Introduction to Emergency Medical Care 1

Introduction to Emergency Medical Care 1
Advance Preparation Prepare anatomy models for demonstration. Research related multimedia links for illustration purposes. Reach out to local child abuse/domestic violence advocacy groups for educational resources. Invite a parent of a special health care needs child to class. Prepare pediatric equipment for scenario purposes. Invite assistant instructors and programmed patients to assist with psychomotor sessions.

OBJECTIVES 35.1 Define key terms introduced in this chapter. Slides 19, 21, Describe the anatomic and physiologic characteristics of infants and children compared to adults and the implications of each for assessment and care of the pediatric patient. Slides 19–26 continued

OBJECTIVES 35.3 Discuss the normal vital signs ranges for infants and children. Slide Adapt history-taking and assessment techniques to patients in each pediatric age group. Slides 28–30 continued

OBJECTIVES 35.5 Discuss special considerations in dealing with adolescent patients. Slide Discuss the importance of involving caretakers in the assessment and emergency care of pediatric patients and anticipate reactions of parents and caregivers in response to an ill or injured child. Slides 34–35 continued

OBJECTIVES 35.7 Discuss the use of the pediatric assessment triangle in assessing pediatric patients. Slides 38– Explain special aspects of the steps of assessment for pediatric patients, including the scene size-up, primary assessment, secondary assessment with physical exam, and reassessment. Slides 42–58 continued

OBJECTIVES 35.9 Demonstrate adaptations to techniques and equipment to properly manage the airway, ventilation, and oxygenation of pediatric patients. Slides 60–69 continued

OBJECTIVES 35.10 Compare and contrast the causes, presentation, and management of shock in pediatric and adult patients. Slides 70– Recognize the particular concern for preventing heat loss in pediatric patients. Slide 73 continued

OBJECTIVES 35.12 Recognize the signs, symptoms, and history associated with common pediatric medical emergencies including: difficulty breathing, croup, epiglottitis, fever, meningitis, diarrhea and vomiting, seizures, altered mental status, poisoning, drowning, and sudden infant death syndrome (SIDS). Slides 76–91 continued

OBJECTIVES 35.13 Discuss injury patterns common in pediatric trauma patients. Slides 94– Discuss care for burns in pediatric patients. Slides 109–110 continued

OBJECTIVES 35.15 Recognize indications of child abuse and neglect, and explain your ethical and legal responsibilities when you suspect child abuse or neglect. Slides 112–117 continued

OBJECTIVES 35.16 Manage pediatric patients with special challenges, including those dependent on tracheostomy tubes, home artificial ventilators, central intravenous lines, gastrostomy tubes, and shunts. Slides 120–126

MULTIMEDIA Slide 32 Communicating With Toddlers Video
Slide 36 Caring and Empathy Video Slide 92 Information About SIDS Video These videos appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.

Anatomic and physiologic characteristics of children
Psychological and personality characteristics of children of different ages How to interact with pediatric patients and their supporters and caregivers continued

How to assess the pediatric patient
How to identify and treat special concerns with the ABCs, shock, and potential hypothermia How to assess and care for various pediatric medical emergencies, especially respiratory disorders continued

How to assess and care for various pediatric trauma emergencies
How to deal with issues of child abuse and neglect and children with special needs

Topics Developmental Characteristics of Infants and Children
Supporting the Parents or Other Care Providers Assessing the Pediatric Patient Special Concerns in Pediatric Care Pediatric Medical Emergencies Planning Your Time: Plan 205 minutes for this chapter. Developmental Characteristics of Infants and Children (30 Minutes) Supporting the Parents or Other Care Providers (15 minutes) Assessing the Pediatric Patient (30 minutes) Special Concerns in Pediatric Care (15 minutes) Pediatric Medical Emergencies (30 minutes) Pediatric Trauma Emergencies (30 minutes) Child Abuse and Neglect (20 minutes) Infants and Children With Special Needs (20 minutes) The EMT and Pediatric Emergencies (15 minutes) Note: The total teaching time recommended is only a guideline. continued

Topics Pediatric Trauma Emergencies Child Abuse and Neglect
Infants and Children With Special Challenges The EMT and Pediatric Emergencies

Developmental Characteristics of Infants and Children
Teaching Time: 30 minutes Teaching Tips: Bring children of various ages to class. Demonstrate anatomic differences compared to adults. Use multimedia graphics to highlight anatomic differences. Consider using graphics of the pediatric airway and of the developing skull. Put anatomic differences in context. Use real-world examples to discuss why these differences might impact assessment or treatment. Use a pediatric airway manikin to demonstrate the differences in airway anatomy.

Pediatric Age Categories
Newborns and infants: birth to 1 year Toddlers: 1–3 years Preschool: 3–6 years School age: 6–12 years Adolescent: 12–18 years Point to Emphasize: The term pediatric refers to patients who have not yet reached the age of puberty. Talking Points: Normal pulse rate ranges: 120–160/minute in newborns to 60–105/minute in adolescents. Normal respiration rate ranges: 30–50/minute in newborns to 12–20/minute in adolescents. Normal blood pressure ranges: average 99/65 in preschoolers to average 114/76 in adolescents.

Anatomic and Physiologic Differences
Infants and children differ from adults in psychology, anatomy, and physiology Understanding differences will help you assess and care for young patients Point to Emphasize: Pediatric anatomy is most different when considering the head, the airway, the respiratory system, and the chest. Class Activity: Bring children of various ages to class, or assign homework to examine key anatomic differences. Consider developing a check sheet that each student must complete for a live child or infant.

The Head Talking Points: A child’s head is proportionately larger than an adult’s until age 4. Because of this, children often fall head first. As a result you should suspect head injury whenever there is a serious MOI. Up to 12–18 months infants will have a soft spot just to the anterior center of the skull called the anterior fontanelle. A sunken fontanelle may indicate dehydration and a bulging fontanelle may indicate elevated intercranial pressure.

