Pediatric Medical Emergencies

1. Pediatric Medical Emergencies Condell Medical Center EMS System August, 2007 CE Site Code#10-7200E1207 Prepared by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives Upon successful completion of this module, the EMS provider should be able to: • identify critical situations in the pediatric population • identify and appropriately state interventions for a variety of EKG rhythms • actively participate in a pediatric code situation • successfully complete the quiz with a score of 80% or better

3. Children are not small adults!

4. Relationship of Head to Body Changes

5. Pediatric Population Defined • A patient under the age of 16 is considered to be a pediatric patient • This means the patient is 15 years of age or less • When medications are calculated based on the pediatric patient weight, the dose is to never exceed the amount that would be administered to an adult!

6. Children and EMS Adults may be glad to see EMS arrive but children are often frightened when EMS comes to their rescue

7. Critical Determination • Rapid assessment needs to be performed to determine: • Is this child sick or not? • Any sick child needs immediate attention and intervention

8. Pediatric Assessment Triangle(PAT) • Helps establish a general impression • Used to: • establish a level of severity • determine urgency for life support • identify key physiological problems • Provider to assess: • appearance • work of breathing • circulation to skin

9. Pediatric Assessment Triangle (PAT)

10. Pediatric Assessment Triangle (PAT) • Does not require any equipment to complete • Uses observational and listening skills • Can be completed in under 60 seconds • To be used as you “cross the room” to make contact with the patient

11. Pediatric Assessment Triangle (PAT) • Evaluates underlying cardiopulmonary, neurological, and metabolic states • Can help identify the general physiological problem for the child • PAT does not replace vital signs and the ABCDE’s but precedes & compliments them

12. Pediatric Assessment • Scene size-up • General assessment - pediatric assessment triangle (PAT) • Initial assessment • ABCDE’s and transport decision • Additional assessment • focused history and physical exam; detailed physical exam if trauma • Ongoing assessment

13. Pediatric Assessment Triangle Appearance Reflects adequacy of: • oxygenation • ventilation • brain perfusion • homeostasis • CNS function

14. Assessing Appearance Evaluate: • muscle tone • mental status/interactivity level • consolability • look or gaze • speech or cry

15. Pediatric Assessment TriangleBreathing Reflects: • adequacy of oxygen • oxygenation • ventilation

16. Assessing Breathing Evaluate: • body position • visible movement of chest or abdomen • <6-7 years old is primarily a diaphragmatic breather (belly breather) • respiratory rate & effort • audible airway sounds

17. Pediatric Assessment Triangle Circulation Reflects: • adequacy of cardiac output and perfusion of vital organs (core perfusion)

18. Assessing Circulation Evaluate: • skin color • peripheral cyanosis refers to the extremities • central cyanosis is always pathological; evaluated in the central part of the body: mucous membranes of the mouth and trunk area • reflects decreased oxygen in arterial blood • Trunk mottling indicates hypoxemia • Cyanosis indicates respiratory failure and vasoconstriction

19. Principles of Infant Assessment • Ask caregiver for patient’s name & use it • To decrease the infant’s stress, perform assessment in the following order: • observation • auscultation • palpation • Approach infant slowly, calmly, and talk in quiet voices; warm your hands before contact • Try to be at patient’s eye level

20. Infant Assessment • Observe interaction between caregiver and infant • Consider offering a toy as a distraction • Perform assessment based on acuity level • if quiet & calm, obtain respiratory rate and breath sounds • if critical, obtain most important information 1st • Make non-threatening contact 1st • make 1st contact with extremity & can also obtain capillary refill simultaneously

21. Principles of Toddler Assessment • Beginning to assert independence but fearful of separation from caregiver • Approach slowly; keep contact to a minimum • Be at eye level • If possible, allow toddler to stay on caregiver’s lap • Introduce equipment slowly and use distraction (ie: penlight, toy) • A toddler is the center of his universe - ask questions about them (ie: pets, clothing, events)

22. Toddler Assessment • Keep choices limited (ie: “should I use the red or blue package”) • Ask open ended questions; avoid yes/no questions • Praise toddler to get cooperation • Use simple, concrete terms • Perform most critical part of assessment 1st moving in toe-to-head order • Ask caregiver to assist (ie: removing clothing, holding stethoscope) • Toddlers do not sit still

23. Principles of Preschooler Assessment • Magical and illogical thinkers; fear loss of control; short attention spans • Use simple terms; explain procedures immediately before performing • Allow child to handle equipment • It’s okay to set limits (ie: “you can cry but you cannot kick”) • Focus on one thing at a time

24. Principles of School-aged Assessment • Fear separation from caregiver; loss of control, pain, & physical disability • Speak directly to child, then to caregiver • Respect privacy, these children are modest • Don’t offer too much information; do use terms the child can understand; explain immediately before the procedure is done

25. School-Aged Assessment • Don’t negotiate unless there really is a choice (ie: IV in right or left hand, not if it is okay to start the IV) • Offer praise for cooperation • Physical assessment okay to be performed in head-to-toe format

26. Principles of Adolescent Assessment • Time for experimentation and risk-taking behaviors • Struggle with independence, loss of control, body image, sexuality, and peer pressure • Relying more on friends than family • When ill or injured, often revert back to lower maturity level • Explain what you are going to do and why

27. Adolescent Assessment • Encourage questions and involvement of the adolescent • Show respect; speak directly to teen • Respect privacy and confidentiality • Be honest and nonjudgmental

28. Pediatric Assessment - Appearance • Provides most important look into the status of the child - are they sick or not? • Start observation as you 1st enter the scene and while the child is still with the caregiver • immediate hands-on may increase agitation, crying and may interfere with a true picture • immediate hands-on is necessary if the child is unconscious or obviously critically ill

