Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Infants and Children Chapter 13.

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Outline Differences in A and P Assessment Common Conditions Child Abuse Differences in A and P Assessment Common Conditions Child Abuse

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. It is a natural human reaction to feel a high level of anxiety when faced with a seriously ill or injured child. Lack of familiarity adds to anxiety.

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Airway Differences Trachea more narrow Tongue larger Back of head relatively large compared to rest of body More easily obstructed Trachea more narrow Tongue larger Back of head relatively large compared to rest of body More easily obstructed

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Head Size Larger Head can occlude the airway Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Airway Considerations Place a folded towel under the shoulders to keep the head in a neutral position Carefully measure a suction tip to avoid over-insertion and trauma Use tongue blade to insert OPA Place a folded towel under the shoulders to keep the head in a neutral position Carefully measure a suction tip to avoid over-insertion and trauma Use tongue blade to insert OPA

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Airway Considerations Nasal airways are not used in infants and children Use a bulb syringe to suction the nose and mouth of an infant or toddler Nasal airways are not used in infants and children Use a bulb syringe to suction the nose and mouth of an infant or toddler

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Other Differences Compensate well but only for a short period of time Can deteriorate rapidly Lose heat quickly Compensate well but only for a short period of time Can deteriorate rapidly Lose heat quickly

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment Family-centered care Form a general impression –Interaction with environment –Playing –Moving around –Attentive to voices, faces, activity –Eye contact Family-centered care Form a general impression –Interaction with environment –Playing –Moving around –Attentive to voices, faces, activity –Eye contact

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment Is this child sick? Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Assessment Respiratory status –Breathing effort –Chest expansion –Nasal flaring –Retractions –Noisy breathing Respiratory status –Breathing effort –Chest expansion –Nasal flaring –Retractions –Noisy breathing Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Circulation Palpate brachial pulse for infants and toddlers Palpate radial pulse for older children Assess skin color, temperature, and moisture Palpate brachial pulse for infants and toddlers Palpate radial pulse for older children Assess skin color, temperature, and moisture

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. FBAO - Partial Alert Good skin color May have stridor, crowing or wheezing May have muscle retractions between ribs Good circulation, has strong, equal pulses in the extremities Alert Good skin color May have stridor, crowing or wheezing May have muscle retractions between ribs Good circulation, has strong, equal pulses in the extremities

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. FBAO - Partial Management –Allow the child to assume a comfortable position –Avoid agitation of the child Management –Allow the child to assume a comfortable position –Avoid agitation of the child

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. FBAO - Complete Altered level of consciousness Cyanosis Ineffective cough Increased respiratory effort Child cannot cry or speak Altered level of consciousness Cyanosis Ineffective cough Increased respiratory effort Child cannot cry or speak

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. FBAO - Complete Management –Airway must be cleared immediately –Use ECC guidelines taught in your CPR class –Attempt ventilation by mouth-to-mask Management –Airway must be cleared immediately –Use ECC guidelines taught in your CPR class –Attempt ventilation by mouth-to-mask

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Respiratory Distress If untreated, may lead to respiratory failure and respiratory arrest Signs –Infant with RR > 60 breaths/min –Child with RR > 30–40 breaths/min –Nasal flaring –Muscle retractions between the ribs If untreated, may lead to respiratory failure and respiratory arrest Signs –Infant with RR > 60 breaths/min –Child with RR > 30–40 breaths/min –Nasal flaring –Muscle retractions between the ribs

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Respiratory Distress Stridor Cyanosis Grunting Altered mental status Stridor Cyanosis Grunting Altered mental status

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Respiratory Failure RR < 20 breaths/min (infant) RR < 10 breaths/min (child) Limp muscle tone Unresponsive Slow or absent pulse Cyanosis RR < 20 breaths/min (infant) RR < 10 breaths/min (child) Limp muscle tone Unresponsive Slow or absent pulse Cyanosis

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment Scene size-up Initial assessment Physical exam (if needed) Ongoing assessment Scene size-up Initial assessment Physical exam (if needed) Ongoing assessment

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. The infant or child in respiratory distress may decompensate rapidly. Continuously monitor the airway,breathing, pulse, level of consciousness & skin color.

