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Copyright © 2004, Mosby Inc. All rights reserved.
Chapter 30
Infants and Children
Slide 1
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Case History
You respond to a child in respiratory distress.
On arrival, you observe a 3-year-old boy
experiencing difficulty breathing with a
“barking” cough, stridor, and active accessory
muscle use. Your initial assessment reveals
hot and dry skin, cyanosis, “seesaw”
breathing, and retractions between the ribs.
The mother advises you that the child awoke
from sleep 30 minutes ago. The symptoms
have become progressively worse.
Slide 2
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Spiral of Pediatric Arrest
Slide 3
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Newborns and Infants –
Birth to 1 Year of Age
• Minimal stranger anxiety
• Do not like to be separated from parents
• Do not want to be suffocated by an oxygen mask
• Need to be kept warm
 Make sure hands and stethoscope are warmed before touching
child.
• Breathing rate best obtained at a distance
• Examine heart and lungs first, head last.
Slide 4
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Toddlers – 1 to 3 Years
• Do not like to be touched
• Do not like being separated from parents
• Do not like having clothing removed
 Remove, examine, replace
• May feel suffocated by an oxygen mask
Slide 5
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Toddlers – 1 to 3 Years
• Children think their illness/injury is punishment
 Reassure child that he or she was not bad.
• Afraid of needles and fear of pain
 Provide encouragement but be honest.
 If possible, keep child close to parent.
• Head-to-toe approach
Slide 6
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Preschoolers – 3 to 6 Years
• Do not like to be touched
• Do not like being separated from parents
• Do not like having clothing removed
 Remove, examine, replace
• Do not want to be suffocated by an oxygen mask
Slide 7
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Preschoolers – 3 to 6 Years
• Children think that the illness/injury is a punishment
 Reassure child that he or she was not bad.
• Afraid of blood and fear of pain
• Fear of permanent injury
• Modest
Slide 8
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School Age – 6 to 12 Years
• Afraid of blood
• Fear of pain and permanent injury
• Fear of disfigurement/permanent injury
• Modest
• Should be treated as adults.
• May desire to be assessed privately, away from parents or
guardians
Slide 9
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Adolescents – 12 to 18 Years
• Fear of disfigurement/permanent injury
• Modest
• Should be treated as adults.
• May desire to be assessed privately, away from
parents or guardians
Slide 10
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Anatomic and Physiologic Concerns –
Airway
• Small airways throughout the respiratory system
• Easily blocked by secretions and airway swelling
• Tongue is large relative to small mandible.
 Can block airway in an unconscious infant or child
• Positioning
 Do not hyperextend the neck
• Infants are obligate nose breathers.
 Suctioning nasopharynx can improve breathing.
Slide 11
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Comparison of Airway Anatomy
Slide 12
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Suctioning
• Vacuum
 Child – 300 mm Hg
 Newborn – 100 mm Hg
• Technique
 Child – large-bore, rigid catheter
 Newborn and infant – soft catheter or bulb syringe
Slide 13
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Oral Airways
• Used for patients who do not have a gag
reflex
• Insert directly using tongue blade.
• Take care to avoid injury to soft tissues.
Slide 14
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Sizing
• Multiple sizes
• Sizing technique
 Corner of the lips to
bottom of earlobe
Slide 15
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Breathing
• Respiratory rate higher
than adults
• Interventions
 Humidified oxygen
 Keep patient warm
 If PPV necessary, do not
overinflate; watch for
gastric inflation.
Slide 16
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Compensatory Ability
• Children can compensate well for short
periods of time.
 Increased breathing rate
 Increased effort of breathing
• Compensation is followed rapidly by
decompensation.
 Rapid respiratory muscle fatigue
 General fatigue of the infant
Slide 17
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Circulation – Pulse Rate
Slide 18
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Circulation – Blood Pressure
• Blood pressure increases with age.
• Use appropriate size BP cuff.
• Use formula to determine lower limit for systolic BP
 70 + (2 x Age in years)
• Systolic BP <70 mm Hg with tachycardia and cool
skin are indicators of shock.
Slide 19
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Circulation – Bleeding and Shock
• Hypovolemic – most common shock found in
children
 Bleeding
 Dehydration
Slide 20
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Dehydration in Children
Slide 21
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Blood or Fluid Loss
• Average blood volume – 80 ml/kg
• Children can maintain BP until almost 40% of
fluid volume is lost.
 Low BP is a LATE sign of shock.
