Caring for Infants and Children

Caring for Infants and Children
23 Caring for Infants and Children

Define the following terms:
Objectives Review the major stages of lifespan development for the pediatric patient (Chapter 4). Define the following terms: Abuse Adolescent Croup Epiglottitis Febrile Infant Mandated reporter Neglect (continued)

Define the following terms:
Objectives Define the following terms: Pediatric Assessment Triangle (PAT) Retractions School age Shaken-baby syndrome Sudden Infant Death Syndrome (SIDS) Toddler Work of breathing (continued)

Explain the components of the pediatric assessment triangle.
Objectives Explain various techniques that can be employed to maximize successful assessment of the pediatric patient. Explain the components of the pediatric assessment triangle. State the most common cause of cardiac arrest in the pediatric patient. Describe the signs and symptoms of sudden infant death syndrome (SIDS). Explain the appropriate steps for management of a suspected SIDS death. (continued)

Describe common signs and symptoms of abuse and neglect.
Objectives Describe common signs and symptoms of abuse and neglect. Explain the role of the Emergency Medical Responder in cases of suspected abuse and/or neglect. Explain the assessment and management of the following emergencies in pediatric patients: Upper airway obstruction Lower reactive airway disease Seizures Shock (continued)

Demonstrate the application of the pediatric assessment triangle.
Objectives Demonstrate the ability to properly assess and care for a pediatric patient. Demonstrate various techniques that can be employed to maximize successful assessment of the pediatric patient. Demonstrate the application of the pediatric assessment triangle. Demonstrate sensitivity for the feelings of the family while caring for an ill or injured pediatric patient. (continued)

Objectives Recognize the emotional impact that responding to pediatric patients can have on the Emergency Medical Responder. Value the role of the Emergency Medical Responder with respect to patient advocacy.

Media Slide 20 Pediatric Body Systems Animation

Topics Caring for the Pediatric Patient
Assessment of Infants and Children Managing Specific Medical Emergencies Managing Trauma Emergencies

CARING FOR THE PEDIATRIC PATIENT

Caring for the Pediatric Patient
Characteristics of Infants and Children Approach them slowly; establish eye contact; ask permission to get closer. Let them know someone will call their parents. Get down at eye level with child. Let them see your face and expressions; speak directly to them. Discussion Question: How can practice sessions and training drills with only pediatric patients improve responder's skills?

Talking Point: Keep in mind that responders in uniform may be frightening to some children. Be as nonthreatening as possible. Help Me Joey, my foot hurts. Get down at eye level and speak directly to the child.

Characteristics of Infants and Children Pause to find out if child understands what you have said or asked. Quickly determine any life-threatening problems; care for them immediately. Perform a toe-to-head assessment. (continued)

Infants

Children

Characteristics of Infants and Children Always tell children what you are going to do before each step of assessment. Never lie to children. Offer comfort by stroking their foreheads or holding their hands. Do not direct all your conversation to parents; talk to child. Talking Point: It is considered offensive by some cultures to touch or pat a child on his or her head; so it's best to avoid this practice when providing comfort. (continued)

Characteristics of Infants and Children Work with reactions of parents or primary caregivers; ask anxious caregivers to help you with tasks. Parents will know how to manage any special pediatric medical equipment. Help keep the parents calm. Discussion Question: Why might it be helpful to conduct your assessment while the child is in his/her mother's arms?

Age, Size, and Response Infants: babies from birth to one year old. Toddlers: child from one to three years old. Preschool: child from three to six years old. School age: child between the ages of 6 and 12 years. Adolescent: child between the ages of 12 and 18 years old. Discussion Question: How might providing medical treatment to a 17 year-old adolescent, who is the size of a fully grown man, differ from the medical care given to an adult? How might the emotional care for this same patient differ?

