Transcript child body

32: Pediatric Assessment and Management
Cognitive Objectives
(1 of 3)
6-1.4 Indicate various causes of respiratory
emergencies.
6-1.5 Differentiate between respiratory distress and
respiratory failure.
6-1.6 List steps in the management of foreign body
airway obstruction.
Cognitive Objectives
(2 of 3)
6-1.7
Summarize EMS care strategies for
respiratory distress and respiratory failure.
6-1.8
Identify the signs and symptoms of shock
(hypoperfusion) in the infant and child patient.
6-1.9
Describe the methods of determining end
organ perfusion in the infant and child patient.
6-1.10 State the usual cause of cardiac arrest in
infants and children versus adults.
Cognitive Objectives (3 of 3)
6-1.12 Describe the management of seizures in the
infant and child patient.
6-1.14 Discuss the field management of the infant
and child trauma patient.
•
There are no affective objectives for this chapter.
Psychomotor Objectives (1 of 2)
6-1.21 Demonstrate the techniques of foreign body
airway obstruction removal in the infant.
6-1.22 Demonstrate the techniques of foreign body
airway obstruction removal in the child.
6-1.23 Demonstrate the assessment of the infant
and child.
Psychomotor Objectives (2 of 2)
6-1.24 Demonstrate bag-valve-mask artificial
ventilations for the infant.
6-1.25 Demonstrate bag-valve-mask artificial
ventilations for the child.
6-1.26 Demonstrate oxygen delivery for the infant
and child.
Additional Objectives*
Cognitive
1. Describe the steps in positioning an infant and/or child
to maintain an open airway.
2. Summarize neonatal resuscitation procedures.
Affective
None
Psychomotor
3. Demonstrate the techniques necessary in neonatal
resuscitation.
*These are noncurriculum objectives.
Pediatric Assessment
and Management
• Caring for sick and injured children presents
special challenges.
• EMT-Bs may find themselves anxious when
dealing with critically ill or injured children.
• Treatment is the same as that for adults in most
emergency situations.
Scene Size-up
• Take note of your surroundings.
• Scene assessment will supplement additional
findings.
• Observe:
– Position of the patient
– Condition of the home
– Clues to child abuse
Initial Assessment
• Begins before you touch the
patient
• Form a general impression.
• Determine a chief complaint.
• The Pediatric Assessment
Triangle can help.
Pediatric Assessment Triangle
• Appearance
– Awake
– Aware
– Upright
• Work of breathing
– Retractions
– Noises
• Skin circulation
Assessing the ABCs
• Ensure airway is open and
position patient.
• Breathing assessment
– Effort
– Obstructions
– Rate
• Circulation assessment
– Rate
– Skin color, temperature,
and capillary refill
Transport Decision
• Children under 40 lb should be transported in a
child safety seat, if the situation allows.
• Seat should be secured to the cot or captain’s
chair.
• Cannot be secured to bench seat
• Child may have to be transported without a seat,
depending on condition.
Focused History and Physical Exam
• Should be completed on scene unless severity
requires rapid transport
• Young children should be examined toe to head.
• Focused exam on noncritical patients
• Rapid exam on potentially critical patients
Vital Signs by Age
Age
Respirations
(breaths/min)
Pulse
(beats/min)
Systolic Blood
Pressure
(mm Hg)
Newborn: 0 to 1 mo
30 to 60
90 to 180
50 to 70
Infant: 1 mo to 1 yr
25 to 50
100 to 160
70 to 95
Toddler: 1 to 3 yr
20 to 30
90 to 150
80 to 100
Preschool age: 3 to 6 yr
20 to 25
80 to 140
80 to 100
School age: 6 to 12 yr
15 to 20
70 to 120
80 to 110
Adolescent: 12 to 18 yr
12 to 16
60 to 100
90 to 110
Older than 18 yr
12 to 20
60 to 100
90 to 140
Respirations
• Abnormal respirations are a common sign
of illness or injury.
• Count respirations for 30 seconds.
• In children less than 3 years, count the rise
and fall of the abdomen.
• Note effort of breathing.
• Listen for noises.
Pulse
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In infants, feel over the brachial or femoral area.
In older children, use the carotid artery.
Count for at least 1 minute.
Note strength of the pulse.
Blood Pressure
• Use a cuff that covers two thirds of the
upper arm.
• If scene conditions make it difficult to
measure blood pressure accurately,
do not waste time trying.
Skin Signs
• Feel for
temperature and
moisture.
• Estimate capillary
refill.
Detailed Physical Exam
and Ongoing Assessment
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Status changes frequently in children.
The PAT can help with reassessment.
Repeat vital signs frequently.
If child deteriorates, repeat the initial assessment.
Care of the Pediatric Airway (1 of 2)
• Position the airway.
• Position the airway in a neutral sniffing position.
• If spinal injury is suspected, use jaw-thrust
maneuver to open the airway.