Airway and Respiratory System
Talking Points: Infants typically breathe through their noses, so a nasal obstruction can impair breathing. The trachea (windpipe) is often softer and more flexible in infants and children. This makes it much more easily obstructed by swelling and foreign objects. Critical Thinking: Are anatomic differences always related to age? Consider conditions that might impact growth and therefore create similar anatomic differences.

Chest and Abdomen Less developed, more elastic in young patients
Infants and children: abdominal breathers Abdominal organs less protected than in adults Knowledge Application: Have students work in small groups. Assign each group a pediatric anatomic difference and have group members discuss the potential implications for assessment and treatment. Give points for visual aids.

Body Surface Larger than adult’s in proportion to body mass
More prone to heat loss through skin More vulnerable to hypothermia Talking Points: In addition to greater loss of body heat because pediatric patients’ heads and bodies are proportionately different from that of an adult, the extent of a burn is calculated differently. This special formula was described in Chapter 28. Discussion Topic: Discuss why the “skin surface compared to body mass” issue in pediatrics is important. How might it impact various injuries and conditions?

Blood Volume Talking Point: Blood loss that might be considered moderate in an adult can be life-threatening for a child. A newborn doesn’t have enough blood to fill a 12-ounce soda can. Discussion Topics: Describe the key anatomic differences between pediatric patients and adults. Describe how anatomic differences in pediatric patients might impact assessment or treatment. Knowledge Application: Have students work in small groups. Assign each group a pediatric patient of a different age. Have groups research and report on potential anatomic differences. Discuss the impact of these differences on assessment and treatment.

Psychological and Personality Characteristics
Point to Emphasize: Each pediatric age group has its own general characteristics of psychosocial development. EMTs should understand baseline expectations. Talking Points: Crying is an expected response in children, especially younger children, and a lack of it can often indicate altered mental status. Crying may make assessment difficult, but it is still possible. Position yourself at the child’s eye level. Speak slowly and quietly to help keep the child calm. Never let the potential of upsetting a child prevent appropriate treatment.

Think About It What techniques would you utilize when attempting to assess a crying infant? Talking Points: Besides the points about assessing a crying child made here, have students brainstorm other ways of calming the child and making assessment easier.

Interacting with the Pediatric Patient
Point to Emphasize: EMTs can improve pediatric interaction by taking into account psychosocial differences and by following best practice guidelines. Talking Points: School-aged children will be able to describe more clearly how they feel and what happened. They will talk honestly, but may feel that injury or illness is punishment for what they did. They must be reassured and told it is all right to feel sick, to be hurt, or to cry. Include parents, teachers, or care providers. continued

Identify yourself Let child know that someone has called or will call parents If no life threats, continue at a calm pace during the evaluation process Let child have a nearby toy Kneel at child’s eye level continued

Smile Touch or hold child’s hand or foot Do not use equipment without first explaining what you will do with it Let child see your face Stop occasionally to find out if child understands Never lie to child Talking Points: Be honest at all times. If something is going to hurt, let the child know. Be sure to tell the child that you are there to help and will not leave. Discussion Topic: Describe how psychosocial development issues might change the way in which you interact with a pediatric patient. How might your approach and interaction be different in a 40-year-old compared to a 4-year-old?

The Adolescent Patient
Talking Points: Adolescents like to be treated as adults and are very sensitive to violations of their dignity or being patronized. When ill or injured, they regress emotionally and need as much support as children. They are also worried about peer opinion and changes to their bodies. However, do not delay treatment or care because you feel the patient may be embarrassed. Knowledge Application: Have students create a growth chart on a class whiteboard. Draw a line representing age and have students fill in key anatomic changes and psychosocial milestones.

Communicating With Toddlers Video
Video Clip Communicating With Toddlers Why should you avoid telling a child what to anticipate too far in advance? How should you position yourself when assessing a child? What are some other guidelines to use when communicating with a toddler? Discuss how to interact with a parent whose child is hurt. Click here to view a video on the subject of communicating with toddlers. Back to Directory

Supporting the Parents or Other Care Providers
Teaching Time: 15 minutes Teaching Tips: Although this is a brief section, it is essential. Emphasize the importance of caregiver interaction. Put the information into the context of a parent’s viewpoint. Discuss how students would feel if their own child were being treated. Caregiver interaction will be necessary on almost every pediatric call. Add caregiver interaction to scenarios throughout this lesson.

Supporting the Parents or Other Care Providers
Possible reactions to child’s illness/injury: denial, shock, crying, screaming, anger, self-blame, guilt May interfere with care of child Ask to help by holding/comforting child and giving medical history Points to Emphasize: The approach that an EMT uses to interact with a pediatric patient and his caregivers significantly impacts the ability to assess and treat the patient effectively. Caregiver reaction varies greatly when a child is sick or injured. The EMT should be prepared for a variety of emotions. The calm and professional demeanor of the EMT will project a calming influence on persons involved in the pediatric emergency scene. Discussion Topics: Discuss how appropriate caregiver interaction can improve the pediatric emergency scene. Describe steps that the EMT might take to improve caregiver reaction on a pediatric emergency scene. Class Activity: Have a class discussion. Ask parents in the class to describe how they would like to be treated if their child were sick or injured. Knowledge Application: Role-play parent interaction. Have students divide into groups and role-play the parts of a pediatric emergency. Practice interaction strategies. Critical Thinking: When might it be appropriate not to involve a caregiver in the care of a child?

Caring and Empathy Video
Video Clip Caring and Empathy What is the difference between empathy and sympathy? Why should an EMT be empathetic toward the patient? Discuss ways in which an EMT can express genuine care for a patient and his family. How can an EMT adjust communication to meet the needs of a pediatric patient? Click here to view a video on the subject of caring and empathy for patient and family. Back to Directory

Assessing the Pediatric Patient
Teaching Time: 30 minutes Teaching Tips: Prepare a diagram or a handout of the pediatric assessment triangle. Multimedia graphics of sick children will enhance discussions of pediatric assessment. Consider showing video clips. Review previous lessons and discuss history taking and family interaction.