Special Considerations Child's head is proportionately larger and heavier than his body. Handle head of newborn with caution because of fontanels (soft spots). Teaching Tip: Describe the implications of the proportionally large infant or young child head. How might an EMR have to adjust treatment to account for its size?

Click here to view an animation on the anatomy of children and body systems.
BACK TO DIRECTORY

Developmental Characteristics of Infants and Children
(continued) Developmental Characteristics of Infants and Children

(continued) (continued) Developmental Characteristics of Infants and Children

(continued) Developmental Characteristics of Infants and Children

Special Considerations Airway and respiratory systems of infant and child are not fully developed. Infants are primarily nose breathers. Overextending child's neck during airway management can cause trachea to collapse and obstruct airway. Teaching Tip: Use multimedia graphics to highlight anatomical differences. Consider using graphics of the pediatric airway and the developing skull. (continued)

When an infant or young child is supine, the head will tip forward, obstructing the airway.

To keep the airway aligned, place a folded towel under Joshua’s shoulders.

Special Considerations Chest is more elastic; when child's breathing is labored or distressed, chest movement is obvious. Look for loss of symmetry (unequal appearance on both sides of chest); unequal chest movement with breathing; bruising over chest. Discussion Question: What are the key anatomical differences between pediatric patients and adults? (continued)

Special Considerations Abdominal organs (liver and spleen) are large for size of cavity; more susceptible to injury. Can lose large amount of blood into pelvic cavity; result of trauma to pelvic girdle. Assess circulation, sensation, and motor function in distal extremities. Teaching Tip: Use a liquid to demonstrate the amount and appearance of a serious pediatric blood loss. (continued)

Special Considerations Bones are less developed and more flexible; growth plate is developing tissue and weakest area of growing bone. Infants and children have large amount of total surface area (skin) in proportion to total body mass. Discussion Questions: Why is the “skin surface compared to body mass” issue in pediatrics important? How might it impact various injuries and conditions? (continued)

Special Considerations Smaller the patient, the less blood volume patient has. Pulse and respiratory rates vary with size of child; smaller the child, higher rates are. (continued)

Pulse and Respiratory Rates

Special Considerations Blood pressure varies in children and depends on sex, age, and height. Time of day Physical activity Emotional moods or feelings Physical condition Use appropriate size cuff. Discussion Question: Are anatomical differences always related to age? Consider conditions that might affect growth and therefore create similar anatomical differences.

Think About It You respond to the home of a 9-month-old female who began choking on a small toy and now cannot breathe. How will you proceed? While attempting to dislodge the obstruction, the baby becomes unresponsive. What do you do next? Class Activity: Using infant manikins, direct students to work in pairs to provide relief from foreign body airway obstruction followed by CPR.

ASSESSMENT OF INFANTS AND CHILDREN

Assessment of Infants and Children
Scene Size-up Approach slowly so you do not frighten child. Determine scene safety; number of patients involved. Determine MOI or NOI. Don PPE. Call immediately if additional resources needed.

Primary Assessment In children, general impression is important indicator of severity of illness. Pediatric assessment triangle (PAT): tool used to perform general impression of pediatric patient; elements are appearance, work of breathing, and circulation (perfusion). Teaching Tip: Prepare a diagram or a handout of the Pediatric Assessment Triangle to distribute to students. Discussion Question: How do these components relate to your scene size-up? (continued)

Discussion Question: How might the PAT aid your assessment, treatment, and decision-making process?
Help me Mexica, I feel poopy  Pediatric assessment triangle. (American Academy of Pediatrics)

Primary Assessment High priority infant or child Poor general impression Altered mental status Airway problem Respiratory distress or inadequate breathing Developing shock; evidence of bleeding that may result in shock Discussion Question: What are some pediatric-specific findings that indicate respiratory distress? (continued)

Primary Assessment Airway first concern in care of any patient. Infant's tongue can easily obstruct airway. Do not perform blind finger sweeps. Provide oxygen to children by using blow-by technique per local protocols.

