Chapter 16 Pediatric Emergencies National EMS Education Standard

Chapter 16 Pediatric Emergencies

National EMS Education Standard Competencies (1 of 8) Special Patient Populations Recognizes and manages life threats based on simple assessment findings for a patient with special needs while awaiting additional emergency response.

National EMS Education Standard Competencies (2 of 8) Pediatrics Age-related assessment findings and agerelated assessment and treatment modifications for pediatric-specific major diseases and/or emergencies • Upper airway obstruction • Lower airway reactive disease • Respiratory distress/failure/arrest

National EMS Education Standard Competencies (3 of 8) Pediatrics (cont’d) • Shock • Seizures • Sudden infant death syndrome Patients With Special Challenges • Recognize and report abuse and neglect

National EMS Education Standard Competencies (4 of 8) Medicine Recognizes and manages life threats based on assessment findings of a patient with a medical emergency while awaiting additional emergency response.

National EMS Education Standard Competencies (5 of 8) Respiratory Anatomy, signs, symptoms, and management of respiratory emergencies including those that affect the • Upper airway • Lower airway

National EMS Education Standard Competencies (6 of 8) Trauma Uses simple knowledge to recognize and manage life threats based on assessment findings for an acutely injured patient while awaiting additional emergency medical response.

National EMS Education Standard Competencies (7 of 8) Special Considerations in Trauma Recognition and management of trauma in • Pregnant patient • Pediatric patient • Geriatric patient

National EMS Education Standard Competencies (8 of 8) Anatomy and Physiology Uses simple knowledge of the anatomy and function of the upper airway, heart, vessels, blood, lungs, skin, muscles, and bones as the foundation of emergency care.

Introduction • Sudden illness and medical emergencies are common in children and infants. • Anatomical differences exist between adults and children. • Respiratory care for children is extremely important.

General Considerations (1 of 3) • Managing a pediatric emergency can be one of the most stressful situations you face as an EMR. – You must remain calm and professional. – Unless you are prepared, your anxiety and fear may interfere with your ability to deliver proper care.

General Considerations (2 of 3) • The parents can be either allies or a potential problem. – Talk to both the parents and the child as much as possible. – Try to develop a rapport with the child. – Squat, kneel, or sit down and establish eye contact. – Ask simple questions about the pain.

General Considerations (3 of 3) • The parents (cont’d) – Be honest with the child. – Some agencies provide the child with a trauma teddy bear to hold while being examined.

Pediatric Anatomy and Function (1 of 3) • Differences between children and adults – A child’s airway is smaller in relation to the rest of the body compared to an adult’s airway. – A child’s tongue is relatively larger than an adult’s.

Pediatric Anatomy and Function (2 of 3) • Differences between children and adults (cont’d) – A child’s upper airway is more flexible than that of an adult. – For at least the first 6 months of their lives, infants can breathe only through their noses. – When the demands on a child’s respiratory system change, the child is able to quickly compensate by increasing breathing efforts.

Pediatric Anatomy and Function (3 of 3) • Differences between children and adults (cont’d) – Infants and children have limited abilities to compensate for changes in temperature as compared to adults.

Examining a Child • Use the same five steps as in the adult patient assessment sequence: – Perform a scene size-up. – Complete a primary assessment. – Complete a secondary assessment by examining the child from head to toe. – Obtain a medical history. – Perform reassessments as needed.

The Pediatric Assessment Triangle (1 of 5) • The PAT helps you quickly form a general impression of the child using only your senses of sight and hearing. Used with permission of the American Academy of Pediatrics, Pediatric Education for Prehospital Professionals, © American Academy of Pediatrics, 2000. – Can be used to assess a child from a distance

The Pediatric Assessment Triangle (2 of 5) • Appearance – Indicator of how well the heart, lungs, and central nervous system are working – Compare the child’s appearance with what you would expect from a healthy child. – Assess eye contact, muscle tone, and skin color. – Reassess regularly because the appearance can change quickly.

The Pediatric Assessment Triangle (3 of 5)

The Pediatric Assessment Triangle (4 of 5) • Work of breathing – More accurate indicator of a child’s condition than merely determining the respiratory rate – Determined by measuring four factors

The Pediatric Assessment Triangle (5 of 5) • Circulation to the skin – Three characteristics are used to assess the circulation.