Pediatric Assessment Triangle
Point to Emphasize: The pediatric assessment triangle is a tool that allows for a rapid assessment of the severity of an injury or illness by reviewing the appearance, work of breathing, and skin of a pediatric patient. Talking Points: The PAT helps categorize your assessment from across the room. It addresses three critical elements and helps identify immediate life threats. Consider mental status utilizing AVPU (alertness, verbal, unresponsive). Is the child acting appropriately? Discussion Topics: Discuss how you would use the pediatric assessment triangle. How might it aid your assessment, treatment, and decision-making process? Class Activity: Show video clips of sick children. Ask students to apply the pediatric assessment triangle. Discuss their general impressions.

Scene Size-Up and Safety—Pediatric
Talking Points: Even though it is a rare occurrence, children may be at risk from violence. Enter the scene slowly. Look around carefully for any mechanism of injury. Discussion Topics: Describe the components of the pediatric assessment triangle. How do these components relate to your scene size-up?

Primary Assessment: Pediatric Care
Rapidly identifies critical patient Essential component of pediatric assessment Discussion Topic: Why is the primary assessment so important in children?

Forming a General Impression
Talking Points: A great deal of information can and should be gathered from the doorway, before you approach and possibly upset the patient. Is the child well or sick? Generally the child’s behavior and appearance will provide this answer. Critical Thinking: Why is establishing a general impression of a pediatric patient so important? How might the assessment change from the doorway to the point at which you lay hands on the patient?

Assessing Mental Status
Alert Verbal Painful Gently tap unresponsive infant or child Talking Points: Never shake an infant or child.

Assessing Airway Talking Points: Consider not only if the airway is open, but whether it is endangered by depressed mental status, secretions, blood, vomitus, foreign bodies, face or neck trauma, and lower respiratory infections. Be careful not to hyperextend the neck.

Assessing Breathing Talking Points: If the patient is not breathing or breathing inadequately, provide artificial respirations or oxygen. Assess chest expansion, effort of breathing, sounds of breathing, breathing rate, and skin color.

Assessing Circulation
Talking Points: As with an adult check for pink, warm, dry skin and a normal pulse as signs of adequate perfusion. Check a radial pulse in a child and a brachial or femoral pulse in an infant. In patients 5 years or younger, also check the capillary refill.

Identifying Priority Patients
Talking Points: A patient who is considered a high priority for transport is one who gives a poor general impression. The patient may be unresponsive and listless, may not recognize the parent or primary caregiver, or is not comforted when held by a parent but becomes calm and quiet when set down. The patient may have a compromised airway, may be in respiratory distress, or have inadequate breathing causing respiratory distress. The patient has the possibility of shock or uncontrolled bleeding.

Secondary Assessment: Pediatric
Point to Emphasize: Consider anatomic and psychosocial differences when conducting the secondary assessment of a pediatric patient. Talking Points: At times the child might be the only source of history. If this is the case, ask simple yes-or-no questions while obtaining a medical history. A child who can’t tell you where it hurts can usually point. Perform a focused assessment for a medical patient and rapid assessment for a trauma patient. Do your exam in trunk-to-head order to avoid frightening the child. Take and record vital signs, assessing blood pressure only in children older than 3 years. Class Activity: Role-play assessment scenarios. Use programmed patients or manikins and use students as family members to simulate pediatric history taking and assessment.

Physical Exam: Pediatric
Start with toes/trunk and work way toward head. If no injuries, patient should be held in parent’s lap Protect child’s modesty Explain why each piece of clothing must be removed Talking Points: To assist with exams, some providers carry stuffed animals like teddy bears. They can comfort the child, and can be used as a model to explain the examination. Let the child keep the toy after the examination. Many parents, teachers, and day care personnel teach children that strangers should not remove their clothing or touch them. The children that you examine may not understand your intentions and may resist. Some children may become upset because they feel you are taking something away from them. Take your time and do not rush children into accepting all that is happening. Remember that children rapidly lose body heat, so if you expose them, quickly cover them with a blanket. Discussion Topic: Describe how anatomic differences might change the way in which you would conduct a physical examination of a small child.

Physical Exam: Head Do not apply pressure to soft spots
Meningitis and head trauma can cause bulging of fontanelle Sunken fontanelle may be due to dehydration Class Activity: Show video clips of sick pediatric patients. Have groups of students identify critical findings and discuss treatment strategies.

Physical Exam: Nose and Ears
Talking Points: Look for blood and clear fluids coming from the nose and ears. Suspect a skull fracture if present. Children are nose-breathers, so mucus or blood clot obstructions can make it hard for them to breathe. Physical Exam: Nose and Ears

Physical Exam: Neck Vulnerable to spinal cord injuries
Children have proportionately larger and heavier heads Muscles and bone structures are less developed May be sore, stiff, or swollen

Talking Points: If there is no suspected spinal injury, place a flat, folded towel under the patient’s shoulders to get the appropriate airway alignment. Hyperextension or flexion may close off the airway. For medical respiratory problems, the child will probably want to sit up. Physical Exam: Airway

Physical Exam: Chest Be alert for wheezes and other noises
Check for symmetry Check for bruising Check for paradoxical motion and retraction Talking Points: Remember that even though a child’s ribs may not be broken, there may be underlying injuries to the chest organs.

Physical Exam: Abdomen and Pelvis
Note if rigid Check for distension or discoloration Abdominal injury may impede movement of the diaphragm Pelvis Check for stability of pelvic girdle Talking Points: Because a child’s abdominal organs are large in relation to the size of the abdominal cavity, and because there is little protection offered by the still-undeveloped abdominal muscles, these organs are more susceptible to trauma than an adult’s. Children who are 8 years or younger are belly breathers, therefore be aware of any abdominal injury that can compromise breathing.

Physical Exam: Extremities
Capillary refill Distal pulse Pulses Motor Sensory Talking Points: The bones of an infant are more pliable than in older patients. They bend, splinter, and buckle before they fracture.