Hold the oxygen mask close to the child's face to provide blow-by oxygen. I can breathe better now, thanks Darryl.

Secondary Assessment Focus on getting history and conducting physical exam. For child who is seriously injured or sick, perform a rapid assessment. Patient with significant MOI Unresponsive patient Discussion Question: How might the procedures for obtaining pediatric vital signs differ from the adult procedures? (continued)

Secondary Assessment Child responding or acting normally. Trauma patient with no significant MOI Responsive medical patient Physical exam similar to adult except, for frightened or crying infant or young child, perform in reverse order (toe to head). Discussion Question: Blood pressure is considered a late and inherently unreliable finding in pediatric patients. Why might this be the case?

Reassessment Status of child can change rapidly and frequently. Reassess mental status, maintain airway, monitor breathing, check pulse, and reevaluate skin color, temperature, and condition. Take vital signs every five minutes for unstable patients; every 15 for stable patients. Class Activity: Using infant and child manikins or pediatric patient volunteers, direct students to complete an assessment. Discuss successful and unsuccessful strategies.

Think About It You respond to an apartment to find a 7-year-old female supine on a sofa. Her mother reports that she has been complaining of a sore throat for several days. She appears lethargic, her respirations are shallow, and her skin is very hot and flushed, even after taking a fever reducer. How will you proceed?

MANAGING SPECIFIC MEDICAL EMERGENCIES

Managing Specific Medical Emergencies
Respiratory Emergencies Most common cause of cardiac arrest in infants and children is respiratory arrest. Review Chapter 8 for signs and symptoms and management of partial and complete airway obstruction for pediatric patients. (continued)

(continued) Algorithm for the emergency care of pediatric patients with respiratory emergencies.

Respiratory Emergencies Difficulty breathing Simple cold Respiratory infection Apnea: interrupted breathing Sleep apnea: interrupted breathing while sleeping. Discussion Question: Why should the EMR consider any airway problem or breathing difficulty a life-threatening emergency in the pediatric patient? (continued)

Respiratory Emergencies Croup: acute respiratory condition common in infants and children; barking type of cough or stridor. Epiglottitis: swelling of epiglottis (leaf like flap) caused by bacterial infection; may cause airway obstruction. Teaching Tip: Use multimedia graphics to demonstrate croup and epiglottitis. Provide audio clips of stridor and discuss signs of impending respiratory failure. Compare and contrast the pathophysiology of croup and epiglottitis. Discuss the differences in the signs and symptoms of each.

Respiratory Distress: Signs-Symptoms Wheezing or high-pitched harsh noise, or grunting Exhaling with abnormal effort Breathing faster or slower than normal; inadequate; requires assisted ventilations and oxygen Use of accessory muscles to breathe Talking Point: Do NOT waste time trying to listen to lung sounds before administering oxygen. (continued)

Respiratory Distress: Signs-Symptoms Child holding a tripod position Drooling Nasal flaring Cyanosis (late sign) Critical Thinking: Why is it important to avoid any actions that might agitate or stimulate the child in respiratory distress? (continued)

Respiratory Distress: Signs-Symptoms Capillary refill of more than two seconds (late sign) Slow heart rate (late sign) Altered mental status (late sign) Critical Thinking: Why might capillary refill, slow heart rate, and AMS be late (and ominous) signs in the pediatric patient? Discuss how typically healthy children have the capacity to compensate longer than adults, but quickly decompensate without warning.

Respiratory Emergencies Asthma can be life-threatening if left untreated. Use prescribed medication or inhaler. Signs and Symptoms Shortness of breath Wheezing Obvious respiratory distress Discussion Question: How would you describe the signs and symptoms of a critical asthma patient? (continued)

Respiratory Emergencies Asthma Signs and Symptoms Cough Faster than normal breathing rate Increased heart rate Sleepiness or slowed response Bluish (cyanotic) tint to skin (continued)

Respiratory Emergencies Provide oxygen by pediatric-size nonrebreather mask or using blow-by technique. Provide assisted ventilations with pediatric-size bag-mask and supplemental oxygen; call for support. HOMEWORK: Assign individual students or small groups a pediatric respiratory disorder. Have the students or groups research and then present to the class the pathophysiology, signs, symptoms, and treatment strategies.

