Transcript Start Traige

Seattle/King County EMT-B Class
Topics
1
Pediatric Emergencies: Chapter 31
2
Pediatric Assessment: Chapter 32
3
Pediatric SICK/NOT SICK
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Pediatric Emergencies
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Airway Differences
• Larger tongue
relative to the mouth
• Larger epiglottis
• Less well-developed
rings of cartilage in
the trachea
• Narrower, lower
airway
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Breathing Differences
• Infants breathe faster than children or
adults.
• Infants use the diaphragm when they
breathe.
• Sustained, labored breathing may lead
to respiratory failure.
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Circulation Differences
• The heart rate increases for illness and
injury.
• Vasoconstriction keeps vital organs
nourished.
• Constriction of the blood vessels can
affect blood flow to the extremities.
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Skeletal Differences
• Bones are weaker and more flexible.
• They are prone to fracture with stress.
• Infants have two small openings in the
skull called fontanels.
• Fontanels close by 18 months.
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Growth and Development
Thoughts and behaviors of children usually
grouped into stages:
•
•
•
•
•
Infancy
Toddlers
Preschool
School age
Adolescence
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Infant—First year of life
• They respond mainly to
physical stimuli.
• Crying is a way of
expression.
• Usually prefer to be
with caregiver.
• If possible, have
caregiver hold the infant
as you start your
examination.
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Toddler—1 to 3 years of age
• They begin to walk
and explore the
environment.
• They may resist
separation from
caregivers.
• Make any
observations you can
before touching a
toddler.
• They are curious and
adventuresome.
1
Preschool—3 to 6 years of age
• They can use simple language
effectively.
• They can understand directions.
• They can identify painful areas when
questioned.
• They can understand when you explain
what you are going to do using simple
descriptions.
• They can be distracted by using toys.
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School Age—6 to 12 years of age
• They begin to think like adults.
• They can be included with the parent
when taking medical history.
• They may be familiar with physical exam.
• They may be able to make choices.
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Adolescent—12 to 18 years of age
• They are very concerned about body
image.
• They may have strong feelings about
being observed.
• Respect an adolescent’s privacy.
• They understand pain.
• Explain any procedure that you are doing.
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Family Matters
• When a child is ill or injured, you have
several patients, not just one.
• Caregivers often need support when
medical emergencies develop.
• Children often mimic the behavior of
their caregivers.
• Be calm, professional, and sensitive.
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Pediatric Emergencies
Dehydration
• Vomiting and diarrhea
• Greater risk than adults
Fever
• Rarely life threatening
• Caution if occurring with rash
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Pediatric Emergencies, cont'd
Meningitis
• Inflammation of the tissue that
covers the spinal cord and brain.
• Caused by an infection.
• If left untreated can lead to brain
damage or death.
1
Pediatric Emergencies, cont'd
Febrile seizures
• Common between 6 months and 6
years
• Last less than 15 minutes
Poisoning
• Signs and symptoms vary widely.
• Determine what substances were
involved.
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Physical Differences
• Children and adults suffer different
injuries from the same type of incident.
• Children’s bones are less developed
than an adult’s.
• A child’s head is larger than an adult’s,
which greatly stresses the neck in
deceleration injuries.
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Psychological Differences
• Children are not as psychologically
mature.
• They are often injured due to their
undeveloped judgment and lack of
experience.
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Injury Patterns: Automobile Collisions
• The exact area of
impact will
depend on the
child’s height.
• A car bumper
dips down when
stopping
suddenly, causing
a lower point of
impact.
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Injury Patterns: Sports Activities
• Head and neck injuries can occur from
high-speed collisions during contact
sports.
• Immobilize the cervical spine.
• Follow local protocols for helmet
removal.
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Head Injuries
• Common injury among children
• The head is larger in proportion to an
adult.
• Nausea and vomiting are signs of
pediatric head injury.
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Chest Injuries
• Most chest injuries in
children result from
blunt trauma.
• Children have soft,
flexible ribs.
• The absence of
obvious external
trauma does not
exclude the likelihood
of serious internal
injuries.
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Abdominal Injuries
• Abdominal injuries are very common in
children.
• Children compensate for blood loss better
than adults but transition into shock more
quickly.
Watch for:
• Weak, rapid pulse
• Cold, clammy skin
• Poor capillary refill
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Injuries to the Extremities
• Children’s bones bend more easily
than adults’ bones.