Reassessment: Pediatric
Mental status Maintain open airway Monitor breathing Reassess pulse Talking Points: Pediatric patients are constantly changing. Continual assessment is essential to good patient care. continued

Reassessment: Pediatric
Monitor skin color, temperature, and moisture Reassess vital signs Ensure all appropriate care and treatment are being given Talking Points: Patients who are stable have vitals reassessed every 15 minutes. Unstable patients have vitals taken every 5 minutes.

Special Concerns in Pediatric Care
Teaching Time: 15 minutes Teaching Tips: Use pediatric manikins to demonstrate airway and breathing management techniques. Take time to review pediatric BCLS and foreign body airway procedures. These will be rarely used skills, but they will be absolutely necessary if the need arises. Take time now to create muscle memory. Relate this lesson to previous discussions about shock. Discuss how this pathophysiology is different in children.

Maintaining an Open Airway
Align and open airway Use head-tilt, chin-lift if no trauma; jaw-thrust with spinal immobilization if trauma is suspected Suction Check blockage of airway by tongue Points to Emphasize: Airway and breathing maintenance, shock care, and prevention of hypothermia are universal points of importance with regard to pediatric care. Anatomic differences slightly alter the typical approach to airway management. EMTs must account for these differences. Discussion Topic: Describe the steps involved in opening a pediatric airway. How is this process different in a child?

Oropharyngeal Airway Talking Point: If the patient doesn’t have a gag reflex, you can insert an oral airway. Push down on the tongue while lifting the jaw.

Nasopharyngeal Airway
Talking Points: If patient has a gag reflex but no head or facial injury, you may insert a nasopharyngeal airway. Review use of the nasopharyngeal airway and contraindications such as head and facial injury. Knowledge Application: Have students work in small groups. Use pediatric airway manikins and equipment to practice airway and breathing management. Nasopharyngeal Airway

Clearing an Airway Obstruction
Identify type: partial or complete Partial obstruction Place patient in position of comfort Offer high-flow oxygen Transport Complete obstruction Perform airway clearance techniques Talking Points: When placing children with partial airway obstruction in position of comfort, do not allow them to lie down. For total airway obstruction in infants less than 1 year old, perform back blows and chest thrusts and use finger sweeps to remove visible objects. Attempt artificial ventilations with a pocket mask or bag-valve-mask. Discussion Topic: Describe the process for clearing a foreign body airway obstruction in a pediatric patient. Knowledge Application: Use a pediatric manikin to simulate foreign body airway scenarios. Practice treatment strategies. continued

Talking Points: Note back blows and properly supporting the infant to dislodge the object. continued

Talking Points: Note chest thrust used to relieve total airway obstruction in the infant.

Providing Supplemental Oxygen and Ventilations
Talking Points: For the blow-by oxygen technique, hold or have the parent hold oxygen tubing or the pediatric nonrebreather mask 2 inches from the patient’s face. Some departments have blow-by devices in the form of stuffed animals. Some children respond well when oxygen tubing is pushed through the bottom of a paper cup, especially if the cup is colorful or has a picture drawn inside it. Do not use styrofoam cups. Discussion Topic: Discuss how you might deliver supplemental oxygen if your pediatric patient will not tolerate a mask. continued

Talking Points: Appropriate sizing of the oxygen mask or BVM is necessary for positive seal resulting in the appropriate amount of oxygen being delivered to the patient. continued

Point to Emphasize: The rate and depth of positive pressure ventilations are different in the pediatric population. Talking Points: Avoid breathing too hard into a pocket mask. Ventilations should be performed at 12–20 per minute or every 3–5 seconds for an infant or child up to puberty, and 10–12 per minute or one every 5–6 seconds if the child has reached puberty. continued

Talking Points: A nonrebreather mask always provides more efficient oxygen delivery and many children tolerate it well. Use blow-by only when more efficient methods fail. Skill Demonstration: Using a pediatric manikin and age-appropriate equipment, demonstrate the following skills: opening the airway, inserting an airway adjunct, positive pressure ventilation, foreign body airway maneuvers, CPR.

Common Causes of Shock in Pediatric Patients
Diarrhea and/or vomiting Infection Trauma (especially abdominal injuries) Blood loss Allergic reactions Poisoning Cardiac events (rare)

Signs and Symptoms of Shock in Pediatric Patients
Talking Points: Infants and children are able to compensate for shock for a long time. Compensating methods fail at approximately 30% blood loss, and then hypovolemic shock develops rapidly. This means that a child may appear to be fine, then “go sour” in a hurry, in contrast to the adult patient in whom hypovolemic shock develops earlier and more gradually, making it easier to assess and treat than in a child. Discussion Topic: Describe the most important signs and symptoms of shock in a pediatric patient. How might they be different in an adult? Class Activity: Describe pediatric shock. Have a discussion on how best to recognize it. Discuss how signs may differ in an adult.

Caring for Shock in Pediatric Patients
Talking Points: The definitive care for shock takes place in the hospital (usually in the operating room). Since infants and children are prone to go into hypotensive shock—shock in which the blood pressure has dropped severely—so suddenly, it is important not to wait for signs of hypotensive shock to develop. Provide oxygen and transport as quickly as possible. Critical Thinking: Falling blood pressure is considered a late and inherently unreliable finding in pediatrics. Why might this be the case?

Protecting Against Hypothermia
Cover patient’s head and body Keep patient compartment warm Avoid rough handling Consult medical control about active rewarming of patient Point to Emphasize: Pediatric patients may be more susceptible to hypothermia than adults are. Talking Points: Field care for children is the same as for adults. Avoid rough handling or inserting anything in the patient’s mouth, as these may result in ventricular fibrillation or cardiac arrest in the severely hypothermic child. Suction very gently if suctioning is necessary, and be alert to the possibility of cardiac arrest. Knowledge Application: Use programmed patients or pediatric manikins to simulate assessment scenarios. Be sure to include shock and respiratory issues. Discuss decision-making and recognition strategies.