If respirations are inadequate, provide assisted ventilations with the bag-mask device. Ventilate ‘em Ed!

Seizures Cause sudden change in mental status, sensation, behavior, movement. Convulsion: severe forms of seizure that cause violent muscle contractions. Result of high fever, epilepsy, infections, poisoning, low blood sugar (hypoglycemia), head injury. Discussion Question: What is the pathophysiology and treatment of a febrile seizure? (continued)

Seizures Febrile seizures caused by fever should be taken seriously. After seizure, normal for child to be either lethargic and difficult to arouse or agitated and combative. Any child who has had a seizure must have a medical evaluation. Talking Point: Febrile seizures can be frightening to a parent. In addition to providing patient care, reassure the parents or primary caregiver.

Altered Mental Status Low blood sugar (hypoglycemia) Poisoning Infection Head injury Decreased oxygen levels Shock Seizures

Shock Losing large amounts of fluid from diarrhea and vomiting; dehydration Blood loss Abdominal injuries; other trauma Allergic reactions; poisoning Shock from fluid loss occurs quickly in infants and is a serious emergency. Critical Thinking: Why is it important to treat for shock even before a child presents with signs and symptoms? (continued)

Algorithm for the emergency care of pediatric patients with signs of shock.

Shock Decompensated shock: body's compensating mechanisms suddenly fail. Rapid heart and respiratory rate Weak or absent pulse Delayed capillary refill Decreased urine output Critical Thinking: Mental status is a key indicator of shock, but is often difficult to assess in the pediatric population. How might you determine the mental status of a patient who is too young to talk?

Fever Body's normal response to many childhood diseases and infections is high temperature or fever. May be caused by heat exposure, noninfectious disease, childhood immunization shots. Critical Thinking: Why might a fever be more serious in a neonate? (continued)

Fever Fever with rash, long bouts of diarrhea and vomiting, little intake of fluids, that rose rapidly with or without seizure are all indications that potentially serious medical condition may be present. Child with high fever will be flushed (red) and dry. Critical Thinking: Why might it be helpful to ask the caregiver if a fever reducer has been given and if so; at what time and at what dose?

Algorithm for the emergency care of pediatric patients with signs of fever.

Hypothermia Children lose body heat through their heads. Children cannot conserve heat well; does not take long to develop hypothermia. Unable to regulate temperatures as well as adult bodies can. Can become chilled through environment, injury, or illness. Body surface area is greater Talking Point: Adults need to be careful not to assume that because they are tolerating a cool environment, that a child is able to tolerate it equally.

Diarrhea and Vomiting Dehydration: lose of large amounts of needed body fluids through vomiting and diarrhea; normal reactions to illness. Infants more susceptible to dehydration than adults. Sunken eyes and fontanels Discussion Question: How might dehydration lead to shock in pediatric patients? Discuss treatment strategies. (continued)

Diarrhea and Vomiting Feverish for some time; vomiting without taking in any fluids; had diarrhea for several days. Balance of fluids-in to fluids-out needed to maintain muscle and organ function. Shock can result when large amounts of fluids are lost.

Poisoning Can affect any or all of body's systems; can rapidly threaten life of child. Drowning Child submerged in water may still be alive or clinically dead (no breathing and no heartbeat) but not biologically dead (brain cells are still alive). Teaching Tip: Review local protocol for contacting medical direction for poisoning. Share the number for the Poison Control Center.

