INFANTS & CHILDREN
Kiddos Cause Anxiety for the Pre-Hospital Provider. This is Caused by the Lack of Dealing With This Special Population as Well as a Fear of Failure. Understanding the Special Factors Involved, Such as Body Size, Development, and Normal Vital Sign Ranges is Important in Their Emergency Medical Care.
OVERVIEW
- Ways of Dealing With Children of Different Ages
- Differences of Anatomy Between Kids & Adults
- Identify & Treat Respiratory Conditions in Kids
- Differences Between Kids & Adults When Dealing With Shock & Trauma
CLASSIFICATION of CHILDREN
DEVELOPMENTAL CONCERNS
- Newborns & Infants (Birth – 1 Year)
- Minimal Stranger Anxiety
- Don’t Like to be Separated from Parents
- Don’t Like to be Smothered w/ O2 Mask
- Need to be Kept Warm
- Do Tasks Before They Become Upset
- Listen to Lungs
- Assess Breathing & Circulation
DEVELOPMENTAL CONCERNS
- Toddlers (1 – 3 Years)
- Don’t Like to be Touched
- Don’t Like Separation from Parents
- Don’t Like Clothing Removed
- Don’t Like to be Smothered w/ O2 Mask
- Assure Child They are Not Bad
- They Think Illness/Injury is Punishment
- Afraid of Needles & Pain
- Examine Feet to Head
DEVELOPMENTAL CONCERNS
- Preschool (3 – 6 Years)
- Don’t Like to be Touched
- Don’t Like Separation from Parents
- Don’t Like Clothing Removed
- Don’t Like to be Smothered w/ O2 Mask
DEVELOPMENTAL CONCERNS
- Preschool (3 – 6 Years) (cont.)
- Assure Child They are Not Bad
- They Think Illness/Injury is Punishment
- Afraid of Needles, Pain, Blood, Permanent Injury
- Fear Possible Disfigurement
- Curious, Cooperative, Communicate
- Explain What You Are Doing
- Allow Patient to Give History & Information
- Examine Feet to Head
DEVELOPMENTAL CONCERNS
- School Aged (6 – 12 Years)
- Modest - Replace Clothing if Removed
- Afraid of Blood
- Fear Pain
- Fear of Permanent Injury, Disfigurement
- Explain What You Are Doing
- Allow Patient to Give History & Information
DEVELOPMENTAL CONCERNS
- Adolescent (12 – 18 Years)
- Modest
- Fear of Permanent Injury, Disfigurement
- May Want Assessed Privately
- They Expect to be Treated Like an Adult
- May Think They Are Indestructible
DEVELOPMENTAL CONCERNS
- Adolescent (12 – 18 Years)
- Try to respect the emerging adult, yet reassure the remaining child.
- Explain as you examine.
- Be calm, reassuring, and respectful.
- Respect the young adult’s modesty and need for privacy.
AIRWAY A&P CONCERNS
- Small Airway are Easily Blocked
- Secretions
- Swelling
- Tongue is Relatively Large Compared to Mandible
- Easily Blocks Airway
- Do Not Hyperextend Neck to Open Airway
AIRWAY A&P CONCERNS
- Infants Breath Mostly Thru Nose
- Suction Snot & Clean Boogers
- Compensate Well
- Decompensate Rapidly
OTHER DIFFERENCES
- HEAD
- Bigger, softer.
- Infants and small children have disproportionately larger heads (until about age 4). Note the effect of padding.
- Fontanelles (soft spots) exist until about 12-18 months old.
- Sunken may indicate dehydration
- Bulging may indicate crying or head injury
OTHER DIFFERENCES
- CHEST & ABDOMEN
- Increased elasticity of chest
- Primarily abdominal breathers (infants primarily nose-breathers)
- Less protection than adults for internal organs
OTHER DIFFERENCES
- BODY SURFACE
- Larger in proportion to body mass
- Increased risk of hypothermia
- Burn injuries calculated differently
ASSESSMENT
Two methods:
Pediatric Assessment Triangle (PAT)
OR
Step-by-Step assessment
PAT General Impression
"From the Doorway"
- Observe appearance:
- Mental status
- Body position/Muscle tone
- Observe breathing effort.