Think About It How do you balance the need to examine a hypothermic patient with the need to keep the patient covered to maintain warmth? Talking Points: Getting the patient out of the cold, damp environment, if possible, helps. Keeping the patient’s head covered while assessing the rest of the body is essential.

Pediatric Medical Emergencies
Teaching Time: 30 minutes Teaching Tips: Use anatomic models or multimedia graphics to demonstrate anatomic differences in the airway and respiratory systems of a pediatric patient. Use multimedia graphics to demonstrate croup and epiglottitis. Provide audio or video clips of stridor and discuss signs of impending failure. This section lends itself well to scenario work. Tie in previous lessons with simulated patients.

Respiratory Disorders
Likeliest cause of cardiac arrest in a child, other than trauma Distinguish whether probable cause is upper or lower airway problem Care for upper airway obstruction not indicated for lower airway disorder Critical to be alert for early signs of respiratory failure Point to Emphasize: The most likely cause of cardiac arrest in a child, other than trauma, is respiratory failure. Class Activity: Research and discuss local protocols regarding pediatric cardiac arrest. What are the local guidelines? Knowledge Application: Use manikins to simulate pediatric cardiac arrest scenarios. Have teams of students practice assessment and treatment.

Signs of Breathing Difficulty
Nasal flaring Retractions Use of abdominal muscles Stridor (high-pitched, harsh sound) Audible wheeze Grunting More than 60 breaths/min Talking Points: Recognizing respiratory distress or failure is an important goal of assessment of a pediatric patient. continued

Signs of Breathing Difficulty
Altered mental status Slowing or irregular respiratory rate Cyanosis Decreased muscle tone Poor peripheral perfusion Decreased heart rate Discussion Topic: Describe the signs of respiratory failure as they might appear in a child. Class Activity: Have a class discussion about recognizing respiratory failure. Relate previous discussions to pediatric patients. Critical Thinking: You are treating an infant in respiratory distress. You notice that his respiratory rate begins to slow and that his pulse drops from 180 to 60 beats per minute. What do these changes in vital signs indicate? How would you respond?

Differentiating Upper and Lower Airway Disorders
Upper airway disorder Affects mouth, throat, larynx Foreign body obstructions, trauma, swelling from burns and infections Commonly identified by difficulty breathing, stridor, or difficulty speaking Point to Emphasize: Although identifying the exact cause of respiratory distress may not be possible, distinguishing an upper airway problem from a lower airway problem will help target immediate treatments. continued

Differentiating Upper and Lower Airway Disorders
Affects large and small bronchiole tubes, alveoli Asthma, pneumonia, other respiratory infections Commonly identified by difficulty breathing, wheezing lung sounds Talking Points: In general, with suspected airway diseases you should transport as quickly as possible if you see or hear wheezing, breathing effort on exhalation, or rapid breathing. Discussion Topic: Discuss how you might differentiate an upper airway disorder from a lower airway disorder. Knowledge Application: Use a programmed patient to simulate respiratory distress scenarios. Have teams assess and treat a variety of complaints. Discuss treatment strategies.

Croup Mild fever and some soreness (daytime) Loud seal-bark cough
Difficulty breathing Restlessness Paleness with cyanosis Point to Emphasize: Recognizing assessment findings of common pediatric respiratory problems will help focus treatment. Talking Points: In the evening, what was a mild fever and soreness turns to a seal-like bark and progresses in the evening hours. Treatment is aimed at placing the patient in position of comfort (usually sitting up). High-flow oxygen (humidified) is preferred. Cool night air may provide relief, but move patient slowly to the ambulance. Do not delay transport unless ordered to by medical direction. Knowledge Application: Have students work in small groups. Assign each group a pediatric respiratory medical emergency. Have the group research and present on pathophysiology and signs and symptoms. Discuss treatment strategies.

Epiglottitis Sudden onset of high fever
Painful swallowing (child often drools) Tripod position Patient sits very still Appears more ill than with croup Talking Points: Patients will often drool to avoid swallowing. Contact ALS. Immediately transport the child sitting on parent’s lap. Provide-high concentration oxygen from a humidified source. Constantly monitor for developing respiratory distress. Do not place anything in the child’s mouth. Discussion Topic: Compare and contrast the assessment findings of epiglottitis and croup.

Fever Remove child’s clothing Cover in towel soaked in tepid water
Monitor for shivering Follow protocols for water or ice chips Don’t submerge in cold water Point to Emphasize: EMTs never should regard a fever as unimportant. Fever can be the most important sign of a variety of serious conditions.

Meningitis Monitor ABCs, vital signs
Provide high-concentration oxygen by nonrebreather mask Ventilate with BVM or pocket mask if necessary Provide CPR Be alert for seizures Transport immediately Point to Emphasize: Personal protective equipment is important when dealing with probable infectious disorders such as meningitis or diarrhea. Talking Points: Meningitis is a life-threatening infection of the lining of the brain. It occurs between the ages of 1 month and 5 years. The signs and symptoms consist of high fever, stiff neck, lethargy, irritability, headache, and sensitivity to light. In an infant the fontanelles may be bulging unless the child is dehydrated. Movement is painful and the child doesn’t want to be touched or held, and may have seizures. Some forms of meningitis are highly infectious requiring EMS personnel to be evaluated and given antibiotics by a physician.

Diarrhea and Vomiting Maintain open airway Provide oxygen
Contact medical control if signs of shock are present Immediate transport Talking Points: Some systems recommend that you save a sample of the vomit and rectal discharge. Infants are more susceptible to the effects of dehydration because a greater percentage of their body is water and their fluid maintenance needs are greater.

Seizures Maintain open airway (not oral airway)
Position on side if no spinal injury Be alert for vomiting Provide oxygen Transport Talking Points: Fever is the most common cause of seizures in infants and children. Consider seizures life-threatening. During assessment, ask, “Has the child had prior seizures?” If yes, then question if this is a normal seizure pattern. (How long did it last?) Has the child had a fever? Has the child taken any anti-seizure or other medications? Be aware that seizures may be caused by head trauma. Discussion Topic: Describe the treatment priorities for the following pediatric medical emergencies: fever, meningitis, nausea and vomiting, seizures.