Sudden Infant Death Syndrome (SIDS) Sudden unexplained death of apparently healthy baby during sleep. Most common first year of life but can occur in children as old as two years. Causes and theories still being investigated. Start emergency care as you would for any patient in cardiac arrest. Teaching Tip: Discuss the important components of a SIDS-related history, including how best to interact with parents.

Think About It 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 will you proceed?

MANAGING TRAUMA EMERGENCIES

Managing Trauma Emergencies
Trauma number one cause of death in people 1 to 18 years of age. Motor-vehicle crashes Drowning; burns Firearms; falls Blunt and penetrating trauma Abuse; entrapment Crushing Teaching Tip: Discuss prevention and the role the EMR can play in promoting prevention of injuries to children.

Algorithm for the emergency care of an injured pediatric patient.

(continued) Algorithm for the assessment and emergency care of injured pediatric patients with musculoskeletal emergencies.

(continued) Algorithm for the assessment and emergency care of pediatric patients with bleeding, shock, and soft-tissue injuries.

Burns Rule of nines percentage of body surface area different for children: 18 percent to head and neck 18 percent to chest and abdomen 9 percent to each arm 18 percent to entire back 14 percent for each leg 1 percent to genital area (continued)

Burns Carefully and quickly care for burned area with dry, sterile, non-adherent dressings or sheets. Follow local protocols. Burns are excruciatingly painful; children are likely to be frantic; rapid transport is important.

Suspected Abuse and Neglect Abuse: physical, emotional, or sexual mistreatment of another person. Calls involving pediatric patients can be especially difficult emotionally. Collect information, perform assessments, provide care without making judgment or expressing your suspicion, distaste, or disbelief. Teaching Tip: Review state regulations regarding reporting child abuse and neglect. (continued)

Suspected Abuse and Neglect Report concerns and impressions to ambulance personnel, medical direction, social services, health department, or law enforcement per local protocols. Mandated reporters: those designated by law to report cases of suspected abuse or neglect. Discussion Question: What is the role of an EMR in a potential abuse situation? (continued)

Suspected Abuse and Neglect Psychological abuse: emotional or verbal abuse that seriously affects child's positive emotional development, well-being, and self-esteem. Neglect: failure of parents/caregivers to adequately provide for person's basic physical, social, emotional, and medical needs. 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 and are present. Could this be considered an abuse scenario, and if so, why? (continued)

Suspected Abuse and Neglect Sexual abuse: physical sexual contact or exposure and sexual exploitation by displaying or photographing children for sexual purposes or with sexual intent. Do not expect abuser to admit sexual abuse is reason for call. Talking Point: Adults are often uneasy talking about sexual abuse. Remember that the EMR must always be an advocate for a patient, regardless of the uncomfortable nature of the abuse. (continued)

Suspected Abuse and Neglect Physical abuse: any form of violent, harmful contact with a child or any disfiguring act performed on child. Child's relationship with parents or parent's attitude toward child or situation may be clue to abuse. Discussion Questions: What are the primary concerns? What are other additional concerns? (continued)

Suspected Abuse and Neglect Shaken-baby syndrome: abuser violently shakes infant or small child, creating whiplash-type motion that causes acceleration-deceleration injuries. It is a serious emergency. Teaching Tip: Describe the elements of a well-documented call about suspected abuse involving shaken-baby syndrome.

Safety Seats Many safety seats are not installed correctly; children are often not secured properly by safety straps/harnesses. Any vehicle crash should lead you to suspect child has been injured. Discussion Question: How might evaluating mechanism of injury enhance your patient assessment? Why might this be important in a pediatric patient?

