can occur. Growth plates are susceptible to fracture. Treat fractures in the same manner as in adults, but do not use adult splints unless the child is large enough to fit the device.

Burns Most common burns involve exposure to hot substances, items, or caustic materials. 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.

Submersion Injury Drowning or near drowning Second most common cause of unintentional death of children in the U.S. Assessment and reassessment of ABCs are critical. Patient may be in respiratory or cardiac arrest.

Family Matters When children are injured, rescuers will have to deal with caregivers as well. Calm parents = calm children Keep caregiver with child. Support and inform family often. Act calm, confident, and professional.

Child Abuse Child 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 it to authorities.

Considerations 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?

Considerations 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?

Considerations 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 that look like gloves or socks? Is there an unexplained decreased level of consciousness?

Considerations 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?

Emergency Medical Care Take care of ABCs. Treat all injuries. Arrange for transport if you suspect abuse. Do not make accusations. Law enforcement and child protective services must investigate all reports of abuse.

Response to Pediatric Emergencies Providers may experience a wide range of emotions after dealing with a child or infant. You may feel anxious if you have limited experience with children; therefore, practice is necessary. After difficult incidents, a debriefing may be helpful.