Altered Mental Status Be alert for MOI Be alert for signs of shock
Look for evidence of poisoning Attempt to get history of diabetes and seizure disorder

Poisoning Contact poison control center Consider activated charcoal
Provide oxygen Transport Continue to monitor responsiveness

Care for Unresponsive Poisoning Patient
Ensure open airway Provide oxygen Be prepared to provide artificial ventilation Transport Rule out trauma

Drowning Provide artificial ventilation or CPR Protect airway
Consider spinal immobilization Protect against hypothermia Treat any trauma Transport

Sudden Infant Death Syndrome
No accepted reason why these babies die Treat as any patient in cardiac or respiratory arrest Resuscitate unless there is rigor mortis Give emotional support for parents Point to Emphasize: It is not up to the EMT to diagnose SIDS. EMTs should treat such patients as they would any other cardiac arrest. Knowledge Application: Role-play death and dying scenarios. Have students play the parts of different participants and act out caregiver interaction on a pediatric arrest scene.

Information About SIDS Video
Video Clip Information About SIDS What is SIDS? What causes SIDS? What age group does SIDS typically affect? What is the Back to Sleep Campaign? Click here to view a video on the subject of Sudden Infant Death Syndrome (SIDS). Back to Directory

Pediatric Trauma Emergencies
Teaching Time: 30 minutes Teaching Tips: Use a discussion about pediatric trauma to underscore earlier (and later) lectures on adult trauma. Treatment is actually very similar. Readdress mechanism of injury and ways in which anatomic differences alter injury patterns. Provide a pediatric reference for mechanism of injury. Describe specific anatomic differences and ways in which they could lead to potential traumatic injuries. Consider exposed abdominal organs, pliable chest, and other significant differences.

Pediatric Injury Patterns
During motor vehicle collisions Unrestrained: head and neck Restrained: abdominal, lower spinal When struck by vehicle Head Abdominal, possible internal bleeding Lower extremity, possible fractured femur Point to Emphasize: Different anatomy leads to slightly different patterns of traumatic injury in pediatric patients. Providers should use their knowledge of pediatric A&P to enhance the assessment and treatment. Talking Points: Trauma is the number one cause of death in infants and children. Blunt trauma far exceeds penetrating trauma in this age group. Much of this trauma occurs because children are curious and learning about their environment. Exploring often leads to injury from accidental falls (or things falling on them), burns, entrapment, crushing, and other MOIs. Knowledge Application: Use multimedia graphics to demonstrate various mechanisms of injury. Discuss how these mechanisms might impact the assessment of a pediatric patient. Critical Thinking: Why is the rate of trauma-related death so high in the pediatric population? continued

Pediatric Injury Patterns
Talking Points: In the scene shown, what types of injuries should the EMT suspect based on the MOI? Discussion Topic: Discuss how evaluating mechanism of injury might enhance your patient assessment. Why might this be important in a pediatric patient? Class Activity: Reach back and reuse the multimedia graphics that you used during the initial mechanism of injury lesson in Chapter 13. Show the graphics again and discuss how mechanism of injury might apply to the pediatric patient. Pediatric Injury Patterns

Examine Head Talking Points: The head is proportionately larger and heavier in smaller children. This leads to head injury when the head is propelled forward in a collision.

Talking Points: Head injury presents with shock
Talking Points: Head injury presents with shock. Respiratory arrest is a common secondary side effect. The most frequent signs are altered mental status, nausea, and vomiting. Examine Eyes

Examine Neck

Examine Chest Talking Points: The less-developed respiratory muscles of the chest and more elastic ribs make the pediatric chest more easily deformed.

Contents of Thorax Talking Points: Though pediatric ribs rarely fracture there is more likely to be injury to the structures underneath them.

Auscultate for Breath Sounds
Talking Points: Appropriate evaluation of lung sounds is a requirement, especially due to the anatomical proximity in relation to the diaphragm and abdominal organs. If injured, these structures may also interfere with breathing.

Examine Abdomen Talking Points: Because the abdominal muscles are less developed in children, there can be many hidden injuries in the pediatric patient. Suspect internal abdominal injury when the patient deteriorates even without evidence of external injury. In addition, air in the stomach can distend the abdomen and interfere with artificial ventilation. This may also lead to vomiting. Be prepared to suction the patient.

Abdominal Quadrants Talking Points: Divide the abdomen into quadrants and examine each one, while remembering which organs are located in each quadrant.

Examine Pelvis Talking Points: The pelvis should be evaluated for any fracture.

Examine Arms Talking Points: The patient’s arms should be assessed for pulse, motor function, and sensory function. Discussion Topic: Compare and contrast the treatment of trauma in an adult with the treatment of trauma in a pediatric patient.

Examine Legs Talking Points: Lower extremities should be evaluated for pulse, motor function, and sensory function. Extremity injuries are cared for the same way as they are in an adult.

Examine Back and Spine Talking Points: Always check the back for any other injuries. Spinal precautions should be observed in all trauma patients. Knowledge Application: Use a programmed patient or manikin to simulate trauma scenarios. Have teams practice assessment and treatment strategies.

Immobilizing Child With KED
Talking Points: Open the KED and place padding on it to properly position and align the child’s head and body. Log roll the child onto the KED. Fold the side pieces inward to provide side padding and support and to allow visualization of the chest and abdomen. Since the torso straps will be rolled to the inside, secure the torso with tape. Fold the head flaps securely against the child’s head and tape across the head and chin.

Burns Identify candidates for burn centers
Cover burn with nonadherent sterile dressing Ensure open airway Suction as needed Immobilize spine Transport immediately Talking Points: Burns are a common pediatric injury. Children’s body surface area is larger proportionately to body mass, making them more prone to heat loss. Burned patients who become hypothermic have a higher death rate. Keep the infant or child covered to prevent a drop in body temperature. continued

Burns Talking Points: Review the pediatric differences in the “rule of nines” in Chapter 28 to estimate the extent of burns in children and infants.