(continued) Child Safety Seats

Megan Loh, you don’t look happy
Megan Loh, you don’t look happy. Rescuer 1 stabilizes car seat in upright position and applies manual head/neck stabilization. Rescuer 2 prepares equipment, then loosens or cuts the seat straps and raises the front guard. (continued)

Cervical collar is applied to patient as (Rescuer 1) Gabriella maintains manual stabilization of the head and neck. (continued)

As Gabriella maintains manual head/neck stabilization, Johnathan (Rescuer 2) places child safety seat on center of backboard and slowly tilts it into supine position. Both rescuers are careful not to let the child slide out of the chair. For the child with a large head, place a towel under area where the shoulders will eventually be placed on the board to prevent head from tilting forward. (continued)

Rescuer 1 maintains manual head/neck stabilization and calls for a coordinated long axis move onto the backboard. (continued)

Rescuer 1 maintains manual head/neck stabilization
Rescuer 1 maintains manual head/neck stabilization. Rescuer 2 places rolled towels or blankets on both sides of the patient. (continued)

Rescuer 1 maintains manual head/neck stabilization
Rescuer 1 maintains manual head/neck stabilization. Rescuer 2 straps or tapes patient to board at level of upper chest, pelvis, and lower legs. Do not strap across abdomen. (continued)

Rescuer 1 maintains manual head/neck stabilization as Rescuer 2 places rolled towels on both sides of head, then tapes head securely in place across forehead and maxilla (jaw bone) or cervical collar. Do not tape across chin to avoid putting pressure on neck.

Think About It You respond to a 3-year-old male who has been struck by a car. He is lying prone, crying, but not moving. Why might his injuries be more extensive than those of a 30-year-old who was hit by the same car? How will you proceed? Class Activity: Given the scenario provided and using child manikins, direct students to work in groups of three to assess and treat (including immobilization). Circulate around the room to monitor progress and provide guidance.

SUMMARY

Summary Assessment and emergency care of infants and children is same as adults. Consider special characteristics of pediatric patient's anatomy, physiology, and emotional responses.

Summary Infants breathe through the nose.
If obstructed, they may not immediately open their mouths to breathe. Be sure to clear nostrils of secretions.

Summary When managing airway of infant, make sure large head is in neutral position, neither hyperflexed nor hyperextended. Place folded towel under infant's or child's shoulders to maintain spine and airway in neutral alignment.

Summary Care for respiratory distress in infants and children immediately. For respiratory distress, provide oxygen with pediatric-size nonrebreather mask or by using blow-by technique. Follow local protocols.

Summary For severe distress and respiratory arrest, provide assisted ventilations with appropriate device (pocket face mask or pediatric bag-mask device and supplemental oxygen).

Summary Children tolerate high fevers better than adults.
Fever that rises rapidly can cause seizures. Arrange to transport feverish child. Arrange to transport child who is vomiting and has diarrhea.

Summary Care for shock early.
In infant or child, signs and symptoms of shock mean it has progressed and is in the late stages. If you suspect shock may result from the MOI or NOI, provide emergency care immediately.

Summary Infants and children are frequent victims of trauma, because of their size, curiosity, and lack of fear due to their inexperience. Keep in mind that their larger head size and weight make pediatric patients more prone to head and neck trauma.

Summary Be calm, professional, and discreet about suspicions of abuse or neglect in presence of caregivers. Be an advocate for the child. Remember your obligation to report any suspicions to proper authorities.

REVIEW QUESTIONS

What are the components of the pediatric assessment triangle?
Review Questions What are the various techniques that can be used to help with the assessment of the pediatric patient? What are the components of the pediatric assessment triangle? What is the most common cause of cardiac arrest in the pediatric patient? What are the signs and symptoms of sudden infant death syndrome (SIDS)? (continued)

What are common signs and symptoms of abuse and neglect?
Review Questions What are the appropriate steps for management of a suspected SIDS death? What are common signs and symptoms of abuse and neglect? What is the role of the Emergency Medical Responder in cases of suspected abuse and/or neglect? (continued)

Upper airway obstruction? Lower reactive airway disease? Seizures?
Review Questions In treating the pediatric patient, how would you assess and manage: Upper airway obstruction? Lower reactive airway disease? Seizures? Shock?

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Caring for Infants and Children

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