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Circulatory Failure Causes –Trauma –Congenital heart defects –Poisoning and accidental overdose Causes –Trauma –Congenital heart defects –Poisoning and accidental overdose

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Circulatory Failure Signs –Increased heart rate –Absent pulses in the extremities –Pale, cool skin –Altered mental status Signs –Increased heart rate –Absent pulses in the extremities –Pale, cool skin –Altered mental status

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Management Scene size-up Initial assessment Complete physical exam if needed Ongoing assessment If cardiac arrest occurs perform CPR Scene size-up Initial assessment Complete physical exam if needed Ongoing assessment If cardiac arrest occurs perform CPR

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Convulsions can be dramatic but seizures are not usually life threatening Prolonged seizures are of particular concern Convulsions can be dramatic but seizures are not usually life threatening Prolonged seizures are of particular concern Seizure

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Causes Fever Epilepsy Infections Poisoning Low blood sugar Fever Epilepsy Infections Poisoning Low blood sugar Trauma (especially to the head) Inadequate oxygen to the brain Unknown causes

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. History is Important! Is this the first seizure the child has had? If not, is this seizure different from the usual pattern? Does the child take medications for seizures or other problems? Could the child have taken other medication or poisonous substances? Has the child been injured recently? Has the child been ill? Is this the first seizure the child has had? If not, is this seizure different from the usual pattern? Does the child take medications for seizures or other problems? Could the child have taken other medication or poisonous substances? Has the child been injured recently? Has the child been ill?

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Management If the seizure is ongoing, or another seizure occurs, observe and be able to describe the seizure Move objects by which the patient could be injured out of the way Ask all bystanders, except the parents, to leave the area If the seizure is ongoing, or another seizure occurs, observe and be able to describe the seizure Move objects by which the patient could be injured out of the way Ask all bystanders, except the parents, to leave the area

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Management Never force anything into patient’s mouth –Can’t swallow their tongue –May cause trauma/bleeding and airway obstruction Never restrain patient Place soft object under head if necessary Never force anything into patient’s mouth –Can’t swallow their tongue –May cause trauma/bleeding and airway obstruction Never restrain patient Place soft object under head if necessary

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Management Make sure the airway is clear Once the seizure stops keep the airway open if the patient is unresponsive or place in the recovery position Ventilate patient if cyanotic –Although it may be difficult, if the patient is cyanotic during the seizure, attempt to ventilate, if possible Make sure the airway is clear Once the seizure stops keep the airway open if the patient is unresponsive or place in the recovery position Ventilate patient if cyanotic –Although it may be difficult, if the patient is cyanotic during the seizure, attempt to ventilate, if possible

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. AMS May range from confusion, to sleepiness, to combativeness, to unresponsiveness Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

AMS Causes –Low blood sugar –Poisoning –Seizure –Infection –Head injury –↓ O 2 to brain Causes –Low blood sugar –Poisoning –Seizure –Infection –Head injury –↓ O 2 to brain Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Management Ensure an open airway Be prepared to suction Be prepared to assist ventilations Ensure an open airway Be prepared to suction Be prepared to assist ventilations Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Management Recovery position if appropriate Calm and reassure the patient and parents Recovery position if appropriate Calm and reassure the patient and parents Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Sudden Infant Death Syndrome

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. SIDS May occur in the first year of life Causes are not fully understood Some risk factors May occur in the first year of life Causes are not fully understood Some risk factors Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Role of the FR Attempt to resuscitate unless obvious signs of death Calm and comfort the parents as much as possible Interacting with the parents may be the most important role Attempt to resuscitate unless obvious signs of death Calm and comfort the parents as much as possible Interacting with the parents may be the most important role

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Role of the FR Realize that the parents may display a range of emotions including grief, guilt, disbelief and anger Although all infant deaths are not SIDS you do not to make that determination Avoid making any statements that might suggest the parents are to blame Realize that the parents may display a range of emotions including grief, guilt, disbelief and anger Although all infant deaths are not SIDS you do not to make that determination Avoid making any statements that might suggest the parents are to blame

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. What does your scene size up tell you? Is trauma a common problem for children? What does your scene size up tell you? Is trauma a common problem for children? Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Trauma is the leading cause of death in children Blunt trauma is most common, but the incidence of penetrating trauma is increasing Differences in anatomy and physiology may create different injury patterns than expected in an adult Trauma is the leading cause of death in children Blunt trauma is most common, but the incidence of penetrating trauma is increasing Differences in anatomy and physiology may create different injury patterns than expected in an adult Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Motor Vehicle Crashes Unrestrained children may sustain head and neck injuries Improperly restrained children may have abdominal and lower spine injuries Many infant car seats and booster seats are improperly installed, leading to injury Unrestrained children may sustain head and neck injuries Improperly restrained children may have abdominal and lower spine injuries Many infant car seats and booster seats are improperly installed, leading to injury

Pedestrian vs Vehicle Children struck by a vehicle are prone to head, spine, abdominal, and femur injuries

Other Causes Falls from a height and diving into shallow water Burns (flame or scald) Sport injuries Child abuse Falls from a height and diving into shallow water Burns (flame or scald) Sport injuries Child abuse