• Incomplete fractures can occur.
• Do not use adult splinting devices on
children unless the child is large
enough to meet the required
objectives.
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PASG
Pneumatic Anti-shock Garments
We don't use them in King County.
They're being mentioned now because the
state exam may have a few questions about
them.
This has been a public service
announcement…=-)
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Burns
• Most common burns involve exposure to
hot substances.
• Suspect internal injuries from chemical
ingestion when burns are present around
lips and mouth.
• Infection is a common problem with
burns.
• Consider the possibility of child abuse.
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Submersion Injury
• Drowning or near drowning
• 2nd most common cause of
unintentional death of children in the US
• Assessment and reassessment of ABCs
are critical.
• Consider the need for C-spine protection.
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SIDS
Sudden Infant Death Syndrome
Several known risk factors:
• Mother younger than 20 years old
• Mother smoked during pregnancy
• Low birth weight
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Tasks at Scene
• Assess and manage the patient.
• Communicate with and support the
family.
• Assess the scene.
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Assessment and Management
• Assess ABCs and provide interventions
as necessary.
• If child shows signs of postmortem
changes, call medical control.
• If there is no evidence of postmortem
changes, begin CPR immediately.
1
Communication and Support
• The death of a child is very stressful for
the family.
• Provide support in whatever ways you
can.
• Use the infant’s name.
• If possible, allow the family time with
the infant.
1
Scene Assessment
Carefully inspect the environment, following
local protocols.
Concentrate on:
• Signs of illness
• General condition of the house
• Family interaction
• Site where infant was discovered
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Apparent Life-Threatening Event
• Infant found not breathing, cyanotic, and
unresponsive but resumes breathing with
stimulation
• Complete careful assessment.
• Transport immediately.
• Pay strict attention to airway management.
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Death of a Child
• Be prepared to support the family.
• Family may insist on resuscitation efforts.
• Introduce yourself to the child’s
caregivers.
• Do not speculate on the cause of death.
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Death of a Child, continued
• Allow the family to see the child and say
good-bye.
• Be prepared to answer questions posed by
caregivers.
• Seek professional help for yourself if you
notice signs of posttraumatic stress.
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Children With Special Needs
• Children born prematurely who have
associated lung problems
• Small children or infants with congenital
heart disease
• Children with neurologic diseases
• Children with chronic diseases or with
functions that have been altered since
birth
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Tracheostomy Tube
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Artificial Ventilators
• Provide respirations for children unable
to breathe on their own.
• If ventilator malfunctions, remove child
from the ventilator and begin
ventilations with a BVM device.
• Ventilate during transport.
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Central IV Lines
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Gastrostomy Tubes
• Food can back up the esophagus into the
lungs.
• Have suction readily available.
• Give supplemental oxygen if the patient
has difficulty breathing.
1
Shunts
• Tubes that drain excess fluid from
around brain
• If shunt becomes clogged, changes
in mental status may occur.
• If a shunt malfunctions, the patient
may go into respiratory arrest.
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Pediatric Assessment
2
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.
2
Scene Size-up
1. Scene Size-up
• Take note of your
surroundings.
• Scene assessment will
supplement additional
findings.
• Note:
• Position of the patient
• Condition of the home
• Clues to child abuse
2
Initial Assessment
1. Scene Size-up
2. Initial
Assessment
• Decide SICK/NOT SICK
(Begins before you touch
the patient.)
• Determine a chief
complaint.
• The Pediatric Assessment
Triangle can help.
2
Focused History/Physical Exam
1. Scene Size-up
• Should be completed on
scene unless severity
2. Initial
requires rapid transport
Assessment
• Young children should be
examined toe to head.
3. Focused History/
• Focused exam on nonPhysical Exam
critical patients
• Rapid exam on potentially
critical patients
2
Detailed Physical Exam
1. Scene Size-up
2. Initial
Assessment
3. Focused History/
Physical Exam
4. Detailed Physical
Exam
• Status changes frequently
in children.
• The PAT can help with
reassessment.
2
Ongoing Assessment
1. Scene Size-up
2. Initial
Assessment
3. Focused History/
Physical Exam
4. Detailed Physical
Exam
5. Ongoing
Assessment
• Repeat vital signs
frequently.
