1. Pediatrics

2. Pediatric Age Classifications
Newborn First few hours of life
Neonate First 28 days of life
Infant Up to 1 year of age
Toddler 1 to 3 years of age
Preschooler 3 to 5 years of age
School age 6 to 12 years of age
Adolescent The period between the end of childhood (beginning of puberty) and adulthood (18 years of age)

3. Developmental Stages and Approach Strategies
Infants
Toddlers
Preschoolers
School-age children
Adolescents
Major fears
Characteristics of thinking
Approach strategies

4. Anatomy and Physiology Review for Pediatric Patients

5. Head Proportionally larger size Larger occipital region
Fontanelles open in infancy
Face is smaller in comparison to size of head
Paramedic implications

6. Airway Narrower at all levels Infants are obligate nasal breathers
Jaw is posteriorly smaller in young children
Larynx is higher (C3-C4) and more anterior
Cricoid ring is the narrowest part of the airway in young children
Tracheal cartilage is softer
Trachea is smaller in both length and diameter

7. Airway Epiglottis Omega shaped in infants
Extends at a 45degree angle into airway
Epiglottic folds have softer cartilage; more floppy, especially in children

8. Chest and Lungs Ribs are positioned horizontally
Ribs are more pliable and offer less protection to organs
Chest muscles are immature and fatigue easily
Lung tissue is more fragile
Mediastinum is more mobile
Thin chest wall allows for easily transmitted breath sounds

9. Abdomen Immature abdominal muscles offer less protection
Abdominal organs are closer together
Liver and spleen are proportionally larger and more vascular

10. Extremities Bones are softer and more porous until adolescence
Injuries to growth plate may disrupt bone growth
Site for IO access

11. Skin and Body Surface Area (BSA)
Skin is thinner and more elastic
Thermal exposure results in deeper burn
Less subcutaneous fat
Larger surface area to body mass

12. Respiratory System
Tidal volume is proportionally smaller to that of adolescents and adults
Metabolic oxygen requirements of infants and children are about double those of adolescents and adults
Children have proportionally smaller functional residual capacity, and therefore proportionally smaller oxygen reserves

13. Cardiovascular System
Cardiac output is rate dependent in infants and small children
Vigorous but limited cardiovascular reserve
Bradycardia is a response to hypoxia
Children can maintain blood pressure longer than adults
Circulating blood volume is proportionally larger than adults
Absolute blood volume is smaller than adults

14. Nervous System Develops throughout childhood
Developing neural tissue is more fragile
Brain and spinal cord are less well protected by skull and spinal column
Open fontanelles in early months

15. Metabolic Differences
Infants and children have limited glycogen and glucose stores
Blood glucose can drop very low in response to stressors
Significant volume loss can result from vomiting and diarrhea
Children are prone to hypothermia due to increased body surface area
Newborns and neonates are unable to shiver to maintain body temperature

16. Illness and Injury by Age Group
Some childhood diseases and disabilities are predictable by age group
Neonate (first 28 days of life)
1– to 5–month–old infant
6– to 12–month–old infant
1– to 3–year–old child
3 –to 5–year–old child
6–to 12–year–old child
12–to 15–year–old adolescent

17. General Principles of Pediatric Assessment

18. General Considerations
Many components of the initial patient evaluation can be done by observing the patient
Use the parent/guardian to assist in making the infant or child more comfortable as appropriate
Interacting with parents and family
Normal responses to acute illness and injury
Parent/guardian and child interaction
Intervention techniques

19. Scene Assessment Observe the scene for hazards or potential hazards
Observe the scene for mechanism of injury/illness
Ingestion
Pills, medicine bottles, household chemicals, etc.
Child abuse
Injury and history do not coincide, bruises not where they should be for mechanism of injury, etc.
Position patient found

20. Scene Assessment
Observe the parent/guardian/caregiver interaction with the child
Do they act appropriately?
Is parent/guardian/caregiver concerned?
Is parent/guardian/caregiver angry?
Is parent/guardian/caregiver indifferent?

21. Initial Assessment General impression
General impression of environment
General impression of parent/guardian and child interaction
General impression of the patient/pediatric assessment triangle
A structure for assessing the pediatric patient
Focuses on the most valuable information for pediatric patients
Used to ascertain if any life-threatening condition exists
Components
Figure 43-1

22. Triage Decisions Initial triage decisions
Urgent –proceed with rapid ABC assessment, treatment, and transport
Non urgent –proceed with focused history, detailed physical examination after initial assessment

23. Vital Functions Determine level of consciousness AVPU scale
Alert
Responds to verbal stimuli
Responds to painful stimuli
Unresponsive
Modified Glasgow Coma Scale
Signs of inadequate oxygenation

24. Airway and Breathing Airway – determine patency
Breathing should proceed with adequate chest rise and fall
Signs of respiratory distress
Tachypnea
Use of accessory muscles
Nasal flaring
Grunting
Bradypnea
Irregular breathing pattern
Head bobbing
Absent breath sounds
Abnormal breath sounds

25. Circulation Pulse Blood pressure Skin color Active hemorrhage Central
Peripheral
Quality of pulse
Blood pressure
Measuring BP is not necessary in children less than 3 years of age
Skin color
Active hemorrhage

26. Normal Vital Signs Group Breaths/min Beats/min
Normal Vital Signs
Group
Breaths/min
Beats/min
Expected Mean for Blood Pressure
(Systolic/diastolic)
Newborn
30-50
mm Hg/50-68 mm Hg
Infant
20-30
80-140
mm Hg/56-70 mm Hg
Toddler
80-130
mm Hg/50-70 mm Hg
Preschool
80-120
mm Hg/64-70 mm Hg
School age
(12-20)-30
(60-80)-100
mm Hg/64-80 mm Hg
Adolescent
12-20
60-100
mm Hg/70-82 mm Hg