Slide 22
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Shock – Causes
• Rarely a primary cardiac event
• Common causes
 Diarrhea and dehydration
 Trauma
 Vomiting
 Blood loss
 Infection
 Abdominal injuries
Slide 23
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Shock – Causes
• Less common
 Allergic reactions
 Poisoning
 Cardiac
Slide 24
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Signs and Symptoms –
Shock
• Rapid respiratory rate
• Pale, cool, clammy skin
• Weak or absent peripheral pulses
• Delayed capillary refill
Slide 25
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Signs and Symptoms –
Shock
• Decreased urine output
 Ask parents about diaper wetting and look at
diaper.
• Mental status changes
• Absence of tears, even when crying
Slide 26
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Metabolic Considerations
• Keep child warm.
 Higher baseline metabolic rate
» Growing requires more fuel than adults.
» Rapid respiratory and pulse rates
 Need to expend more energy to keep warm.
 Infants <6 months do not have ability to shiver.
Slide 27
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General Impression
• Assessment of mental status
• Effort of breathing
• Color
• Quality of cry/speech
Slide 28
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Interaction with
Environment and Parents
• Normal behavior for child of this age
 Playing
 Moving around
 Attentive versus nonattentive
•
•
•
•
Eye contact
Recognizes parents
Responds to parent’s calling
Response to the EMT
 Should be appropriately upset
• Tone/body position
Slide 29
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Approach to Evaluation
• Begin from across the room.
• Mechanism of injury
• Assessment of surroundings
• General impression of well versus sick
Slide 30
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Assess Breath Sounds
• Present
• Absent
• Stridor
• Wheezing
• Cyanosis
Slide 31
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Detailed Physical Exam
• Begin with a trunk-to-head approach.
 Situation- and age-dependent
 Should help reduce the infant or child’s anxiety
Slide 32
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Common Problems
in Infants and Children
•
•
•
•
•
•
•
•
•
Airway obstructions
Respiratory emergencies
Seizures
Altered mental status
Poisonings
Fever
Shock
Near drowning
SIDS
Slide 33
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Airway Obstruction –
Croup
Slide 34
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Airway Obstruction –
Epiglottitis
Slide 35
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Partial Airway Obstruction –
Infant or Child Alert and Sitting
• Stridor, crowing, or noisy
• Retractions on inspiration
• Pink
• Good peripheral perfusion
• Still alert, not unconscious
Slide 36
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Emergency Medical Care
• Allow position of comfort.
• Assist younger child to sit up.
• Do not lay the child down; may sit on parent’s lap.
• Offer oxygen and transport.
• Do not agitate child, limited examination.
• Do not assess blood pressure.
Slide 37
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Foreign Body Airway Obstruction
(FBAO)
• Determine
 LOC
 Air exchange
 Ability to speak or cry
 History of respiratory infections, fever, barking cough
 History of choking
• Treat all suspected infectious causes of obstruction
as if they are epiglottitis.
Slide 38
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FBAO – The Alert Child
• Keep management to a minimum.
• Keep parents and child calm.
• Allow position of comfort (parent’s arms).
• Administer humidified oxygen if child will allow (without
agitation).
• Transport without delay.
• Do not intervene if child is alert and moving air.
Slide 39
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FBAO – Complete
• Unconscious
 Reopen airway/reattempt ventilation (PPV).
 If infectious cause a possibility, attempt “forced”
PPV and transport rapidly.
 If child has a foreign body obstruction, follow
guidelines for removal.
Slide 40
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Airway Obstruction Management
• Infant
 Back blows
 Chest thrusts
 Finger sweeps (visualized)
• Child
 Abdominal thrusts
 Finger sweeps (visualized)
Slide 41
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Respiratory Emergencies
• Recognize the difference between upper
airway obstruction and lower airway disease.
• Upper airway obstruction
 Stridor on inspiration
• Lower airway disease
 Wheezing
 Breathing effort on exhalation
 Rapid breathing (tachypnea) without stridor
Slide 42
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Early Respiratory Distress
• Nasal flaring
• Intercostal retraction
 Neck muscles, supraclavicular, subcostal retractions
• Stridor
• Neck and abdominal muscles retractions
• Audible wheezing
• Grunting
Slide 43
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Severe Respiratory Distress
• Early signs, plus
 Altered mental status
 Rate >60/min
 Cyanosis
 Decreased muscle tone
 Severe use of accessory muscles
 Poor peripheral perfusion
 Altered mental status
 Grunting
Slide 44
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Respiratory Arrest
• Breathing rate <10/min
• Limp muscle tone
• Unconscious
• Slower, absent heart rate
• Weak or absent distal pulses
Slide 45
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Emergency Medical Care
• Provide oxygen for all respiratory distress.