- Observe circulation (skin color).
ASSESSMENT
General Impression
- Ensure scene safety/Take BSI precautions.
- Observe:
- Mental status
- Effort of breathing
- Skin color
- Quality of cry or speech
- Emotional state
- Response to your presence
- Tone and body position
Observe interaction with environment & parents:
- Normal behavior for age?
- Playing or moving around?
- Attentive?
- Eye contact?
- Recognize & respond to parents?
Initial Assessment
Assess airway:
- Open?
- Adequate?
- Any steps needed to ensure it stays open?
Assess breathing:
- Chest expansion and symmetry
- Effort of breathing
- Nasal flaring
- Retractions
- Rate
Assess respirations using a stethoscope for:
- Crowing or noisy respirations
- Wheezing
- Stridor or grunting
- Equal expansion
Assess circulation:
- Pulse (best location varies by age)
- Capillary refill
- < 2 Seconds
- Skin color, temperature, condition
- BP – Age 3 and Up
- Appropriate Cuff Size
Identify Priority Patients
- Poor general impression
- Unresponsive
- Airway compromise
- Inadequate breathing
- Shock
- Uncontrolled bleeding
Focused History
- Child may be only source.
- Use simple yes/no questions.
Use parents/guardians for information if possible.
Detailed Physical Exam
- Generally, start at trunk and evaluate head last.
- Alter order of steps to fit situation.
- Avoid making child more anxious.
Ongoing Assessment
- Reassess interventions.
- Reassess ABCs.
- Reassess vital signs.
- Continuous reassessment is key!
AIRWAY CONTROL
- Opening Airway
- Head-Tilt Chin-Lift – Don’t Hyperextend
- Jaw Thrust w/ Spinal Immobilization
AIRWAY CONTROL
- Suctioning
- Yankauer (tonsil tip) or French Catheters
- -80 to -120 mmHg of Regulated Suction
- Oxygenate Before & After Suctioning
- DO NOT Suction More Than 10 Seconds
- Monitor Heart Rate & Clinical Appearance
AIRWAY OBSTRUCTIONS
- Infants (< 1 yr old)
- Perform Back Blows and Chest Thrusts
- Visualize Foreign Body to Remove
- Children (> 1 yr old)
- Abdominal Thrusts
- Visualize Foreign Body to Remove
Signs of Partial Airway Obstruction
- Stridorous, crowing, or noisy respirations
- Retractions on inspiration
- Pink mucous membranes and nail beds
- Alert
Treating Partial Airway Obstruction
- Place in position of comfort (parent’s lap okay).
- Administer high-concentration oxygen.
- Transport without agitating.
Complete Airway Obstruction
- No crying or speech
- Initial difficulty breathing that worsens
- Cough becomes weak and ineffective
- Altered mental status, unconsciousness
AIRWAY ADJUNCTS
- Oral Airway
- Initiate Ventilations Before Airway Adjunct
- Patient Should Not Have Gag Reflex - Unconscious
- Sizing Same as an Adult – Mouth to Angle of Jaw
- Technique of Insertion
- Use Tongue Depressor
- Depressor to Base of Tongue
- Push Toward Feet & Upward
- Insert Oropharyngeal Airway Directly Without Rotation
- Nasal Airway
- Initiate Ventilations Before Airway Adjunct
- Sizing & Insertion Same as Adult
- DO NOT Use On Head Injured Patients
- May Be Used if Patient is Not Unconscious
- Should Not Interfere With Gag Reflex
- May Cause Soft Tissue Damage in Nasal Cavity
ARTIFICIAL VENTILATION
- Consider Mask and Bag Size
- Use Proper Size
- Squeeze Slowly, Watch for Chest Rise
- Rate – 20/min
- Provide 100% O2
- Open Airway
- Jaw-Thrust For Trauma Patients
- Mask Seal
- One or Two Handed
- Mouth to Mask Ventilations
- Reduce Tidal Volume
SHOCK (HYPOPERFUSION)
- Diarrhea, vomiting, dehydration
- Trauma and blood loss
- Infection
- Abdominal injuries
SIGNS
- Rapid breathing
- Pale, cool, clammy skin
- Weak/absent peripheral pulses
- Delayed capillary refill
- Decreased urine output
- Inspect diaper/ask parents when last changed
- Changes in mental status
- Lack of tears when crying
EMERGENCY CARE OF SHOCK
- Maintain airway & administer high-concentration oxygen.
