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Chapter 44
Pediatrics
Copyright (c) The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
44-1
Objectives
44-2
Introduction
• Children are not just small adults
• Children have unique physical,
mental, emotional, and
developmental characteristics
44-3
Life Stage
Age
Newly born Birth to several hours after birth
Neonate
Birth to 1 month
Infant
1 to 12 months of age
• Young infant: 0 – 6 months
• Older infant: 6 months – 1 year
Toddler
1 to 3 years of age
Preschooler 4 to 5 years of age
School-age 6 to 12 years of age
child
Adolescent 13 to 18 years of age
Anatomical and Physiological
Differences in Children
44-5
Head
44-6
Face
• Nasal passages
– Small, short, and narrow
– Easily obstructed
– Can lead to respiratory difficulty
– Make sure a newborn’s nose is clear
to avoid breathing problems
44-7
Face
• Mouth opening is usually
small
• Tongue
– Fills the majority of
space in the mouth of an
infant or child
– Most common cause of
upper airway obstruction
in unconscious child
44-8
Airway
• Opening between the vocal cords is higher
in the neck and more toward the front than
in adults
– Flap of cartilage that covers this
opening, the epiglottis, is long, floppy,
narrow and extends at a 45-degree angle
into airway in children
– Damage or swelling in this area can
block the airway
44-9
Airway
• Trachea (windpipe)
– Softer, more flexible, smaller diameter,
and shorter length than in adults
– Rings of cartilage keep windpipe open
• Soft and collapses easily in children
• Extending or flexing the neck too far can
block the airway
44-10
Breathing
• Ribs
– Soft, flexible
– Made up mostly of
cartilage
– Trauma to the chest is
transmitted to lungs
and other internal
structures more easily
44-11
Breathing
• Intercostal muscles
– Not fully developed
until later in
childhood
• Diaphragm
– Primary muscle of
breathing
44-12
Normal Respiratory Rates in Children at Rest
Life Stage
Age
Breaths per Minute
Birth to 1
month
1 to 12 months
30-50
Toddler
1 to 3 years
20-30
Preschooler
4 to 5 years
20-30
School-age
child
Adolescent
6 to 12 years
16-30
13 to 18 years
12-20
Newborn
Infant
20-40
44-13
Breathing
• Higher oxygen demand per kilogram of body
weight
– About twice that of an adolescent or adult
• Smaller lung oxygen reserves
• Increased risk of hypoxia with apnea or
ineffective bag-mask ventilation
44-14
Circulation
• Infants and child have a blood volume of
about 80 mL/kg
– Serious volume loss:
• Child – sudden loss of 1/2 L (500 mL)
• Infant – sudden loss of 100-200 mL
44-15
Normal Heart Rates in Children at Rest
Life Stage
Age
Beats per Minute
Newborn
Birth to 1 month
120-160
Infant
1 to 12 months
80-140
Toddler
1 to 3 years
80-130
Preschooler
4 to 5 years
80-120
School-age
child
Adolescent
6 to 12 years
70-110
13 to 18 years
60-100
44-16
Blood Pressure
•
Measure the blood
pressure (BP) in children
older than 3 years of age
•
The BP of a child is
normally lower than that
of an adult
44-17
Blood Pressure
• Use the following formula to determine the
lower limit of a normal systolic blood
pressure in children 1 to 10 years of age:
Systolic Pressure=
70 + (2 X child’s age in years)
37-18
Metabolism and Temperature Regulation
• Limited glucose stores
• Sensitive to extremes of heat and cold
– Large body surface area (BSA) when
compared with weight
• Greater area of heat loss
– Poorly developed temperature-regulating
mechanisms
44-19
Skin
• Pale (whitish)
– Shock, fright, anxiety
• Bluish (cyanotic)
– Inadequate breathing or poor perfusion
– Critical sign; requires immediate treatment
• Blotchy (mottled)
– Shock, hypothermia, or cardiac arrest
• Flushed (red)
– Fever, heat exposure, allergic reaction
44-20
Abdomen
• Abdominal muscles less developed
– Situated more anteriorly
– Provide less protection of rib cage
• Seemingly insignificant forces can cause
serious internal injury
• Liver and spleen are proportionally larger
– More frequently injured
– Multiple organ injury common
44-21
Extremities
• Bones softer
• Growth plates of the bones are weaker than
ligaments and tendons
– Injury to the growth plate can result in
differences in bone length
• Immobilize a sprain or strain because it is
more likely a fracture
44-22
Assessment of
Infants and Children
44-23
Scene Size-Up
44-24
Scene Size-Up
• In most situations, include the patient’s
caregiver
• Watch the interaction between the caregiver
and the child
– Agitated caregiver = agitated child
– Calm caregiver = calm child
44-25
Primary Survey
General Impression
• Appearance
• (Work of) Breathing
• Circulation
• Sick or not sick?
