Transcript Copyright © Texas Education Agency, 2014.

Pediatric Emergencies
Copyright © Texas Education Agency, 2014. All rights reserved.
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Copyright © Texas Education Agency,
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2014. All rights reserved.
Developmental Characteristics of
Infants and Children
• The term pediatric refers to patients who have
not yet reached the age of puberty.
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2014. All rights reserved.
Pediatric Anatomy and Physiology
• Normal pulse rate ranges: 120–160/minute in newborns to 60–
105/minute in adolescents. Normal respiration rate ranges: 30–
50/minute in newborns to 12–20/minute in adolescents. Normal
blood pressure ranges: average 99/65 in preschoolers to average
114/76 in adolescents.
• Pediatric anatomy is most different when considering the head, the
airway, the respiratory system, and the chest.
• A child’s head is proportionately larger than an adult’s until age 4.
• Up to 12–18 months infants will have a soft spot just to the anterior
center of the skull called the anterior fontanel.
• Infants typically breathe through their noses, so a nasal obstruction
can impair breathing.
• The trachea (windpipe) is often softer and more flexible in infants
and children.
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2014. All rights reserved.
Pediatric Anatomy and Physiology
• This makes it much more easily obstructed by swelling and foreign
objects.
• Greater loss of body heat because pediatric patients’ heads and
bodies are proportionately different from that of an adult.
• Blood loss that might be considered moderate in an adult can be
life-threatening for a child. A newborn doesn’t have enough blood
to fill a 12-ounce soda can.
• Each pediatric age group has its own general characteristics of
psychosocial development. EMTs should understand baseline
expectations.
• Crying may make assessment difficult, but it is still possible. Position
yourself at the child’s eye level. Speak slowly and quietly to help
keep the child calm. Never let the potential of upsetting a child
prevent appropriate treatment.
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2014. All rights reserved.
Psychosocial Development
• Each pediatric age group has its own general characteristics of
psychosocial development. EMTs should understand baseline
expectations.
• Be honest at all times. If something is going to hurt, let the child
know. Be sure to tell the child that you are there to help and will
not leave.
• Adolescents like to be treated as adults and are very sensitive to
violations of their dignity or being patronized. When ill or injured,
they regress emotionally and need as much support as children.
They are also worried about peer opinion and changes to their
bodies. However, do not delay treatment or care because you feel
the patient may be embarrassed.
• You should always inquire about onset, provocation, quality,
radiation, severity, and time (OPQRST).
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2014. All rights reserved.
Supporting the parents and other care
providers.
• Emphasize the importance of caregiver interaction.
Describe how artery disease leads to heart problems.
• Put the information into the context of a parent’s
viewpoint.
• Caregiver interaction will be necessary on almost every
pediatric call.
• The approach that an EMT uses to interact with a pediatric
patient and his caregivers significantly impacts the ability to
assess and treat the patient effectively.
• Caregiver reaction varies greatly when a child is sick or
injured. The EMT should be prepared for a variety of
emotions. The calm and professional demeanor of the EMT
will project a calming influence on persons involved in the
pediatric emergency scene.
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2014. All rights reserved.
Assessing the Pediatric Patient
• The pediatric assessment triangle (PAT) is a
tool that allows for a rapid assessment of the
severity of an injury or illness by reviewing
– Appearance: tone, interactiveness, consolability,
look/gaze, speech/cry
– Work of breathing: abnormal airway sounds,
abnormal positioning, retractions, nasal flaring,
head bobbing
– Circulation to the skin: pallor, mottling, cyanosis
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2014. All rights reserved.
Assessing the Pediatric Patient
• Consider the child’s mental status utilizing AVPU (Alert,
Verbal, Painful, and Unresponsive). Is the child acting
appropriately?
• A great deal of information can and should be gathered
from the doorway, before you approach and possibly
upset the patient.
• Never shake an infant or child.
• If the patient is not breathing or breathing
inadequately, provide artificial respirations or oxygen.
Assess chest expansion, effort of breathing, sounds of
breathing, breathing rate, and skin color.
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2014. All rights reserved.
Assessing the Pediatric Patient
•
•
•
As with an adult check for pink, warm, dry skin and a normal pulse as signs of
adequate perfusion. Check a radial pulse in a child and a brachial or femoral pulse
in an infant. In patients 5 years or younger, also check the capillary refill.
A patient who is considered a high priority for transport is one who gives a poor
general impression. The patient may be unresponsive and listless, may not
recognize the parent or primary caregiver, or is not comforted when held by a
parent but becomes calm and quiet when set down. The patient may have a
compromised airway, may be in respiratory distress, or have inadequate breathing
causing respiratory distress. The patient has the possibility of shock or
uncontrolled bleeding.