Respirations (1 of 2) • Count respirations for 30 seconds and multiply by 2. • Look for signs of respiratory distress. – Assess how much work the child is doing to breathe. – Look for abnormal breath sounds such as noisy breathing, snoring, crowing, grunting, and wheezing.

Respirations (2 of 2) • Look for signs of respiratory distress. (cont’d) – Determine whether the child is holding himself or herself in an abnormal position. – Check for retractions of the neck and chest. – Look for flaring of the nostrils.

Pulse Rate (1 of 2) • The normal pulse rate of a child is faster than an adult’s normal rate. • For a child younger than 1 year, palpate a brachial pulse. Courtesy of Jennifer and Marc Lemaire.

Pulse Rate (2 of 2)

High Body Temperature • High temperatures are accompanied by: – Flushed, red skin – Sweating – Restlessness • To feel a high temperature, touch the child’s chest and head. • A child’s heart rate increases with each degree of temperature rise.

Respiratory Care (1 of 2) • It is important to open and maintain the airway and to ventilate adequately any child with respiratory problems.

Respiratory Care (2 of 2) • Causes of cardiopulmonary arrest in children – Suffocation caused by aspiration of a foreign body – Infections of the airway such as croup and epiglottitis – Sudden infant death syndrome (SIDS) – Accidental poisonings – Injuries around the head and neck

Treating Respiratory Emergencies (1 of 7) • Opening the airway – Use the head tilt– chin lift maneuver on children who have not sustained any injury to the neck or head. – Do not hyperextend the child’s neck when you tilt the head back.

Treating Respiratory Emergencies (2 of 7) • Opening the airway (cont’d) – If there is a possibility of injury to the head or neck, try the jaw-thrust maneuver. • Basic life support – CPR for children is different from adult CPR. • If you are alone and EMS has not been called, perform five cycles (2 minute) of CPR before activating the EMS system.

Treating Respiratory Emergencies (3 of 7) • Basic life support (cont’d) – Use the heel of one hand or two hands to perform chest compressions. – Compress the sternum one half to one third the depth of the chest.

Treating Respiratory Emergencies (4 of 7) • Basic life support (cont’d) – CPR for infants is different from adult CPR. • Check for responsiveness by tapping the infant’s foot or gently shaking the shoulder. • Give gentle rescue breaths. • Check the brachial pulse. • Use your middle and ring fingers to compress the sternum just below the nipple line. • Compress the sternum one half to one third the depth of the chest.

Treating Respiratory Emergencies (5 of 7) • Suctioning – Clear the airway initially by turning the patient on his or her side and use your gloved finger to scoop out the substance. – Use suctioning to remove the rest of the foreign substance. – Suctioning can be a lifesaving procedure.

Treating Respiratory Emergencies (6 of 7) • Suctioning (cont’d) – The procedure for suctioning is the same as for adults, with the following exceptions: • Use a tonsil tip or rigid tip to suction the mouth. • Use a flexible catheter to suction the nose of a child. • Use a bulb syringe to suction the nose of an infant. • Never suction for more than 5 seconds. • Try to ventilate and reoxygenate the patient before repeating the suctioning.

Treating Respiratory Emergencies (7 of 7) • Airway adjuncts – Oral airways can maintain an open airway after you have opened the patient’s airway manually. – Use the steps in Skill Drill 16 -1 to insert an oral airway in a child or an infant. – EMRs rarely use nasal airways for children.

Mild Airway Obstruction (1 of 2) • Place the child on his or her back, tilt the head, and lift the chin in the usual manner. • Remove the object if it is clearly visible in the mouth and can be removed easily. – If not, do not attempt to remove the object as long as the child can still breathe. • Children should be transported to the emergency department.

Mild Airway Obstruction (2 of 2) • Administer oxygen if it is available and you are trained to use it. – Place the oxygen mask over the child’s mouth and nose. – Do not try to get an airtight seal. – Hold the mask 1" to 2" away from the child’s face.

Severe Airway Obstruction in Children (1 of 3) • Severe airway obstruction is a serious emergency. • Signs and symptoms – Poor air exchange – Increased breathing difficulty – Silent cough – Inability to speak – No movement

Severe Airway Obstruction in Children (2 of 3) • Use the Heimlich maneuver. – It provides enough energy to expel most foreign objects.