- Ventilate as needed.
- Control bleeding.
- Elevate legs.
- Keep warm.
- Transport.
COMMON PROBLEMS
- Respiratory, Respiratory, Respiratory
- Partial Airway Obstruction
- Medical – Croup, Epiglottitis
- Stridor, Crowing, Noisy Breathing
- Retractions on Inspiration
- Usually Pink, Good Perfusion, & Alert
- Emergency Care
- Position of Comfort, Usually w/ Parent
- Administer O2
- Don’t Agitate, Keep Quiet, Limit Exam
COMMON PROBLEMS
- Complete Airway Obstruction or
- Partial A.O. w/ Alt LOC or Cyanosis
- No Crying, Speaking or Cyanosis
- Ineffective Cough
- Stridor, Noisy Breathing
- Loss of Consciousness
- Emergency Care
- Clear the Airway
- Attempt Ventilations
COMMON PROBLEMS
- Difference Between Upper Airway Obstruction and Lower Airway Disease
- Upper Airway = Stridor on Inspiration
- Lower Airway Disease
- Wheezing
- Effort on Expiration – Can’t Blow Off Gases
- Rapid Breathing (Tachypnea)
INCREASED BREATHING EFFORT
- Early Signs of Respiratory Distress
- Nasal Flaring
- Intercostal Retraction
- Supraclavicular Retraction
- Subcostal Retraction – Seesaw Breathing
- Stridor or Wheezing
- Grunting
- Drooling – Unable to Swallow
INCREASED BREATHING EFFORT
- More Emergent Signs of Respiratory Distress
- Things Are Getting Desperate Now !!!
- Heart Rate < 60 Beats/min
- Cyanosis
- Decreased Muscle Tone
- Severe Accessory Muscle Use
- Poor Peripheral Perfusion
- Altered Mental Status
- Grunting
INCREASED BREATHING EFFORT
- You and the Patient are Losing the Game !!!
- Respiratory Arrest
- Breathing < 10 Minute
- Limp Muscle Tone
- Unconscious
- Slow or Absent Heart Rate
- Weak or Absent Peripheral Pulses
EMERGENCY CARE
- Oxygen for Breathing Patients
- Ventilations w/ O2
- Respiratory Arrest
- Imminent Respiratory Arrest
- Remember a Patient Not Breathing is a Dead Patient – This is No Time to be Shy
SEIZURES
- Chronic Seizures are Rarely Life-Threatening
- May be Brief or Prolonged
- Assess for Injuries That May Have Occurred
- Causes of Seizures
- Fever, Infections, Poisoning, Hypoglycemia, Trauma, Hypoxia, or may be Idiopathic in Kids
- Status Epilepticus – True Emergency
- A Seizure That Occurs, After a Previous Seizure, Without the Patient Regaining Consciousness
SEIZURES
- Questions to Ask
- Does the Child Have a History of Seizures?
- Is/Was This a Normal Seizure Pattern?
- Does the Child Take Anti-Seizure Medication?