27. Transition Phase
Used to allow the infant or child to become familiar with you and your equipment
Use depends on the seriousness of the patient's condition
For the conscious, non-acutely ill child
For the unconscious, acutely ill child do not perform the transition phase but proceed directly to treatment and transport

28. Focused History–Approach
For infant, toddler, and preschool age patient, obtain from parent/guardian
For school age and adolescent patient, most information may be obtained from the patient
For older adolescent patient question the patient in private regarding sexual activity, pregnancy, illicit drug and alcohol use

29. Focused History–Content
Chief complaint
Nature of illness/injury
How long has the patient been sick/injured
Presence of fever
Effects on behavior
Bowel/urine habits
Vomiting/diarrhea
Frequency of urination
Past medical history
Infant or child under the care of a physician
Chronic illnesses
Medications
Allergies

30. Detailed Physical Examination
Should proceed from head-to-toe in older children
Should proceed from toe-to-head in younger children (less than 2 years of age)
Depending on the patient’s condition, some or all of the following assessments may be appropriate:
Pupils
Capillary refill
Hydration
Pulse oximetry
ECG monitoring

31. On-Going Assessment Appropriate for all patients
Should be continued throughout the patient care encounter
Purpose is to monitor the patient for changes in:
Respiratory effort
Skin color and temperature
Mental status
Vital signs (including pulse oximetry measurements)
Measurement tools should be appropriate for size of child

32. General Principles in Patient Management
Principles of management depend on patient’s condition and may include:
Basic airway management
Advanced airway management
Vascular access (IV, IO)
Fluid resuscitation
Pharmacological
Nonpharmacological
Transport considerations
Psychological support/communication strategies

33. Communicating With Children
Begin conversations with both the child and parent
Be aware you are collecting the child’s history from a parent’s point of view
Your interview can put the parent on the defensive
Be cautious not to be judgmental if the parents have not provided proper care or safety for the child before your arrival
Be observant but not confrontational
Make contact with the child in a gradual approach as you are interviewing the parent

34. Communicating With Children
Speak to children at eye level
Use a quiet, calm voice
Be aware of your nonverbal communication
Be knowledgeable of communication with children according to their age group

35. Specific Pathophysiology, Assessment, and Management

36. Respiratory Compromise
Several conditions manifest chiefly as respiratory distress in children including:
Upper and lower foreign body airway obstruction
Upper airway disease (croup, bacterial tracheitis, and epiglottitis)
Lower airway disease (asthma, bronchiolitis, and pneumonia)
Most cardiac arrests in children are secondary to respiratory insufficiency thus, respiratory emergencies require rapid prehospital assessment and management

37. Respiratory Compromise
Attempt to calm and reassure the child with respiratory compromise
It is important not to:
Agitate the conscious patient (avoid IVs, blood pressure measurements, examining the patient’s mouth)
Lay the child down (supine)
When possible, allow the parent or other caregiver to remain with the child
Advise the receiving hospital of the patient’s status as soon as possible

38. Special Considerations for Pediatric Patients in Shock
Several special considerations must be taken into account when caring for a child in shock
Circulating blood volume
Body surface area and hypothermia
Cardiac reserve
Respiratory fatigue
Vital sign assessment

39. Dehydration
Profound fluid and electrolyte imbalances can occur in children as a consequence of diarrhea, vomiting, poor fluid intake, fever, or burns
Compromises cardiac output and systemic perfusion if:
Child loses the fluid equivalent of 5% or more total body weight
Adolescent loses 5% to 7% of total body weight
Signs and symptoms
Management

40.      Assessment of Degree of Dehydration in Isotonic Fluid Loss
Assessment of Degree of Dehydration in Isotonic Fluid Loss
Clinical Parameters
Mild
Moderate
Severe
 Body weight loss
Infant
Adult
 5% (50-mL/kg)
3% (30-mL/kg)
 10% (100-mL/kg)
6% (60-mL/kg)
 15% (150-mL/kg)
9% (90-mL/kg)
Skin turgor
Slightly 
 
  
Fontanelle
Possibly flat or depressed
Depressed
Significantly depressed
Mucous membranes
Dry
Very dry
Parched
Skin perfusion
Warm with normal color
Cool (extremities); pale
Cold (extremities)
Heart rate
Mildly tachycardic
Moderately tachycardic
Extremely tachycardic
Peripheral pulses
Normal
Diminished
Absent
Blood pressure
Normal
Normal
Reduced
Sensorium
Normal or irritable
Irritable or lethargic
Unresponsive

41. Severe dehydration.

42. Hemorrhage
Even a relatively small amount of blood loss can be quite serious for the pediatric patient
Management

43. Sudden Infant Death Syndrome (SIDS)
Defined as the sudden death of an apparently healthy infant that remains unexplained by history and a thorough autopsy
The disease cannot be predicted or prevented, although positioning during sleep may be a factor
Incidence
Pathophysiology
Risk factors
Management

44. Child Abuse and Neglect
Follow local protocol in reporting suspected abuse and discuss any suspicions of child abuse or neglect with medical direction

45. Abuse Age considerations Characteristics of the abuser Types of abuse
Indicators of abuse
Historical
Psychosocial
Signs of physical abuse
Signs of emotional abuse
Physical indicators
Behavioral indicators
Signs of sexual abuse
Figure 43-4