Care of the Pediatric Airway (2 of 2)
• Positioning the airway:
– Place the patient on a
firm surface.
– Fold a small towel
under the patient’s
shoulders and back.
– Place tape across
patient’s forehead to
limit head rolling.
Oropharyngeal Airways
• Determine the appropriately
sized airway.
• Place the airway next to the
face to confirm correct size.
• Position the airway.
• Open the mouth.
• Insert the airway until flange
rests against lips.
• Reassess airway.
Nasopharyngeal Airways (1 of 2)
• Determine the appropriately
sized airway.
• Place the airway next to the
face to make certain length
is correct.
• Position the airway.
• Lubricate the airway.
Nasopharyngeal Airways (2 of 2)
• Insert the tip into the
right naris.
• Carefully move the tip
forward until the
flange rests against
the outside of the
nostril.
• Reassess the airway.
Assessing Ventilation
• Observe chest rise in older children.
• Observe abdominal rise and fall in younger
children or infants.
• Skin color indicates amount of oxygen getting
to organs.
Oxygen Delivery Devices
• Nonrebreathing mask at 10 to
15 L/min provides 90% oxygen
concentration.
• Blow-by technique at 6 L/min
provides more than 21%
oxygen concentration.
• Nasal cannula at 1 to 6 L/min
provides 24% to 44% oxygen
concentration.
BVM Devices
• Equipment must be the right size.
• BVM device at 10 to 15 L/min provides 90%
oxygen concentration.
• Ventilate at the proper rate and volume.
• May be used by one or two rescuers
One-rescuer BVM Ventilation
A
B
C
D
Airway Obstruction
• Croup
– A viral infection of the airway below the level of
the vocal cords
• Epiglottitis
– Infection of the soft tissue in the area above the
vocal cords
• Foreign body airway obstructions
Signs and Symptoms
• Decreased or absent breath
sounds
• Stridor
• Retractions
• Difficulty speaking
Signs of Severe
Airway Obstruction
• Signs and symptoms
– Ineffective cough (no sound)
– Inability to cry
– Increasing respiratory difficulty, with stridor
– Cyanosis
– Loss of consciousness
Removing a Foreign Body Airway
Obstruction (1 of 5)
• In an unconscious child:
– Place the child on a firm, flat surface.
• Open airway using head tilt-chin lift maneuver.
– Inspect the upper airway and remove any
visible object.
– Attempt rescue breathing.
• If unsuccessful, reposition head and try again.
– If ventilation is still unsuccessful begin CPR.
Removing a Foreign Body Airway
Obstruction (2 of 5)
• Place heel of one hand on lower half of sternum
between the nipples.
• Administer 30 chest compressions at a depth of
1/3 to 1/2 the depth of the chest.
Removing a Foreign Body Airway
Obstruction (3 of 5)
• Open airway using head tilt-chin lift maneuver.
If you see the object, remove it.
• Repeat process.
Removing a Foreign Body Airway
Obstruction (4 of 5)
• In a conscious child:
– Kneel behind the
child.
– Give the child five
abdominal thrusts.
– Repeat the technique
until object comes out.
Removing a Foreign Body Airway
Obstruction (5 of 5)
• If the child becomes
unconscious, inspect the
airway.
• Attempt rescue
breathing.
• If airway remains
obstructed, begin CPR.
Management of Airway
Obstruction in Infants
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Hold the infant facedown.
Deliver five back slaps.
Bring infant upright on the thigh.
Give five quick chest thrusts.
Check airway.
Repeat cycle as often as
necessary.
Neonatal Resuscitation
• Resuscitation measures include:
– Positioning airway
– Drying
– Warming
– Suctioning
– Tactile stimulation
Neonatal Equipment
Additional Efforts
• Deliver chest compressions
at 120 per minute.
• Coordinate chest
compressions with
ventilations at a ratio of 3:1.
• If meconium is present,
suction infant vigorously.
BLS Review
• Cardiac arrest in children is commonly due to
respiratory arrest.
• Many causes of respiratory arrest
• For purposes of pediatric BLS:
– Infancy ends at 1 year of age.
– Childhood extends from 1 year of age to
onset of puberty (12 to 14 years of age).
Determine Responsiveness
• Gently tap on shoulder and speak loudly.
• If responsive, place in position of comfort.
• If you find an unresponsive child when you are not
on duty:
– Provide BLS for about 2 minutes.
– Then call EMS system.
Airway
• Airway may be obstructed by tongue.
• Use head tilt-chin lift technique or jaw-thrust
maneuver to open the airway.
• Jaw-thrust maneuver is safer if possibility of
neck injury exists.
Breathing
• Look, listen, and feel.
• Provide rescue
breathing if needed.
• Perform Sellick
maneuver to prevent
gastric distention.
Circulation
• Assess circulation after airway is open and two
rescue breaths have been given.
• Check for pulses.
• Evaluate for other signs of circulation.
• Take at least 5 seconds but not more than 10
seconds trying to find a pulse.