44-26
Level of Responsiveness (Mental Status)
• An alert infant or young child (younger
than 3 years of age)
– Smiles
– Orients to sound
– Follows objects with her eyes
– Interacts with those around her
44-27
Level of Responsiveness (Mental Status)
• Most children will be agitated or resist
your assessment
44-28
Cervical Spine Protection
• Take spinal precautions if:
– You suspect trauma to head, neck, or back
– The child is unresponsive with an
unknown nature of illness
44-29
Airway
• If child’s airway is open, check breathing
• If the airway is not open, listen for sounds
of an airway problem
– Snoring
– Gurgling
44-30
Airway
• Sniffing position
44-31
Airway
• Tripod position
44-32
Airway
• If unresponsive, open the airway:
– If no trauma is suspected, use the head
tilt-chin lift maneuver
– if trauma is suspected, use the jaw thrust
without head tilt
44-33
Airway
44-34
Clearing the Airway
• Recovery position
• Finger sweeps
• Suctioning
44-35
Airway Adjuncts
• Oral airway
• Nasal airway
44-36
Breathing
• Observe the chest and abdomen
• Count the ventilatory rate
44-37
Circulation
• Compare central and peripheral pulses
• If no pulse, or if a pulse is present but the
rate is less than 60 beats/min with signs of
shock, begin chest compressions
• Control severe bleeding, if present
44-38
Common Problems
in Infants and Children
44-39
Airway Obstructions
• Most episodes of choking in infants and
children occur during eating or play
44-40
Airway Obstructions
• Complete airway obstruction
– Patient is unable to speak, cry, cough, or
make any other sound
• Partial airway obstruction
– Patient has noisy breathing
44-41
Airway Obstructions
• Signs of a partial obstruction with poor air
exchange may include:
– Weak, ineffective cough that sounds like
gasping
– High-pitched noise on inhalation (stridor)
– Difficulty breathing or speaking
– Turning blue (cyanosis)
44-42
Respiratory Emergencies
• Upper airway problems usually
occur suddenly
• Lower airway problems usually
take longer to develop
44-43
Respiratory Emergencies
• Three levels of severity:
1. Respiratory distress
•
Increased work of breathing (respiratory effort)
2. Respiratory failure
•
•
Patient becomes tired and can no longer
maintain good oxygenation and ventilation
Not enough oxygen in the blood and/or
ventilation to meet the demands of body
tissues
3. Respiratory arrest
•
Patient stops breathing
44-44
Signs of Respiratory Distress
• Alertness, irritability,
anxiousness,
restlessness
• Noisy breathing
• Breathing rate faster
than normal for the
patient’s age
• Increased depth of
breathing
• Nasal flaring
• Mild increase in heart
rate
• Retractions
• Head bobbing
• See-saw ventilations
(abdominal breathing)
• The use of neck
muscles to breathe
• Changes in skin color
44-45
Signs of Respiratory Failure
• Sleepiness or agitation
• Combativeness
• Limpness; the patient
may be unable to sit up
without help
• A breathing rate is
initially fast with
periods of slowing and
then eventual slowing
• An altered mental
status
•
•
•
•
•
A shallow chest rise
Nasal flaring
Retractions
Head bobbing
Pale, mottled, or bluish
skin
• Weak peripheral pulses
44-46
Care of Respiratory Distress
• Place the patient in a position of comfort
• Reposition the patient’s airway for better
airflow if necessary
• Give oxygen if indicated
– Maintain an oxygen saturation level of 95%
or higher
• The patient with asthma may need
assistance using his metered-dose inhaler
44-47
Care of Respiratory Failure/Arrest
• Assist breathing with a bag-mask device
• Deliver each breath over 1 second
• Breathing rate:
– 12 to 20 breaths per minute
– 1 breath every 3 to 5 seconds
• Check pulse every few minutes
44-48
Cardiopulmonary Failure
• Respiratory failure + shock
44-49
Cardiopulmonary Failure
Signs and Symptoms
• Mental status
changes
• A weak ventilatory
effort
• Slow, shallow
breathing
• Pale, mottled, or
bluish skin
• A slow pulse rate
• Weak central pulses
and absent
peripheral pulses
• Cool extremities
• Delayed capillary
refill
44-50
Care of Cardiopulmonary Failure
• Make sure the patient’s airway is open
• Take spinal precautions as necessary
• Assist breathing
– Bag-mask device
• Perform chest compressions if necessary
44-51
Possible Causes of Altered Mental Status
• Low blood oxygen
level
• Head trauma
• Seizures
• Infection
• Shock
• Low blood sugar
• Drug or alcohol
ingestion
• Abuse
• Fever
• Respiratory failure
44-52
Care of Patient with
Altered Mental Status
•
•
•
•
•
•
Scene size-up
Perform a primary survey
Make sure the patient’s airway is open
Perform a physical exam
Be prepared to suction
If no trauma suspected, place patient in
recovery position
• Comfort, calm, and reassure the patient
• Transport