Severe Airway Obstruction in Children (3 of 3) • Relieving an airway obstruction in a conscious child is the same as for an adult, with a few exceptions. – When opening a child’s airway, tilt the head back just past the neutral position. – If you are by yourself, perform CPR for five cycles before activating the EMS system.

Severe Airway Obstruction in Infants (1 of 4) • An infant is very fragile. • If you suspect an airway obstruction, assess the infant to determine whether any air exchange is occurring. – If the infant is crying, the airway is not completely obstructed. – If no air is moving in or out of the infant’s mouth and nose, suspect an obstructed airway.

Severe Airway Obstruction in Infants (2 of 4) • Use a combination of back slaps and the chest-thrust maneuver. – Assess the infant’s airway and breathing. – Place the infant in a face-down position over your one arm and deliver five back slaps between the shoulder blades.

Severe Airway Obstruction in Infants (3 of 4) • Use a combination of back slaps and the chest-thrust maneuver. (cont’d) – Turn the infant face-up. – Deliver five chest thrusts in the middle of the sternum with your two fingers. – Repeat these steps until the object is expelled or until the infant becomes unresponsive.

Severe Airway Obstruction in Infants (4 of 4) • If the infant becomes unresponsive, continue with the following steps: – Ensure that EMS has been activated. – Begin CPR. – Continue CPR until personnel with more advanced EMS skills arrive.

Swallowed Objects • If small, round objects do not become airway obstructions, they usually pass uneventfully through the child. • Sharp or straight objects are dangerous if swallowed. – Arrange for prompt transport.

Respiratory Distress (1 of 3) • Signs of respiratory distress – A breathing rate of more than 60 breaths/min in infants – A breathing rate of more than 30 to 40 breaths/min in children – Nasal flaring on each breath – Retraction of the skin between the ribs and around the neck muscles – Stridor

Respiratory Distress (2 of 3) • Signs of respiratory distress (cont’d) – Cyanosis of the skin – Altered mental status – Combativeness or restlessness • Treatment of respiratory distress – Try to determine the cause. – Support the child’s respirations by placing the child in a comfortable position, usually sitting.

Respiratory Distress (3 of 3) • Treatment of respiratory distress (cont’d) – Keep the child as calm as possible by letting a parent hold the child if practical. – Prepare to administer oxygen if it is available and you are trained to use it. – Monitor the child’s vital signs. – Arrange for prompt transport.

Respiratory Failure/Arrest (1 of 5) • Often results as respiratory distress proceeds • Signs and symptoms – A breathing rate of fewer than 20 breaths/min in an infant – A breathing rate of fewer than 10 breaths/min in a child – Limp muscle tone

Respiratory Failure/Arrest (2 of 5) • Signs and symptoms (cont’d) – Unresponsiveness – Decreased or absent heart rate – Weak or absent distal pulses • A child in respiratory failure is on the verge of experiencing respiratory and cardiac arrest.

Respiratory Failure/Arrest (3 of 5) • Treatment – Support respirations by performing mouth-tomask ventilations. – Administer oxygen if it is available. – Begin chest compressions if the heart rate is absent or less than 60 beats/min. – Arrange for prompt transport.

Respiratory Failure/Arrest (4 of 5) • Circulatory failure – The most common cause of circulatory failure in children is respiratory failure. – Can lead to cardiac arrest – Indicated by an increased heart rate, pale or bluish skin, and changes in mental status

Respiratory Failure/Arrest (5 of 5) • Circulatory failure (cont’d) – If the heart rate is more than 60 beats/min: • Complete the patient assessment sequence. • Support ventilations. • Administer oxygen. • Observe vital signs. – If the heart rate is less than 60 beats/min, begin chest compressions and rescue breathing.

Altered Mental Status (1 of 2) • Causes of altered mental status in children – Low blood glucose level – Poisoning – Postseizure state – Infection – Head trauma – Decreased oxygen levels

Altered Mental Status (2 of 2) • Complete the patient assessment. • Pay particular attention to the patient’s initial vital signs. • Calm the patient and the patient’s family. • Be prepared to support the patient’s ABCs. • Place unconscious patients in the recovery position.