29. Normal/Abnormal Appearance • Normal appearance • good eye contact, has good muscle tone, and good color • Abnormal appearance • poor eye contact, listless, and pale Appearance doesn’t indicate the cause of illness or injury but reflects that a problem is going on

30. Normal Appearance In Setting Of a Critical Situation Maintain index of suspicion in children that look okay initially but may soon become critically ill: • toxicological problems (overdoses) • blunt trauma • powerful compensation abilities may fool the examiner • when the child “crashes” they will crash quickly with rapid progression to decompensated shock

31. Work of Breathing • In the pediatric patient, evaluation of work of breathing gives great insight into the pediatric patient’s oxygenation & ventilation status’ • Listen for abnormal airway sounds • snoring, muffled or hoarse speech, stridor, grunting, wheezing • Look for signs of increased breathing effort • sniffing position, tripoding, refusing to lie down • retractions (neck, intercostal, substernal muscles) • nasal flaring

32. Tripod Positioning-leaning forward, hands resting on thighs

33. Costal retractions & use of accessory neck muscles

34. Abnormal Breath Sounds • Upper airway obstruction • snoring, muffled, hoarse speech, stridor • stridor - high-pitched inspiratory sound; abnormal airflow across partially obstructed upper airway • Potential causes • croup • foreign body • aspiration • bacterial upper airway infection • bleeding, edema

35. Abnormal Breath Sounds • Grunting • exhaling against a partially closed glottis • keeps alveoli open for maximum gas exchange • sound heard best at end of exhalation • often present with moderate to severe hypoxia • reflects poor gas exchange due to fluid in lower airways • Potential causes • pneumonia • pulmonary contusion • pulmonary edema

36. Abnormal Breath Sounds • Wheezing • continuous high-pitched musical sound; a whistle • movement of air across partially blocked small airways • in disease process heard earliest during exhalation • as obstruction increases, heard during inhalation and exhalation • with increased obstruction heard audibly • Most common cause - asthma • Other potential causes • bronchiolitis • lower airway foreign body aspiration

37. Abnormal Visual Signs - Increased Work of Breathing Providers must evaluate visually to determine evidence of increased work of breathing • this means all patients need to be eventually undressed for observation of the neck & chestwall • Sniffing position - severe upper airway obstruction; used as attempt to increase airflow • Tripoding - refuses to lie down, leans forward on outstretched arms; attempting to use accessory muscles to breath

38. Retractions - use of accessory muscles to help breath; using extra muscle power to move air into lungs; more prominent in child than adult; • includes head bobbing - use of neck muscles during severe hypoxia • includes nasal flaring - exaggerated nostril opening during inspiration; moderate to severe hypoxia

39. Respiratory Distress

40. Evaluating Respirations • Respiratory rate • Best to count for a minimum of 30 seconds due to the natural irregularity of the pattern • Breath sounds • Place the stethoscope as lateral as possible • Pulse oximetry • Evaluate results along with work of breathing • Readings above 94% indicates probably good oxygenation

41. Normal Respiratory Rates By Age • Infant 30-60 breaths/minute* • Toddler 20-30 breaths/minute* • Preschooler 20-30 breaths/minute* • School-aged child 20-30 breaths/minute* • Adolescent 15-20 breaths/minute* Trending more helpful than a single reading *Values differ by source

42. Abnormal Visual Signs - Poor Circulation to the Skin • Cold environment may cause false skin signs • Inspect skin and mucous membranes • Look at face, chest, abdomen, extremities, and lips • Dark complexion patients • assess lips and mucous membranes

43. Circulation to skin reflects overall status of core circulation • pallor - early sign; compensated shock • mottling - constriction of blood vessels to the skin • cyanosis - late finding of respiratory failure or shock; critical finding that indicates immediate resuscitative action

44. Evaluating Circulation • Heart rate - bradycardia is ominous sign • Pulse quality • Brachial is the peripheral site for a child under one • Central pulse - femoral in infants and young children; carotid in older child or adolescent • Skin temperature and capillary refill • Good locations are at the kneecap or the forearm • Blood pressure • Should make an attempt on children older than 3 • Cuff size should cover 2/3 the length of the upper arm

45. Normal Heart Rates by Age • Infant 100-160 beats per minute • Toddler 90-130 beats per minute • Preschooler 80-120 beats per minute • School-aged child 70-120 beats per minute • Adolescent 70-120 beats per minute Bradycardia indicates critical hypoxia and/or ischemia and indicates need for immediate interventions

46. Region X Pediatric SOP’s

47. Region X Routine Pediatric Care SOP’s • General patient assessment - pediatric assessment triangle (PAT) • appearance • work of breathing • circulation to skin • Initial assessment - ABCDE’s • Identify priority patient and make transport decision

48. Additional assessment and interventions • vital signs • determine weight and age • pulse oximeter before & during O2 • cardiac rhythm if applicable • IV/IO access (20 ml/kg administered under 20 minutes if fluid challenge is necessary) • determine blood glucose if indicated • altered level of consciousness • unconscious, unknown reason • known diabetic and related problem • reassess previous assessments & appropriateness of interventions performed

49. Detailed physical exam • Contact Medical Control • Transport to closest most appropriate hospital Always remember to keep child warm; hypothermia increases the rate of complications and negative outcome

50. Altered Level of Consciousness • Dextrose • Sugar to replace depleted stores • Brain extremely sensitive to a drop in glucose levels • Dose if less than 1 year old • 12.5% 4 ml/kg • Dose for ages 1 - 15 (>1 - <16) • 25% 2 ml/kg • Dose for ages 16 and over • 50%