Child Abuse and Neglect
Teaching Time: 20 minutes Teaching Tips: Remind students that the prime objective in a potential abuse scenario is treating medical problems. Beware allowing other considerations to come before important medical interventions. Teach students to recognize abuse of all types. Remind students that physical abuse is just one form of abuse. Use multimedia graphics to demonstrate the signs of physical abuse. Review your state’s mandated reporting law. Know regulations regarding child abuse.

Signs of Possible Physical and Sexual Abuse
Slap marks, bruises, abrasions, lacerations, incisions Broken bones Head injuries Abdominal injuries Bite marks Burn marks Points to Emphasize: There is no distinction as to race, creed, ethnicity, or economic background with regard to child abuse. Psychological abuse, neglect, physical abuse, and sexual abuse are all forms of child abuse. As they assess any child, EMTs should be alert for characteristic physical findings of potential abuse. Scene clues and social interaction also can demonstrate potential abuse. Discussion Topic: Discuss the forms of child abuse and neglect. Give specific examples of each type. Knowledge Application: Have students work in small groups. Assign each group a different type of abuse. Have each group research and report on the findings associated with its topic.

Possible Indicators That Adult Is Abuser
Inappropriate concern about child Trouble controlling anger Appears to be in deep depression Indications of alcohol or drug abuse Suicidal thoughts Discussion Topic: Describe scene clues and assessment findings that might suggest abuse or neglect. Knowledge Application: Role-play caregiver interaction scenarios. Have students practice handling various family-related situations. Critical Thinking: You are called to treat a woman in the custody of police. She was arrested after fighting with another woman over drugs. Her children were present at the fight and are present now. Could this be considered an abuse scenario? If so, why?

Care for Abuse Patients
Dress and provide other appropriate care Preserve evidence Transport Talking Points: In preserving evidence, discourage the child from going to the bathroom. Give nothing by mouth. Do not have the child wash or change clothes. Knowledge Application: Use a programmed patient to simulate potential abuse situations. Have teams assess a variety of complications. Discuss treatment strategies.

Role of EMT in Cases of Suspected Abuse or Neglect
Gather information from adults without judgment Talk with child separately Plainly and clearly report to medical staff any finding or suspicion regarding physical or sexual abuse Point to Emphasize: If an EMT encounters potential abuse, he should not be judgmental. The focus should be on providing care and transport for the child. Talking Points: As you assess the patient and provide appropriate care, control your emotions and hold back accusations. Do not indicate to the parents or other adults at the scene that you suspect child abuse or neglect. Do not ask the child if he has been abused. If you are suspicious about the mechanism of injury, transport the child even though the severity of injury may not warrant such action. continued

Role of EMT in Cases of Suspected Abuse or Neglect
Use terms suspected and possible even when talking to partner, hospital staff, police, and superiors Contact state child abuse reporting hotline Point to Emphasize: Reporting potential abuse is a professional and ethical responsibility of the EMT. In some states, it is a legal requirement. Talking Points: Be familiar with your state laws. Even if reporting possible child abuse or neglect is not a legal requirement in your state, it is a professional obligation. As an EMT, you may be the only advocate an abused child has. Be conscientious. Also bear in mind that your suspicions may be unfounded. Not every injury to a child is the result of child abuse. Suspicions should be aroused not by individual injuries but by patterns of injuries and behavior. Discussion Topics: Discuss the role of an EMT in a potential abuse situation. What are the primary concerns? What are other additional concerns? Discuss your state’s laws and regulations regarding mandated reporting of child abuse. Class Activities: Present an abuse scenario. As a class, discuss the steps that must occur after the call. Discuss local reporting resources. For the above scenario, assign a call documentation homework assignment. Have each student document the call. Review and critique the documentation during the next session.

Think About It What should be your concern if a parent in a possible child abuse case reveals suicidal ideas? Talking Points: The concern should be that the parent may become homicidal in an attempt to relieve the child’s pain as well as his or her own.

Infants and Children With Special Challenges
Teaching Time: 20 minutes Teaching Tips: Invite the family of a child with special challenges. Parents often are happy to discuss and preplan treatment related to their child’s specific challenge. Present a home ventilator. Review the system and discuss basic troubleshooting techniques. Review family interaction in the context of patient assessment. Underscore the use of family and caregivers to obtain valuable patient information.

Common Special Challenges
Premature infants with lung disease Infants and children with heart disease Infants and children with neurological disease Children with chronic disease or altered function from birth Point to Emphasize: Many children who are dependent upon technology live at home. EMS frequently becomes involved when some element of technology that allows these patients to reside at home fails. Most of the parents or caregivers of children with special challenges have received training on how to handle emergencies. Therefore they can be an important resource for assessment information. Discussion Topic: Discuss the term special health care challenges. What type of patient might that term imply? Consider specific examples.

Tracheostomy Tubes Potential complications Obstruction
Bleeding from or around tube Air leaking around tube Infection Dislodged tube Point to Emphasize: Tracheostomy tubes are placed into the child’s trachea to create an open airway. Obstruction, bleeding, air leakage, infection, and dislodged tubes are potential complications. Discussion Topic: Discuss the role of family and caregivers in an emergency involving a child with special health care challenges. continued

Talking Points: Maintain an open airway, suction the tube as needed, allow the patient to stay in position of comfort, such as parent’s lap. Transport to the hospital. Discussion Topic: Describe the potential complications of a pediatric tracheostomy tube. Tracheostomy Tubes

Home Artificial Ventilators
Talking Points: Care includes maintaining an open airway, artificially ventilating with pocket mask or BVM with oxygen, and transport. Discussion Topic: Describe the necessary interventions for a child who is having trouble breathing on a ventilator. Knowledge Applications: Have students interview the family of a child with special health challenges. Have them discuss particular assessment and treatment challenges. Review a home ventilator system. Demonstrate the technique of disconnecting and manually ventilating.