• Assist ventilation for severe respiratory
distress.
 Respiratory distress and altered mental status
 Presence of cyanosis with oxygen
 Respiratory distress with poor muscle tone
 Respiratory failure
 Provide oxygen and ventilate with bag-valve-mask
for respiratory arrest.
Slide 46
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Submersion Incident/
Near Drowning
• Artificial ventilation is top priority.
• Consider possibility of trauma.
• Consider possibility of hypothermia.
• Consider possible ingestion, especially
alcohol.
Slide 47
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Submersion Incident/
Near Drowning
• Protect airway, suction if necessary.
• Secondary drowning syndrome
 Deterioration after breathing is normal from
minutes to hours after event.
 All near submersion incident victims should be
transported to the hospital.
Slide 48
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Emergency Medical Care
•
•
•
•
•
•
Ensure airway and provide oxygen.
Be prepared to artificially ventilate.
Manage bleeding, if present.
Elevate legs.
Keep warm.
Transport.
 Note need for rapid transport of infant and child
 Secondary examination is completed en route
Slide 49
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Sudden Infant Death Syndrome
(SIDS)
• Sudden death of infants in first year of life
• Causes are many and not clearly understood.
• Baby is most commonly discovered in the
early morning.
Slide 50
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Emergency Medical Care
• Try to resuscitate,unless rigor mortis present.
• Parents will be in agony from emotional
distress, remorse, and imagined guilt.
• Avoid any comments that might suggest
blame to the parents.
Slide 51
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Fever
• Common reason for infant or child ambulance call
• Many causes
 Rarely life-threatening
 Severe cause — meningitis
• Fever with a rash is a potentially serious
consideration.
• Emergency medical care
 Transport.
 Be alert for seizures.
Slide 52
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Seizures
• Seizures in children are rarely life threatening.
• Seizures may be brief or prolonged.
• Assess for presence of injuries.
• Causes
 Fever and infections
 Poisoning
 Hypoglycemia
 Trauma
 Decreased levels of oxygen
 Idiopathic in children
Slide 53
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Seizures – History
• Has the child had prior seizure(s)?
 If yes, is this the child’s normal seizure pattern?
• Has the child taken his or her prescribed antiseizure medications?
Slide 54
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Emergency Medical Care
• Ensure airway position and patency.
• Position patient on side, if no possibility of
cervical spine trauma.
• Have suction ready.
Slide 55
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Emergency Medical Care
• Provide oxygen.
• Respiratory arrest or severe respiratory distress
 Ensure airway position and patency.
 Ventilate with bag-valve-mask
• Transport
• Although brief seizures are not harmful, a more
dangerous underlying condition may exist.
Slide 56
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Head Injury and Seizures
• Seizures can be caused by head injury.
• Inadequate breathing and/or altered mental
status may occur after a seizure.
Slide 57
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Altered Mental Status –
Causes
• Hypoglycemia
• Poisoning
• Postseizure
• Infection
• Head trauma
• Decreased oxygen levels
• Hypoperfusion (shock)
Slide 58
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Emergency Medical Care
• Ensure patency of airway.
• Be prepared to artificially ventilate/suction.
• Transport.
Slide 59
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Poisonings
• Poisoning is a common reason for infant and
child EMS calls.
• Identify suspected container through
adequate history.
• Bring container to receiving facility, if
possible.
Slide 60
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Emergency Medical Care –
Responsive Patient
• Contact medical control.
• Consider need to administer activated charcoal.
• Provide oxygen.
• Transport.
• Continue to monitor patient.
 May become unresponsive
Slide 61
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Emergency Medical Care –
Unresponsive Patient
• Ensure patency of airway.
• Be prepared to artificially ventilate.
• Provide oxygen, if indicated.
• Call medical direction.
• Transport.
• Rule out trauma.
 Trauma can cause altered mental status.
Slide 62
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Trauma
•
•
•
•
•
•
•
•
Motor vehicle passengers
Struck while riding bicycle
Pedestrian struck by vehicle
Falls from height
Diving into shallow water
Burns
Sports injuries of head and neck
Child abuse
Slide 63
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Head Injury
• Open airway
 Modified jaw thrust
• Head injury with internal injuries is likely in children.
• Signs and symptoms of shock with head injury
 Suspicion of other possible injuries
• Respiratory arrest
 Common secondary to head injuries
 May occur during transport
Slide 64
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Head Injury
• Common signs and symptoms are nausea
and vomiting.
• Most common cause of hypoxia is tongue
obstructing the airway.