At times the child might be the only source of history. If this is the case, ask simple
yes-or-no questions while obtaining a medical history. A child who can’t tell you
where it hurts can usually point. Perform a focused assessment for a medical
patient and rapid assessment for a trauma patient. Do your exam in trunk-to-head
order to avoid frightening the child. Take and record vital signs, assessing blood
pressure only in children older than 3 years.
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2014. All rights reserved.
Assessing the Pediatric Patient
• To assist with exams, some providers carry stuffed animals like teddy
bears. They can comfort the child, and can be used as a model to explain
the examination. Let the child keep the toy after the examination. Many
parents, teachers, and day care personnel teach children that strangers
should not remove their clothing or touch them. The children that you
examine may not understand your intentions and may resist. Some
children may become upset because they feel you are taking something
away from them. Take your time and do not rush children into accepting
all that is happening. Remember that children rapidly lose body heat, so if
you expose them, quickly cover them with a blanket.
• Look for blood and clear fluids coming from the nose and ears. Suspect a
skull fracture if present. Children are nose-breathers, so mucus or blood
clot obstructions can make it hard for them to breathe.
• If there is no suspected spinal injury, place a flat, folded towel under the
patient’s shoulders to get the appropriate airway alignment.
Hyperextension or flexion may close off the airway. For medical
respiratory problems, the child will probably want to sit up.
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2014. All rights reserved.
Assessing the Pediatric Patient
• Remember that even though a child’s ribs may not be
broken, there may be underlying injuries to the chest
organs.
• The bones of an infant are more pliable than in older
patients. They bend, splinter, and buckle before they
fracture.
• Pediatric patients are constantly changing. Continual
assessment is essential to good patient care.
• Patients who are stable have vitals reassessed every 15
minutes. Unstable patients have vitals taken every 5
minutes.
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2014. All rights reserved.
Special Concerns in the Pediatric
Patient
• Airway and breathing maintenance, shock care, and prevention of
hypothermia are universal points of importance with regard to
pediatric care. Anatomic differences slightly alter the typical
approach to airway management. EMTs must account for these
differences.
• If the patient doesn’t have a gag reflex, you can insert an oral
airway. Push down on the tongue while lifting the jaw.
• If patient has a gag reflex but no head or facial injury, you may
insert a nasopharyngeal airway. Review use of the nasopharyngeal
airway and contraindications such as head and facial injury.
• When placing children with partial airway obstruction in position of
comfort, do not allow them to lie down. For total airway
obstruction in infants less than 1 year old, perform back blows and
chest thrusts and use finger sweeps to remove visible objects.
Attempt artificial ventilations with a pocket mask or bag-valvemask.
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2014. All rights reserved.
Special Concerns in the Pediatric
Patient
• For the blow-by oxygen technique, hold or have the parent hold oxygen
tubing or the pediatric nonrebreather mask 2 inches from the patient’s
face. Some departments have blow-by devices in the form of stuffed
animals. Some children respond well when oxygen tubing is pushed
through the bottom of a paper cup, especially if the cup is colorful or has a
picture drawn inside it. Do not use Styrofoam cups.
• Appropriate sizing of the oxygen mask or BVM is necessary for positive
seal resulting in the appropriate amount of oxygen being delivered to the
patient.
• Avoid breathing too hard into a pocket mask. Ventilations should be
performed at 12–20 per minute or every 3–5 seconds for an infant or child
up to puberty, and 10–12 per minute or one every 5–6 seconds if the child
has reached puberty.
• A non-rebreather mask always provides more efficient oxygen delivery and
many children tolerate it well. Use blow-by only when more efficient
methods fail.
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2014. All rights reserved.
Special Concerns in the Pediatric
Patient
• Infants and children are able to compensate for shock for a long time.
Compensating methods fail at approximately 30% blood loss, and then
hypovolemic shock develops rapidly. This means that a child may appear
to be fine, then “go sour” in a hurry, in contrast to the adult patient in
whom hypovolemic shock develops earlier and more gradually, making it
easier to assess and treat than in a child.
• The definitive care for shock takes place in the hospital. Since infants and
children are prone to go into hypotensive shock—shock in which the blood
pressure has dropped severely—so suddenly, it is important not to wait for
signs of hypotensive shock to develop. Provide oxygen and transport as
quickly as possible.
• Pediatric patients may be more susceptible to hypothermia than adults
are. Field care for children is the same as for adults. Avoid rough handling
or inserting anything in the patient’s mouth, as these may result in
ventricular fibrillation or cardiac arrest in the severely hypothermic child.