Respiratory Illnesses (1 of 7) • Because infants breathe primarily through their noses, even a minor cold can cause breathing difficulties. • Asthma – Caused by a spasm or constriction and inflammation of smaller airways in the lungs – Usually produces a wheezing sound – Calm and reassure the parents and the child.

Respiratory Illnesses (2 of 7) • Asthma (cont’d) – Place the child in a sitting position. – Pursed-lip breathing relieves some of the internal lung pressures. – Help administer the child’s medication. – Arrange for prompt transport.

Respiratory Illnesses (3 of 7) • Croup – Infection of the upper airway that occurs mainly in children between 6 months and 6 years of age – Results in a hoarse, whooping noise during inhalation and a seal-like, barking cough – Often occurs in colder climates

Respiratory Illnesses (4 of 7) • Croup (cont’d) – A lack of fright and the willingness to lie down are important signs that distinguish croup from epiglottitis. – If the EMS unit is delayed, turn on the hot water in the shower and close the bathroom door. – The moist, warm air relaxes the vocal cords.

Respiratory Illnesses (5 of 7) • Epiglottitis – Severe inflammation of the epiglottis – The flap is so inflamed and swollen that air movement into the trachea is completely blocked. – Usually occurs in children between ages 3 and 6 years

Respiratory Illnesses (6 of 7) • Epiglottitis (cont’d) – Signs and symptoms • The child is usually sitting upright. • The child cannot swallow. • The child is not coughing. • The child is drooling. • The child is anxious and frightened. • The child’s chin is thrust forward.

Respiratory Illnesses (7 of 7) • Epiglottitis (cont’d) – Make the child comfortable with as little handling as possible. – Keep everyone calm. – Administer oxygen. – Arrange for prompt transport.

Drowning (1 of 3) • Caused by submersion in water and initially causes respiratory arrest • Second most common cause of accidental death among children 5 years of age or younger in the United States • Do not put yourself in danger as you attempt a rescue.

Drowning (2 of 3) • Signs and symptoms include lack of breathing and no pulse. • Treatment – Assess the ABCs. – Turn the child onto one side and allow the water to drain out of the child’s mouth. – Use suction if it is available. – Start rescue breathing if necessary.

Drowning (3 of 3) • Treatment (cont’d) – Administer supplemental oxygen. – If no pulse is present, start chest compressions. – Stabilize the neck. – To reduce the risk of hypothermia, dry the child and cover him or her with dry blankets. – Arrange for prompt transport.

Heat-Related Illnesses • Heatstroke is a serious and potentially fatal condition that requires rapid treatment. – Remove the child’s clothing, sponge water over the child, and fan him or her. – You may wrap the child in wet sheets to speed up the evaporation and cooling process. – Arrange for rapid transport.

High Fever (1 of 2) • Fevers are common in children. • Because the temperature-regulating mechanism in young children has not fully developed, a very high temperature can occur quickly. • Most children can tolerate temperatures as high as 104°F (40°C).

High Fever (2 of 2) • Treatment – Uncover the child so that body heat can escape. – Attempt to reduce the high temperature by undressing the child. – Fan the child to cool him or her down. – Protect the child during any seizure, and make certain that normal breathing resumes after each seizure.

Seizures (1 of 3) • Can result from a high fever or from disorders such as epilepsy • Vary in intensity • During a seizure: – The child loses consciousness. – The eyes roll back. – The teeth become clenched. – The body shakes with jerking movements.

Seizures (2 of 3) • During a seizure: (cont’d) – The child’s skin becomes pale or turns blue. – Sometimes the child loses bladder and bowel control. • Treatment – Place the patient on the floor or a bed to prevent injury. – Maintain an adequate airway after the seizure ends.

Seizures (3 of 3) • Treatment (cont’d) – Provide supplemental oxygen. – Arrange for prompt transport. – Monitor the patient’s vital signs and support the ABCs. – After the seizure is over, cool the patient if he or she has a high fever.

Vomiting and Diarrhea • Usually caused by gastrointestinal infections • May produce severe dehydration – The dehydrated child is lethargic and has very dry skin. – Hospitalization may be required to replace fluids. – If you suspect dehydration, arrange for transport.