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Specific Injuries Head –The head is proportionally larger and heavier, and is much more easily injured Chest –Ribs are softer and more pliable –Underlying injuries may occur without rib fracture Head –The head is proportionally larger and heavier, and is much more easily injured Chest –Ribs are softer and more pliable –Underlying injuries may occur without rib fracture

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Specific Injuries Abdomen –The location of the organs is more prominent, so they are less protected Extremities –Managed the same as in adults Abdomen –The location of the organs is more prominent, so they are less protected Extremities –Managed the same as in adults

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Communicate at eye level Involve family Assessment sequence the same Communicate at eye level Involve family Assessment sequence the same Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical examination if needed Ongoing assessment as required Physical examination if needed Ongoing assessment as required Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Critical Points Calm and comfort the child and parents Use a jaw-thrust maneuver if spinal injury is possible Manually stabilize the cervical spine Calm and comfort the child and parents Use a jaw-thrust maneuver if spinal injury is possible Manually stabilize the cervical spine Suction the airway as needed Ventilate the patient if necessary Control bleeding If airway, breathing, and circulation are stable, manually stabilize injured extremities

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Child Abuse and Neglect Abuse = improper or excessive actions so as to cause injury or harm Neglect =giving insufficient attention to someone requiring that attention Can occur in any kind of family in any environment All healthcare providers must be able to recognize signs and symptoms of abuse and neglect Abuse = improper or excessive actions so as to cause injury or harm Neglect =giving insufficient attention to someone requiring that attention Can occur in any kind of family in any environment All healthcare providers must be able to recognize signs and symptoms of abuse and neglect

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Signs and Symptoms Multiple bruises in various stages of healing Injuries that are inconsistent with the story given as to their cause Patterns of injury such as cigarette burns, belt or whip marks, handprints Repeated calls to the same address Multiple bruises in various stages of healing Injuries that are inconsistent with the story given as to their cause Patterns of injury such as cigarette burns, belt or whip marks, handprints Repeated calls to the same address

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Signs and Symptoms Scalding burns with a “glove” pattern Untreated burns Parents seem unconcerned with the injury Conflicting stories from child & caregiver; or from two different caregivers The child is afraid to discuss how the injury occurred Scalding burns with a “glove” pattern Untreated burns Parents seem unconcerned with the injury Conflicting stories from child & caregiver; or from two different caregivers The child is afraid to discuss how the injury occurred

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Shaken Baby Syndrome There may be no visible external injuries Violent shaking of an infant or small child can lead to severe injuries of the brain –Can be fatal Often the child will present with seizures When responding to an infant or child with a seizure keep shaken baby syndrome in mind There may be no visible external injuries Violent shaking of an infant or small child can lead to severe injuries of the brain –Can be fatal Often the child will present with seizures When responding to an infant or child with a seizure keep shaken baby syndrome in mind

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Neglect Lack of adult supervision Appearance of malnutrition Unsafe/unsanitary living environment Untreated chronic illness (asthma, seizures, or diabetes without prescriptions refilled) Untreated injuries or acute illness Lack of adult supervision Appearance of malnutrition Unsafe/unsanitary living environment Untreated chronic illness (asthma, seizures, or diabetes without prescriptions refilled) Untreated injuries or acute illness

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Role of the FR Don’t accuse the parents –This can create an unmanageable scene and delay transport Report what you see and hear, not your interpretation of these findings Don’t accuse the parents –This can create an unmanageable scene and delay transport Report what you see and hear, not your interpretation of these findings

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Need for Debriefing Injury, death, abuse or neglect of a child can lead to strong emotional responses on the part of healthcare providers Recognize your feelings and any signs or symptoms of post-traumatic stress in yourself and others involved in the call Make use of CISM resources available to you as needed Injury, death, abuse or neglect of a child can lead to strong emotional responses on the part of healthcare providers Recognize your feelings and any signs or symptoms of post-traumatic stress in yourself and others involved in the call Make use of CISM resources available to you as needed

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Summary Children and infants have special needs due to their differences in size and overall proportions Principles of care are the same as in adults, but techniques and equipment may need to be altered The airway of the child takes highest priority in his care. Assess the need for a folded towel under the shoulders Children and infants have special needs due to their differences in size and overall proportions Principles of care are the same as in adults, but techniques and equipment may need to be altered The airway of the child takes highest priority in his care. Assess the need for a folded towel under the shoulders

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Summary Be alert to different patterns of injury than in an adult Be aware of the resources available for CISM if needed Be alert to different patterns of injury than in an adult Be aware of the resources available for CISM if needed

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Infants and Children Chapter 13.

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Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Infants and Children Chapter 13.

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