• If child deteriorates, repeat
the initial assessment.
2
Pediatric Assessment Triangle
2
Assessing the ABCs
Airway: position
patient correctly
Work of breathing:
• Effort
• Obstructions
• Rate
Circulation:
• Rate
• Skin color,
temperature, and
capillary refill
2
Transport Decision
• Children under 40 lbs 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.
2
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.
2
Pulse
• 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.
2
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.
2
Skin Signs
• Feel for temperature and moisture.
• Estimate capillary refill.
2
Care of the Pediatric Airway
• Position the airway.
• Position the airway in a neutral sniffing
position.
• If spinal injury is suspected, use jawthrust maneuver to open the airway.
2
Care of the Pediatric Airway, cont'd
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.
2
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.
2
Assessing Ventilation
• Observe chest rise in older children.
• Observe abdominal/chest rise and fall in
younger children or infants.
• Skin color indicates amount of oxygen
getting to organs.
2
Oxygen Delivery Devices
• Nonrebreathing mask
at 10 to 12 L/min
provides 90+% oxygen
concentration.
• Blow-by technique at 6
L/min provides more
than 21% oxygen
concentration.
• Nasal cannula at 4 to 6
L/min provides 24% to
44% oxygen
concentration.
2
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
2
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
2
Signs and Symptoms
• Stridor
• Retractions
• Nasal flaring
• Difficulty speaking
• Decreased or absent breath sounds
2
Complete Airway Obstruction
Signs and symptoms
• Ineffective cough (no sound)
• Inability to cry
• Increasing respiratory difficulty, with
stridor
• Cyanosis
• Loss of consciousness
2
Removing an FBAO
In a RESPONSIVE child:
• Kneel behind the child.
• Give abdominal
thrusts.
• Repeat the technique
until object comes out
or the child becomes
unresponsive.
2
Removing an FBAO, continued
In an UNRESPONSIVE child:
• Place the child on a firm, flat surface.
• Inspect the upper airway and remove
any visible object. (No blind sweeps.)
• Attempt rescue breathing.
• If ventilation is still unsuccessful, CPR
with one exception:
— Visualize in the airway before you
attempt ventilation.
2
Removing an FBAO, continued
• Open airway again to
try and see object.
• Only try to remove
object if you see it.
• Attempt rescue
breathing.
2
Removing an FBAO, continued
• If unsuccessful,
reposition head and
attempt ventilation
again.
• Continue CPR with
one exception:
• Visualize in the
airway before
you attempt
ventilation.
2
Airway Obstruction in Infants
• If RESPONSIVE:
• Deliver 5 back slaps.
• Bring infant upright on the
thigh.
• Give five quick chest
thrusts.
• Check airway.
• Repeat cycle as often as
necessary.
2
Removing an FBAO, continued
•
•
•
•
•
If the infant is UNRESPONSIVE:
Inspect the airway.
Attempt rescue breathing.
Reposition the airway (if needed)
If airway remains obstructed,
CPR with one exception:
• Visualize in the airway
before you attempt
ventilation.
2
Trauma
Extremity injuries in children are generally
managed in the same manner as those in
adults.
2
Trauma, continued
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.
2
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.
2
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.
2
Removing a Child from a Safety Seat
• Remove both the child and the seat from the
vehicle.
• Place immobilization device behind the child.
• Slide child into place on device.
2
Respiratory Emergencies
Signs and Symptoms include:
• Nasal flaring
• Grunting respirations
• Use of accessory muscles
• Retractions of rib cage
• Tripod position in older children
2
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.
2
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.
2
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?
2
Emergency Care for Shock
• Ensure airway.
• Give supplemental
oxygen.
• Provide immediate
transport.
• Continue monitoring
vital signs en route.
• Contact ALS for backup
as needed.
2
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.
2
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.
2
Emergency Care for Seizures
• 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.
2
Emergency Care for Seizures
• Deliver oxygen by mask, blow-by, or
nasal cannula.
• Begin BVM ventilation if no signs of
improvement.
• Call ALS for backup if appropriate.
2
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?”
2
Emergency Care for Dehydration
• Assess the ABCs.
• Obtain baseline vital signs.
• ALS backup may be needed for IV
administration.
Questions
• What questions do you have?
To review this presentation, go to:
http://www.emsonline.net/emtb