44-53
Shock
• Common causes of shock in
infants and children:
– Diarrhea
– Dehydration
– Trauma
– Vomiting
– Blood loss
– Infection
– Abdominal injuries
44-54
Shock
Signs and Symptoms
• Rapid ventilatory rate
• Pale, cool, clammy skin
• Weak or absent peripheral pulses
• Delayed capillary refill
• Decreased urine output
• Mental status changes
• Absence of tears, even when crying
44-55
Emergency Care of Shock
•
•
•
•
•
Request ALS personnel
Give oxygen
Quickly control any bleeding, if present
Shock position if no trauma
If anaphylaxis, contact medical direction for
epinephrine order
• Keep the patient warm
• Transport rapidly
44-56
Fever
• Common reason for infant or child calls
• Febrile seizures
– Seizures caused by fever
– Should be considered potentially lifethreatening
44-57
Meningitis
44-58
Emergency Care of Fever
• Use personal protective equipment
• Remove excess clothing
• Be alert for seizures
• Treat for shock if indicated
• Begin cooling measures if instructed to do
so by medical direction
• Transport
44-59
Seizures
• Common in children
• Should be considered potentially lifethreatening
• May be brief or prolonged
• Assess for injuries that may have occurred
during the seizure(s)
44-60
Seizures
History
• Ask the following questions:
– Is this the child’s first seizure?
– If the child has a history of seizures, is he on a
seizure medication?
– Is this the child’s normal seizure pattern?
– What did the caregiver do for the child during the
seizure?
– Could the child have ingested any medications,
household products, or any potentially toxic
item?
– How long did the seizure last?
– Does the child have a fever?
44-61
Care of Seizures
•
•
•
•
•
•
•
Scene size-up
Perform a primary survey
Give oxygen if indicated
Perform a physical exam
Observe and describe seizure
Comfort, calm, and reassure patient
Protect the patient from injury
44-62
Emergency Care of Seizures
• Make sure the patient’s airway is open
• Place the patient in the recovery position if
there is no possibility of trauma
• Do not restrain the patient
• Do not put anything in the patient's mouth
• Have suction available
• If patient is bluish, ensure the patient’s
airway and assist breathing
44-63
Poisonings
• Ask questions
– Who?
– What?
– Where?
– When?
– Why?
– How?
44-64
Emergency Care of Poisonings
• Use personal protective equipment
• Follow proper decontamination procedures, if
necessary
• Establish and maintain an open airway
• Give oxygen if indicated
• If ingested poison (and patient is awake),
consult medical direction about giving
activated charcoal
• If the patient is unresponsive or seizing,
consult medical direction about checking the
child’s blood sugar
44-65
Drowning
Signs and Symptoms
• Altered mental
status, seizures,
unresponsiveness
• Coughing, vomiting,
choking, or airway
obstruction
• Fast, slow, or
absent pulse
• Cool, clammy, and
pale or cyanotic
skin
• Vomiting
• Absent or inadequate
• Possible abdominal
breathing
distention
• Difficulty breathing
44-66
Emergency Care of Drowning
• Ensure scene safety
• Keep on scene time to a minimum
• Protect patient from temperature extremes
• Give oxygen if indicated
• Remove wet clothing, dry patient
• Begin CPR if indicated
• Transport
44-67
Sudden Infant Death Syndrome (SIDS)
• According to the National Institute of Child
Health and Human Development, SIDS is:
– Sudden and unexpected death of an infant
that remains unexplained after:
• A thorough case investigation, including
performance of a complete autopsy,
• Examination of the death scene, and
• Review of the clinical history
44-68
Sudden Infant Death Syndrome (SIDS)
• Most deaths occur between 2 and 4 months
of age
• Occurs in apparently healthy infants
• Boys are affected more often than girls
• Most SIDS deaths occur at home
• Baby is often discovered in the early
morning
44-69
Sudden Infant Death Syndrome (SIDS)
• Cause is not clearly understood
• Research is ongoing
• Number of deaths has decreased since 1992
44-70
Common Physical Findings of SIDS
• Unresponsive baby who is not breathing and
has no pulse
• Blue or mottled skin
• Frothy sputum or vomitus around the mouth
and nose
• Underside of the baby’s body may look dark
and bruised
• General stiffening of body (rigor mortis) may
be present
44-71
Emergency Care of SIDS
• Attempt to resuscitate unless obvious
signs of death are present
– Check local protocol
• Find out the baby’s name
– Refer to baby by name, not as the baby
or it
• Avoid comments that might suggest the
caregiver is to blame
44-72
Care of SIDS
• Provide emotional support to the caregiver
• If the baby is obviously dead, notify the
caregiver
• Arrange for grief support
• Assess your own emotional needs
44-73
Questions?
44-74