Central Intravenous Lines
Point to Emphasize: Many types of technology support children with special health care needs. EMTs should use the caregiver as a resource when dealing with a malfunction. Talking Points: Central lines are placed close to the heart. Unlike peripheral IV lines, they may be left in place for long term use. Complications may include infection, bleeding, clotting-off of the line, and cracked line. Your care will include applying pressure if there is bleeding and transporting the patient. Central Intravenous Lines

Care for Patients With Gastrostomy Tubes
Be alert for altered mental status Ensure open airway Suction airway as needed Provide oxygen if needed Transport sitting or on right side Talking Points: Gastrostomy tubes are tubes placed through the abdominal wall directly into the stomach. They are used for patients who cannot be fed orally. The largest potential problem is respiratory distress. Patients transported on their right side are transported in that position with the head of the stretcher elevated to reduce the risk of aspiration. Knowledge Application: Use a programmed patient or manikin to create special health care challenge assessment scenarios. Have teams of students practice assessment and treatment strategies. Include family interaction.

Care for Patients With Shunts
Maintain open airway Ventilate with pocket mask or BVM and high-concentration oxygen Transport patient Talking Points: A shunt is a drainage device that runs from the brain to the abdomen to relieve excess cerebrospinal fluid. There will be a reservoir on the side of the skull. If it malfunctions, pressure will increase inside the skull, causing altered mental status. (Altered mental status may also be caused by an infection.) These patients are prone to respiratory arrest. Class Activity: Many services develop preplans for local children with special health care challenges. Use an Emergency Information Form for Children with Special Challenges and create a mock preplan for a special health care challenges child. Critical Thinking: Consider the possibility of a DNR with a special health care child. How might honoring a DNR in the case of a child present circumstances that differ from honoring a DNR in the case of an adult?

The EMT and Pediatric Emergencies
Teaching Time: 15 minutes Teaching Tips: Refer to the lessons on stress in Chapter 2. Discuss pediatric stress in the form of a well-being plan. Ask a critical incident stress professional to come to class and discuss local critical incident stress management resources. Discuss critical incident stress. Emphasize that this type of stress is normal, not a sign of weakness.

Psychiatric Effects on EMT
Pediatric calls are among the most stressful May identify patient with own children May be anxious about dealing with children Most serious stresses over very sick, injured, or abused child, or child who dies during or after emergency care Talking Points: Often the most serious stresses an EMT faces result from pediatric calls that involve a very sick, injured, or abused child, or a child who has died or who dies during or after emergency care. Fortunately, such calls are rare and can be prepared for with advance training. Discussion Topic: Discuss how a serious pediatric call might impact you as a provider after the call is over. Knowledge Application: Design a personalized stress management plan. Include specific steps that you would take to handle critical incident stress. Critical Thinking: Take an inventory of your own personal stressors. What might they be? Do pediatric calls cause stress for everyone?

Dealing With Stress Communicating with and treating children can be learned Care mostly consists of applying knowledge of adult patients and adjusting for children Talk with other EMTs Talk with your service’s counselor Point to Emphasize: When dealing with the aftermath of a stressful pediatric situation, EMTs should use available resources and take active steps to mitigate stress. Talking Points: You may think that you can handle the stress or sorrow by yourself, but experienced EMTs know better. Unless you resolve the impact of stressful events, the problems created may compound and could lead to “burnout.” Discussion Topics: Describe the local procedure for accessing critical incident stress management resources. Discuss what steps you might take if you found a critical incident to be leading to personal stress. Class Activity: Stage a debriefing. Ask a local CISM professional for help and create a mock debriefing session.

Chapter Review

Chapter Review Assessment and treatment of children is often different than for adults. Children often differ from adults both anatomically and psychosocially. continued

Chapter Review Assessment and treatment procedures must take into account these specific differences. As an EMT, you must learn these differences to enable you to better serve this special population.

Remember Pediatric patients present unique anatomy and psychosocial development. EMTs must develop an understanding of core differences to best establish assessment baselines and expectations. continued

Remember Caregiver interaction sets the tone for scene management. Be professional with a calm demeanor. Pediatric assessment triangle allows rapid assessment of severity of injury or illness by reviewing appearance, work of breathing, and skin. continued

Remember Proper pediatric assessment takes into account differences in anatomy and psychosocial development. Airway and breathing maintenance, shock care, and prevention of hypothermia are universal points of importance in pediatric care. continued

Remember Shock is subtle in children. Learn to recognize the signs of compensation. Recognize respiratory failure in children, and differentiate upper and lower airway disorders. continued

Remember Different anatomy leads to slightly different patterns of traumatic injury in pediatric patients. Use your knowledge of pediatric A&P to enhance assessment and treatment. Be alert for findings of potential abuse. Treat medical issues first, then document and report. continued

Remember Many children have special health care needs. Most caregivers are trained to handle emergencies and can be important resources for assessment. Be prepared for unusual circumstances. Critical incident stress management is essential to an EMT’s well-being plan.

Questions to Consider How do you plan to approach your first pediatric call? How do you determine appropriate mental status for a child? Given certain situations, how would you involve the parent or caregiver in treatment?

Critical Thinking You are called to a home for a 3-year-old child who has been running a low-grade fever all day and now is drooling. As you enter the child’s bedroom, you hear what you think is a seal-like bark. continued

Critical Thinking What do you suspect is wrong with this patient? How will you and your partner treat this patient and handle the situation? Talking Points: Although the signs and symptoms seem to point to croup, EMTs should still do a complete assessment of the child to check for other, hidden problems.

Please visit Resource Central on www. bradybooks
Please visit Resource Central on to view additional resources for this text. Please visit our web site at and click on the mykit links to access content for this text. Under Instructor Resources, you will find curriculum information, lesson plans, PowerPoint slides, TestGen, and an electronic version of this instructor’s edition. Under Student Resources, you will find quizzes, critical thinking scenarios, weblinks, animations, and videos related to this chapter—and much more.

Introduction to Emergency Medical Care 1

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