• If infant or child is not breathing, the pulse is often
too slow or absent. CPR will be required.
Infant CPR (1 of 2)
• Place infant on firm
surface and maintain
airway.
• Place two fingers in the
middle of the sternum.
• Use two fingers to
compress the chest 1/3 to
1/2 the depth of the chest
at a rate of 100/min.
Infant CPR (2 of 2)
• Allow sternum to return briefly to its normal
position between compressions.
• Coordinate rapid compressions and
ventilations in a 30:2 ratio.
• Reassess the infant for return of breathing and
pulse after every 2 minutes of CPR.
Child CPR (1 of 2)
• Place child on firm surface
and maintain airway with
one hand.
• Place heel of other hand
over lower half of the
sternum.
– Avoid the xiphoid
process.
• Compress chest 1/3 to 1/2
the depth of the chest at a
rate of 100/min.
Child CPR (2 of 2)
• Coordinate compressions with ventilations in a 30:2
ratio for one rescuer, 15:2 for two rescuers, pausing for
ventilations.
• Reassess for breathing and pulse after every 2 minutes
of CPR.
• If the child resumes effective breathing, place child in
recovery position.
AED Use in Children (1 of 2)
• Can be safely used in children older than 1 year of
age
• Use pediatric-sized pads and a dose-attenuating
system for children 1-8 years old.
– If not available, use adult AED.
• AED is not indicated for use in infants less than 1
year of age.
AED Use in Children (2 of 2)
• AED should be applied to children over
1 year of age after the first 2 minutes of
CPR.
• After 2 minutes of CPR, AED is used to
deliver shocks in the same manner as
with an adult patient.
Trauma (1 of 2)
Extremity injuries in children are generally managed
in the same manner as those in adults.
Trauma (2 of 2)
• Be alert for airway problems on all children with
traumatic injuries.
• Give supplemental oxygen to all children with
possible:
– Head injuries
– Chest injuries
– Abdominal injuries
– Shock
• If ventilation is required, provide at 20 breaths/min.
Immobilization
• Any child with a head or back injury should
be immobilized.
• Young children may need padding beneath
their torso.
• Children may need padding along the sides
of the backboard.
Immobilization in a Child Safety
Seat
• Assess child for injuries and
seat for visible damage.
• If child is injured or seat is
damaged, remove child to
another transport device
• Apply padding around child to
minimize movement.
• Move seat to ambulance and
secure according to the
manufacturer’s instructions.
Removing a Child from
a Child Safety Seat
• Remove both the child and the seat from the
vehicle.
• Place immobilization device behind the child.
• Slide child into place on device.
Signs and Symptoms
of Respiratory Emergencies
• Nasal flaring
• Grunting respirations
• Use of accessory muscles
• Retractions of rib cage
• Tripod position in older children
Emergency Care
• Provide supplemental oxygen in the most
comfortable manner.
• Place child in position of comfort.
– This may be in caregiver’s lap.
• If patient is in respiratory failure, begin
assisted ventilation immediately.
– Continue to provide supplemental
oxygen.
Shock
• Circulatory system is unable to deliver sufficient
blood to organs.
• Many different causes
• Patients may have increased heart rate,
respirations, and pale or mottled skin.
• Children do not show decreased blood pressure
until shock is severe.
Assessing Circulation
• Pulse: Above 160 beats/min suggests shock
• Skin signs: Assess temperature and
moisture
• Capillary refill: Is it delayed?
• Color: Is skin pink, pale, ashen, or mottled?
Emergency Medical Care
for Shock
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Ensure airway.
Give supplemental oxygen.
Provide immediate transport.
Continue monitoring vital signs
en route.
• Contact ALS for backup as
needed.
Seizures
• May present in several different ways
• A postictal period of extreme fatigue or
unresponsiveness usually follows seizure.
• Be alert to presence of medications, poisons,
and possible abuse.
Febrile Seizures
• Febrile seizures are most common in children
from 6 months to 6 years.
• Febrile seizures are caused by fever.
• Generally last less than 15 minutes
• Assess ABCs and begin cooling measures.
• Provide prompt transport.
Emergency Medical Care
of Seizures (1 of 2)
• Perform initial assessment, focusing on the
ABCs.
• Securing and protecting the airway is the
priority.
• Place patient in the recovery position.
• Be ready to suction.
Emergency Medical Care
of Seizures (2 of 2)
• Deliver oxygen by mask, blow-by, or nasal cannula.
• Begin BVM ventilation if no signs of improvement.
• Call ALS for backup if appropriate.
Dehydration
• Determine if child is vomiting or has diarrhea
and for how long.
• “How many wet diapers has the child had
during the day?” (6 to 10 is normal)
• “What fluids are the child taking?”
• “What was the child’s weight before the
symptoms started?”
• “Has the child been normally active?”
Emergency Medical Care
for Dehydration
• Assess the ABCs.
• Obtain baseline vital signs.
• ALS backup may be needed for IV
administration.