AFTER the SEIZURE
- Post Ictal State
- Altered Mental Status
- Possible Breathing Problems
- Usually a Slow Improvement
- Keep Patient Quiet
- Keep By-Standers Away – Provide Privacy
EMERGENCY CARE of SEIZURES
- Assure an Open Airway
- Protect From Injury
- If No Cervical Trauma, Position On Side
- Have Suction Ready
- Provide O2 if Breathing, Ventilate if Not
- Transport
- Brief Seizure May Not Be Life-Threatening, but May Have Underlying Condition
ALTERED MENTAL STATUS
CAUSES
- Hypoglycemia
- Poisoning
- Post Seizure / Post Ictal
- Infection
- Head Trauma
- Hypoxia
- Hypoperfusion
CARE
- Assure an Airway
- Ventilate PRN
- Suction PRN
- Transport
POISONING
- Everything Goes to a Kids Mouth
- Common Call
- Identify Container Through History
- Take Container to Hospital
POISONING
EMERGENCY CARE
- Responsive Patient
- Contact Medical Command
- Consider Use of Activated Charcoal
- O2
- Transport
- Monitor Patient
POISONING
EMERGENCY CARE
- Unresponsive Patient
- Assure Airway
- Ventilate if Needed
- O2
- Contact Medical Command
- Transport
- Rule Out Trauma
FEVER
- Common Call
- Many Causes – Lack of Development of Immune System
- Many Are Not Life-Threatening
- Some Are – ie. Meningitis
- Fever w/ Rash Should be Considered Serious
- Kids Crash Late – Don’t Play Around
HYPOPERFUSION
COMMON
- Diarrhea / Dehydration
- Vomiting
- Trauma
- Blood Loss
- Infection
- Abdominal Injuries
NOT SO COMMON
- Allergic Reactions
- Poisonings
- Cardiac Related Problems
- Unless Congenital
S & S of HYPOPERFUSION
- Rapid Respiratory Rate
- Pale, Cool, Clammy Skin
- Weak or Absent Peripheral Pulses
- Delayed Capillary Refill
- Decreased Urine Output
- Ask Parents
- Diaper Usage
- Mental Status Changes
- Absence of Tears When Crying
EMERGENCY CARE
- Assure Airway
- Ventilate if Needed
- Manage Bleeding if Needed
- Elevate Legs
- Keep Warm
- Rapid Transport
- Remember Kids Crash Late – Drop In BP May Already Be Too Late For Survival !!!
NEAR DROWNING
- Number 1
- Airway / Ventilate
- Suction PRN
- Spinal Trauma
- Hypothermia
- Alcohol Ingestion
- Teens / Adults
- Secondary Drowning Syndrome
- Deterioration of Normal Breathing
- Minutes to Hours After
SIDS
- Sudden Infant Death Syndrome
- Sudden Death in First Year
- Many Causes Not Understood
- Most Discovery is in the Morning
- Should Sleep on Back
- Should Not Sleep with Parents
EMERGENCY CARE of SIDS
- Attempt Resuscitation Unless Rigor Mortis
- Parental Agony
- Emotional Distress
- Remorse
- Imagined Guilt
- Avoid Comments That Suggests Blame
- Utilize Critical Incident Stress Debriefing
TRAUMA
- Trauma is the Leading Cause of Death
- Blunt Trauma Being Most Common
- MVA
- Unrestrained – Head & Neck
- Restrained – Abdominal & Lower Spine
- Still Suspect Neck Injury
TRAUMA
- Bicycle Accidents
- Struck While Riding
- Head, Spinal, & Abdominal Injuries
- Encourage Helmet Use
- PA Law - 12 & Under
TRAUMA
- Pedestrian Accidents
- Abdominal, Leg, Pelvic, Head, & Spinal Injuries
- Suspect Internal Injury
- Examine MOI
- Look for Patterns
TRAUMA
- Other Common Traumatic Injuries
- Falls From Heights
- Diving Into Shallow Water
- Burns
- Sport Injuries
- Child Abuse
SPECIFIC BODY SYSTEMS
- Head
- Assure Open Airway w/ Jaw Thrust
- Head & Internal Injuries Can Occur Simultaneously
- Signs of Shock w/ Head Injury – Look Elsewhere
- Respiratory Arrest Common w/ Head Injury
- Nausea & Vomiting is Inevitable
- Tongue Will Block Airway
- Do Not Use Sand Bags for Head Stabilization
SPECIFIC BODY SYSTEMS
- Chest
- Soft Pliable Ribs
- External Injury can be Significant Internal Injury
- Significant Internal Injury w/o External Injury
SPECIFIC BODY SYSTEMS
- Abdomen