Abdominal Pain • One of the most serious causes of abdominal pain in children is appendicitis. – Seen in people between 10 and 25 years – Usually the child is nauseated, has no appetite, and occasionally will vomit. • Treat every child with a sore or tender abdomen as an emergency. • Arrange for prompt transport.

Poisoning (1 of 6) • Ingestion – An ingested poison is taken by mouth. – Signs and symptoms • Chemical burns, odors, or stains around the mouth • Nausea • Vomiting • Abdominal pain • Diarrhea

Poisoning (2 of 6) • Ingestion (cont’d) – Later symptoms • Abnormal or decreased respirations • Unconsciousness • Seizures – Try to identify the poison, and send the container to the emergency department. – Gather any spilled tablets and replace them in the bottle so they can be counted.

Poisoning (3 of 6) • Ingestion (cont’d) – Contact the local poison control center if transportation is delayed. – You may need to give the child large amounts of water or administer activated charcoal. – Monitor the child’s breathing and pulse. – Arrange for prompt transport.

Poisoning (4 of 6) • Absorption – Occurs when a poisonous substance enters the body through the skin – Localized symptoms include skin irritation or burning. – Systemic signs and symptoms include nausea, vomiting, dizziness, and shock.

Poisoning (5 of 6) • Absorption (cont’d) – Ensure that the child is no longer in contact with the poisonous substance. – Protect yourself from exposure. – Remove the child’s clothing if it is contaminated. – Brush off any dry chemical and then wash the child with water for at least 20 minutes. – Try to identify the poison.

Poisoning (6 of 6) • Absorption (cont’d) – Monitor the child for any changes in respiration and pulse. – If the child has vomited, save a sample and send it to the hospital. – Arrange transport.

Sudden Infant Death Syndrome (1 of 2) • Also called crib death • Sudden and unexpected death of an apparently healthy infant • Usually occurs in infants between the ages of 3 weeks and 7 months • No adequate scientific explanation exists for SIDS. • Be compassionate with the parents.

Sudden Infant Death Syndrome (2 of 2) • If the infant is still warm, begin CPR and continue until help arrives. • If the infant is dead, do not mistake the large, bruise-like blotches on the body for signs of child abuse. – The blotches are caused by the pooling of the infant’s blood after death. – Follow the local protocol for the management of deceased patients.

Pediatric Trauma (1 of 2) • Trauma is the number one killer of children. • Treat an injured child as you would treat an injured adult, but remember these differences: – A child cannot communicate symptoms as well as an adult. – A child may be shy and overwhelmed by adult rescuers.

Pediatric Trauma (2 of 2) • Treat an injured child as you would treat an injured adult, but remember these differences: (cont’d) – You may need to adapt materials and equipment to the child’s size. – A child does not show signs of shock as early as an adult but can progress into severe shock quickly.

Patterns of Injury (1 of 4) • The patterns of injury sustained by children will be related to three factors: – Type of trauma they experience – Type of activity causing the injury – Child’s anatomy • Motor vehicle crashes – Unrestrained patients have more head and neck injuries.

Patterns of Injury (2 of 4) • Motor vehicle crashes (cont’d) – Restrained patients often suffer head, spinal, and abdominal injuries. • Bicycle accidents – Children often suffer head, spinal, abdominal, and extremity injuries. – The use of bicycle helmets can greatly reduce the number and severity of head injuries.

Patterns of Injury (3 of 4) • Children hit by cars often sustain chest, abdominal, thigh, and extremity injuries. • Falls from a height or diving accidents cause head, spinal, and extremity injuries. • Burns are a major cause of injuries to children.

Patterns of Injury (4 of 4) • Treatment regardless of the cause of injury – Check the patient’s ABCs. – Stop severe bleeding. – Treat the patient for shock. – Conduct a full-body assessment. – Stabilize all injuries you find. – If the patient has head lacerations, treat the wounds with direct pressure and bandaging.

Traumatic Shock in Children (1 of 2) • Children show shock symptoms much more slowly than adults do, but they progress through the stages of shock quickly. • If these signs of shock are present, the child is already in severe shock: – Cool, clammy skin – Rapid, weak pulse – Rapid or shallow respirations

Traumatic Shock in Children (2 of 2) • Seizures are relatively common in children who have sustained a serious head injury. • The greatest dangers are airway obstruction and hemorrhage. • Treatment – Open and maintain the airway. – Control bleeding. – Arrange for prompt transport.