Suction very gently if suctioning is necessary, and be alert to the possibility
of cardiac arrest.
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2014. All rights reserved.
Pediatric Medical Emergencies
• The most likely cause of cardiac arrest in a child, other than
trauma, is respiratory failure.
• Recognizing respiratory distress or failure is an important
goal of assessment of a pediatric patient.
• Although identifying the exact cause of respiratory distress
may not be possible, distinguishing an upper airway
problem from a lower airway problem will help target
immediate treatments.
• In general, with suspected airway diseases you should
transport as quickly as possible if you see or hear wheezing,
breathing effort on exhalation, or rapid breathing.
• Recognizing assessment findings of common pediatric
respiratory problems will help focus treatment.
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2014. All rights reserved.
Pediatric Medical Emergencies
• In the evening, what was a mild fever and soreness turns to a seallike bark and progresses in the evening hours. Treatment is aimed at
placing the patient in position of comfort (usually sitting up). Highflow oxygen (humidified) is preferred. Cool night air may provide
relief, but move patient slowly to the ambulance. Do not delay
transport unless ordered to by medical direction.
• Patients will often drool to avoid swallowing. Contact ALS.
Immediately transport the child sitting on parent’s lap. Provide-high
concentration oxygen from a humidified source. Constantly monitor
for developing respiratory distress. Do not place anything in the
child’s mouth.
• EMTs should never regard a fever as unimportant. Fever can be the
most important sign of a variety of serious conditions.
• Personal protective equipment is important when dealing with
probable infectious disorders such as meningitis or diarrhea.
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2014. All rights reserved.
Pediatric Medical Emergencies
• Meningitis is a life-threatening infection of the lining of the brain. It
occurs between the ages of 1 month and 5 years. The signs and
symptoms consist of high fever, stiff neck, lethargy, irritability,
headache, and sensitivity to light. In an infant the fontanelles may
be bulging unless the child is dehydrated. Movement is painful and
the child doesn’t want to be touched or held, and may have
seizures.
• Some forms of meningitis are highly infectious requiring EMS
personnel to be evaluated and given antibiotics by a physician.
• Some systems recommend that you save a sample of the vomit and
rectal discharge. Infants are more susceptible to the effects of
dehydration because a greater percentage of their body is water
and their fluid maintenance needs are greater.
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2014. All rights reserved.
Pediatric Medical Emergencies
• Fever is the most common cause of seizures in infants
and children.
• Consider seizures life-threatening. During assessment,
ask, “Has the child had prior seizures?” If yes, then
question if this is a normal seizure pattern. (How long
did it last?) Has the child had a fever? Has the child
taken any anti-seizure or other medications? Be aware
that seizures may be caused by head trauma.
• It is not up to the EMT to diagnose SIDS. EMTs should
treat such patients as they would any other cardiac
arrest.
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2014. All rights reserved.
Pediatric Trauma Emergencies
• Different anatomy leads to slightly different patterns of traumatic
injury in pediatric patients. Providers should use their knowledge of
pediatric A&P to enhance the assessment and treatment.
• Trauma is the number one cause of death in infants and children.
• Exploring often leads to injury from accidental falls (or things falling
on them), burns, entrapment, crushing, and other MOIs.
• The head is proportionately larger and heavier in smaller children.
This leads to head injury when the head is propelled forward in a
collision.
• Head injury presents with shock. Respiratory arrest is a common
secondary side effect. The most frequent signs are altered mental
status, nausea, and vomiting.
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2014. All rights reserved.
Pediatric Trauma Emergencies
• The less-developed respiratory muscles of the chest and
more elastic ribs make the pediatric chest more easily
deformed.
• Though pediatric ribs rarely fracture there is more likely to
be injury to the structures underneath them.
• Appropriate evaluation of lung sounds is a requirement,
especially due to the anatomical proximity in relation to the
diaphragm and abdominal organs. If injured, these
structures may also interfere with breathing.
• Because the abdominal muscles are less developed in
children, there can be many hidden injuries in the pediatric
patient.
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2014. All rights reserved.
Pediatric Trauma Emergencies
• Suspect internal abdominal injury when the patient deteriorates
even without evidence of external injury. In addition, air in the
stomach can distend the abdomen and interfere with artificial
ventilation. This may also lead to vomiting. Be prepared to suction
the patient.
• Divide the abdomen into quadrants and examine each one, while
remembering which organs are located in each quadrant.
• The pelvis should be evaluated for any fracture.
• The patient’s arms should be assessed for pulse, motor function,
and sensory function.