- More Common Site Than Adults
- Underdeveloped Muscles & Bones
- Deterioration w/o External Injury – Suspect Belly
- Air in Stomach Can Cause Distention
- Interferes w/ Ventilations
SPECIFIC BODY SYSTEMS
- Extremities
- Manage the Same as Adults
- Control Bleeding
- Direct Pressure
- Pressure Points
- Elevation
- Splinting
OTHER TRAUMA CONSIDERATIONS
- PASG / MAST
- Only if Child Fits – Child Size
- Don’t Inflate Abdomen Section
- Not for Infants
- Indicated for Severe Hypoperfusion & Unstable Pelvic Injury
EMERGENCY TRAUMA CARE
- Scene Safe, BSI, ALS Requested, # of Patients
- Assure Airway – Jaw Thrust
- Suction PRN – Large Bore Suction Catheter
- Provide O2
- Assist Ventilations w/ BVM PRN
- Provide Spinal Immobilization Throughout
- Transport
CHILD ABUSE & NEGLECT
Definitions
- Child Abuse
- Improper or Excessive Action so as to Injure or Cause Harm
- Neglect
- Giving Insufficient Attention or Respect to Someone Who has a Claim to that Attention
CHILD ABUSE & NEGLECT
- Abuse & Neglect Can be Seen by EMT
- Be Aware
- Recognize Problem
- Suspect
- Report Objective Findings to Police, Hospital Personnel, CYS
- "Just the Facts Ma’am" – Not What You Think
- Obligated by Law to Report
- Don’t Confront or Accuse in the Field
CHILD ABUSE & NEGLECT
- Signs & Symptoms of Abuse
- Multiple Bruises in Different Stages of Healing
- Injury Inconsistent w/ Mechanism Described
- Repeated Calls to Same Residence
- Fresh Burns
- Parents Seem Inappropriately Concerned
- Conflicting Stories
- Child Fearful About Telling How Injury Occurred
CHILD ABUSE & NEGLECT
- Signs & Symptoms of Neglect
- Lack of Adult Supervision
- Malnourished
- Unsafe Living Environment
- Untreated Chronic Illness
CHILD ABUSE & NEGLECT
- Shaken Baby Syndrome
- CNS Injury is Most Lethal
SPECIAL NEEDS
- Tracheostomy Problems & Care
- Complications
- Obstruction, Bleeding, Air Leak, Dislodged, Infection
- Emergency Care
- Maintain Airway
- Suction
- Position of Comfort
- Transport
SPECIAL NEEDS
- Home Artificial Ventilators
- Various Types
- Parents are Familiar w/ Operation
- Emergency Care
- Assure Airway
- Artificially Ventilate w/ O2
- BVM
- Transport
SPECIAL NEEDS
- Central IV Lines
- Intravenous Therapy
- Complications
- Cracked Line
- Infection
- Clotting
- Bleeding
- Emergency Care
- If Bleeding, Hold Direct Pressure
- Transport
SPECIAL NEEDS
- Gastrostomy Tube
- Feeding Tube
- Tube Directly in Stomach for Feeding
- Can’t be Fed by Mouth
- Diabetic Infants Become Hypoglycemic if Not Fed
SPECIAL NEEDS
- Shunt
- Device Runs From Brain to Abdomen to Drain Excess CSF
- Hydrocephalus
- Excess Pressure, Clogs, Infection
- Lethargy, Irritable, Projectile Vomiting, Seizures
SPECIAL NEEDS
- Shunts (cont.)
- Prone to Respiratory Arrest
- Manage Airway
- Ventilate PRN
- Protect Head During Seizure
- Transport
FAMILY RESPONSE
- Do Not Isolate Patient From Family
- However, You Now Have More Than 1 Patient to Deal With
- Strive For Calm
- Calm Parent = Calm Patient
- Agitated Parent = Agitated Patient
- Pain & Well-Being Leads to Anxiety
- Worsened by Sense of Helplessness
FAMILY RESPONSE
- Parents May be Hostile Toward EMT
- Parents Should Remain During Care
- Unless Condition Warrants Separation
- Parents Can be Instructed to Calm Patient
- Can Hold Patient in Position of Comfort or O2
- Parents are Experts at Normal / Abnormal for Their Child
EMS PROVIDER’S RESPONSE
- Anxiety
- Lack of Experience
- Fear of Failure
- Practice Techniques
- Stress
- What if This was My Own Child?
EMS PROVIDER’S RESPONSE
- What You Have Learned About Adults Can Apply to Children, But You Must Learn the Difference.
- Practice Practice Practice
- Techniques
- Equipment