Car Seats and Children • If you find a child properly restrained in a car seat after a motor vehicle crash, leave the child in the car seat until the ambulance arrives. • In many cases, a child can be transported to the hospital secured in the car seat.

Child Abuse (1 of 4) • Be concerned if the child is withdrawn, fearful, or hostile and is unwilling to discuss how the injuries occurred. • Treat the child’s injuries and, if you suspect abuse, ensure the child’s safety.

Child Abuse (2 of 4) • Signs and symptoms – Multiple fractures – Bruises in various stages of healing – Human bites – Burns – Reports of bizarre accidents

Child Abuse (3 of 4) Courtesy of Ronald Deickmann, M. D.

Child Abuse (4 of 4) • Transport the child. – If the parents object, summon law enforcement personnel. • Signs and symptoms of neglect – Lack of adult supervision – Malnourished-appearing child – Unsafe living environment – Untreated chronic illness

Sexual Assault of Children • In addition to experiencing sexual assault, the child may have been beaten and may have other serious injuries. • Obtain as much information from the child any witnesses. • Provide a caring approach. • All victims of sexual assault should receive transport to an appropriate medical facility.

Emergency Medical Responder Debriefing • Calls involving children tend to produce strong emotional reactions. • You may need to talk about feelings of anger or frustration with a counselor. • By attending debriefing sessions, you can: – Express your feelings – Learn some coping strategies – Maintain a healthy approach to future calls

Summary (1 of 7) • Because the anatomy of children and infants differs from that of adults, special knowledge and skills are needed to assess and treat pediatric patients. • Because both the child and the parents may be frightened anxious, you must behave in a calm, controlled, and professional manner.

Summary (2 of 7) • The child who is unresponsive, is lackluster, and appears ill should be evaluated carefully because the lack of activity and interest signal serious illness or injury. • The three components of the pediatric assessment triangle are overall appearance, work of breathing, and circulation to the skin.

Summary (3 of 7) • It is important to open and maintain the patient’s airway and to ventilate adequately any child with respiratory problems. • Young children often obstruct their upper and lower airway with foreign objects, such as small toys or candy.

Summary (4 of 7) • In complete or severe airway obstruction in a conscious child, you should perform the Heimlich maneuver. If the child becomes unresponsive, begin cardiopulmonary resuscitation. • To relieve an airway obstruction in an infant, use a combination of back slaps and chest thrusts.

Summary (5 of 7) • Three serious respiratory problems in pediatric patients are asthma, croup, and epiglottitis. • Other pediatric medical emergencies include drowning, heat-related illnesses such as heatstroke, high fevers, seizures, vomiting and diarrhea, and abdominal pain.

Summary (6 of 7) • The two most common types of poisonings in children are caused by ingestion (taken by mouth) and absorption (entering through the skin). • Sudden infant death syndrome, also called crib death, is the unexpected death of an apparently healthy infant.

Summary (7 of 7) • Major trauma in children usually results in multiple system injuries. • If you suspect child abuse or sexual assault, you must transport the child to an appropriate medical facility.

Review 1. The purpose of the pediatric assessment triangle (PAT) is to: A. guide the hands-on physical assessment. B. help you determine if the child’s vital signs are appropriate. C. allow you to quickly form a general impression of the child. D. help you remember the systematic assessment process.

Review Answer: C. allow you to quickly form a general impression of the child.

Review 2. Which of the following statements about SIDS is FALSE? A. It usually occurs in children between the ages of 3 and 7 years. B. No adequate scientific explanation exists. C. It occurs in apparently healthy children. D. You should start CPR if the child is still warm when you arrive.

Review Answer: A. It usually occurs in children between the ages of 3 and 7 years.

Review 3. Which of the following is NOT a common respiratory condition in children? A. asthma B. epiglottitis C. pneumonia D. croup

Review Answer: C. pneumonia

Credits • Opener: © Mark C. Ide • Background slide image (ambulance): © Comstock Images/Alamy Images • Background slide images (non-ambulance): © Jones & Bartlett Learning. Courtesy of MIEMSS.