• Lower extremities should be evaluated for pulse, motor function,
and sensory function. Extremity injuries are cared for the same way
as they are in an adult.
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2014. All rights reserved.
Pediatric Trauma Emergencies
• Always check the back for any other injuries. Spinal precautions
should be observed in all trauma patients.
• Open the Kendrick Extrication Device (KED) and place padding on it
to properly position and align the child’s head and body. Log roll the
child onto the KED. Fold the side pieces inward to provide side
padding and support and to allow visualization of the chest and
abdomen. Since the torso straps will be rolled to the inside, secure
the torso with tape. Fold the head flaps securely against the child’s
head and tape across the head and chin.
• Burns are a common pediatric injury. Children’s body surface area is
larger proportionately to body mass, making them more prone to
heat loss. Burned patients who become hypothermic have a higher
death rate. Keep the infant or child covered to prevent a drop in
body temperature.
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2014. All rights reserved.
Child Abuse and Neglect
• The prime objective in a potential abuse scenario
is treating medical problems.
• Physical abuse is just one form of abuse.
• Know regulations and laws regarding child abuse.
• There is no distinction as to race, creed, ethnicity,
or economic background with regard to child
abuse.
• Psychological abuse, neglect, physical abuse, and
sexual abuse are all forms of child abuse.
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2014. All rights reserved.
Child Abuse and Neglect
• EMTs should be alert for characteristic physical findings
of potential abuse. Scene clues and social interaction
also can demonstrate potential abuse.
• In preserving evidence, discourage the child from going
to the bathroom. Give nothing by mouth. Do not have
the child wash or change clothes.
• If an EMT encounters potential abuse, he should not be
judgmental. The focus should be on providing care and
transport for the child.
• As you assess the patient and provide appropriate care,
control your emotions and hold back accusations.
•
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2014. All rights reserved.
Child Abuse and Neglect
• Do not indicate to the parents or other adults at
the scene that you suspect child abuse or neglect.
• Do not ask the child if he has been abused. If you
are suspicious about the mechanism of injury,
transport the child even though the severity of
injury may not warrant such action.
• Reporting potential abuse is a professional and
ethical responsibility of the EMT. In some states,
it is a legal requirement.
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2014. All rights reserved.
Child Abuse and Neglect
• Be familiar with your state laws.
• Even if reporting possible child abuse or neglect is
not a legal requirement in your state, it is a
professional obligation. As an EMT, you may be
the only advocate an abused child has. Be
conscientious.
• Also bear in mind that your suspicions may be
unfounded. Not every injury to a child is the
result of child abuse. Suspicions should be
aroused not by individual injuries but by patterns
of injuries and behavior.
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2014. All rights reserved.
Infants and Children with Special
Challenges
• Many children who are dependent upon technology live at home.
EMS frequently becomes involved when some element of
technology that allows these patients to reside at home fails.
• Most of the parents or caregivers of children with special challenges
have received training on how to handle emergencies. Therefore
they can be an important resource for assessment information.
• Tracheostomy tubes are placed into the child’s trachea to create an
open airway.
• Obstruction, bleeding, air leakage, infection, and dislodged tubes
are potential complications.
• Maintain an open airway; suction the tube as needed, allow the
patient to stay in position of comfort, such as parent’s lap.
Transport to the hospital.
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2014. All rights reserved.
Infants and Children with Special
Challenges
• Care of home artificial ventilators includes maintaining an
open airway, artificially ventilating with pocket mask or
BVM with oxygen, and transport.
• Many types of technology support children with special
health care needs. EMTs should use the caregiver as a
resource when dealing with a malfunction.
• Central lines are placed close to the heart. Unlike
peripheral IV lines, they may be left in place for long term
use.
• Complications may include infection, bleeding, clotting-off
of the line, and cracked line. Your care will include applying
pressure if there is bleeding and transporting the patient.
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2014. All rights reserved.
Infants and Children with Special
Challenges
• Gastrostomy tubes are tubes placed through
the abdominal wall directly into the stomach.
They are used for patients who cannot be fed
orally.
• The largest potential problem is respiratory
distress. Patients transported on their right
side are transported in that position with the
head of the stretcher elevated to reduce the
risk of aspiration.
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2014. All rights reserved.
Infants and Children with Special
Challenges
• A shunt is a drainage device that runs from
the brain to the abdomen to relieve excess
cerebrospinal fluid.
• There will be a reservoir on the side of the
skull. If it malfunctions, pressure will increase
inside the skull, causing altered mental status.
(Altered mental status may also be caused by
an infection.)
• These patients are prone to respiratory arrest.
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2014. All rights reserved.