 Jaw thrust is critically important.
• Do not use sandbags.
Slide 65
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Chest Injury
• Children have very soft, pliable ribs.
• Significant injuries may be present without
external signs.
Slide 66
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Abdomen and Extremities
• More common site of injury in children than adults
• Often a source of hidden injury
• Always consider abdominal injury in the multiple trauma patient
with no external signs whose condition is deteriorating.
• Air in stomach can distend abdomen.
 Interferes with artificial ventilation efforts.
• Extremities
 Injuries are managed in the same manner as adults.
Slide 67
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Other Trauma Considerations
• Pneumatic antishock garments can be used for children.
 Use only if PASG fits child.
 Do not place infant in one leg of trouser
• Indications for PASG use
 Trauma with signs of severe hypoperfusion and pelvic instability
• Do not inflate abdominal compartment.
• Criticality of burns
 Cover with sterile dressing (nonstick).
 Identify candidates for burn centers.
Emergency Medical Care
• Ensure airway position and patency.
• Use jaw thrust.
• Suction as necessary.
• Provide oxygen.
• Assist ventilations as needed.
• Provide spinal immobilization.
• Transport immediately.
Slide 69
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Child Abuse and Neglect
• Definition of abuse
 Improper or excessive action so as to injure or cause harm
• Definition of neglect
 Giving insufficient attention or respect to someone who has
a claim to that attention
• EMT must be aware of condition to be able to
recognize the problem.
Slide 70
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Signs and Symptoms –
Abuse
• Multiple bruises in various stages of healing
• Injury inconsistent with mechanism described.
• Repeated calls to the same address.
• Fresh burns
• Parents are inappropriately unconcerned.
• Conflicting stories
• Child fearful to discuss how the injury occurred.
Slide 71
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Abuse –
Belt Marks
Slide 72
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Abuse –
Bruises on Four Surfaces
Slide 73
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Abuse –
Immersion Scald
Slide 74
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Appearance of Bruises in Various
States of Healing
Age of Bruise
1-3 days
3-7 days
>7 days
>3 weeks
Appearance
Red/blue
Purple
Yellow/brown
Brown to clearing
Slide 75
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Signs and Symptoms –
Neglect
• Lack of adult supervision
• Malnourished-appearing child
• Unsafe living environment
• Untreated chronic illness
• CNS injuries are the most lethal.
 Shaken baby syndrome
Slide 76
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Reporting Abuse
• Do not accuse in the field.
• Accusation and confrontation delays transportation.
• Bring objective information to the receiving facility.
• Reporting required by state law and local regulations.
• Be objective.
 Document what you see and what you hear, NOT what you think.
Slide 77
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Infants and Children
with Special Needs
• Premature babies with lung disease
• Babies and children with heart disease
• Infants and children with neurologic disease
• Children with chronic disease or altered function from
birth
• Often these children will be at home, technologically
dependent.
Slide 78
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Tracheostomy Tubes
Slide 79
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Suction of Tracheostomy
Slide 80
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Gastrostomy Tube
Slide 81
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Central Lines
• Intravenous lines (IVs) placed near the heart for longterm use
• Complications
 Cracked line
 Infection
 Clotting off
 Bleeding
• Emergency medical care
 If bleeding, apply pressure.
 Transport.
Slide 82
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Shunts
• Device running from brain to abdomen to drain excess
cerebrospinal fluid
• Reservoir on side of skull
• Change in mental status
• Prone to respiratory arrest
 Manage airway.
 Ensure adequate ventilation.
• Transport
Slide 83
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Family Response
• A child cannot be cared for in isolation from the family.
 You have multiple patients.
• Strive for calm.
 Calm parents = calm child
 Agitated parents = agitated child
• Anxiety arises from concern over child’s pain; fear for
child’s well-being.
• Anxiety is worsened by sense of helplessness.
Slide 84
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Family Response
• Parent may respond to EMT with anger or hysteria.
• Parents should remain part of the care unless child is
not aware or medical conditions require separation.
• Parents should be instructed to calm child; can
maintain position of comfort and/or hold oxygen.
• Parents may not have medical training, but they are
experts on what is normal or abnormal for their
children and what will have a calming effect.
Slide 85
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Provider Response
• Anxiety from lack of experience with seriously
injured children
• Fear of failure
• Skills can be learned and applied to children.
• Identifying patient with his or her own children
Slide 86
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Provider Response
• Providers should
 Realize that much of what they learned about
adults applies to children
 Remember the differences
• Infrequent encounters with sick children
 Advance preparation is important.
Slide 87
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