Chapter 31 Pediatric Emergencies

2. Chapter 31Pediatric Emergencies

3. Objectives • There are no 1985 objectives for this chapter.

4. Unique Needs of Children • Not uncommon for the prehospital professional to experience anxiety. • The EMT-I must be prepared to deal with parents and caregivers. • The EMT-I must develop assessment and management strategies.

5. Epidemiology (1 of 4) • 10% of EMS calls involve children. • 20,000 pediatric deaths per year. • Trauma is the leading cause of death in children in the U.S. • Falls and abuse are common. • MVAs are the cause for injuries in older children.

6. Epidemiology (2 of 4) • Other causes • Injuries from suicide or homicide • Burns • Drownings • Sports-related injuries

7. Epidemiology (3 of 4) • The EMT-I will respond to calls for ill children involving: • Croup • Bronchiolitis • Febrile seizures • These condition are unique to children

8. Epidemiology (4 of 4) • Children often suffer from the same illnesses as adults. • The key to reducing morbidity and mortality is early and aggressive intervention.

9. Injury and Illness Prevention (1 of 3) • Children are at higher risk for injury and illness than adults. • Adverse effects of injury/illness are more severe.

10. Injury and Illness Prevention (2 of 3) • The EMT-I should be actively involved in programs to reduce child injury/illness. • Teach parents about safe living environments. • Electrical covers • Cabinets containing medications and poisons are secure • Car seats • Helmets for bikes and skateboards

11. Injury and Illness Prevention (3 of 3) • Education on drugs and alcohol • Education regarding recognition of certain illnesses and when it is appropriate to seek medical attention • Community CPR training

12. Growth and Development • Infancy • Toddler years • Preschool age • School age • Adolescence

13. Infant • First year of life. • They respond mainly to physical stimuli. • Crying is their main avenue of expression. • They may prefer to be with caregiver. • If possible, have caregiver hold the infant as you start your examination.

14. Toddler (1 of 2) • 1 to 3 years of age. • At this time they learn to walk. • Injuries are more frequent. • Stranger anxiety may develop. • May resist being separated from primary caregiver.

15. Toddler (2 of 2) • May dislike being restrained. • Make as many observations as you can before you touch the child. • Easily distracted.

16. 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 what you are going to do using simple descriptions. • They can be distracted by using toys.

17. School-Age Child • 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.

18. The 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.

19. Anatomy and Physiology • The next section discusses pediatric anatomy and physiology, including differences in: • Head • Airway • Chest and lungs • Abdomen • Extremities • Skin • Respiratory system • Cardiovascular system • Nervous system • Metabolic differences

20. The Head (1 of 2) • Proportionately larger than adults’ • More prone to head trauma. • Care must be taken in positioning the child’s airway. • Injured child younger than 3 years – place thin pad under head to maintain neutral position. • Ill child younger than 3 years– place folded sheet under head to obtain sniffing position.

21. The Head (2 of 2) • Anterior fontanelles are open during infancy. • Fontanelles are areas where the infant’s skull bones have not fused together. • Bulging suggests increased intracranial pressure. • Sunken suggests dehydration.

22. The Airway (1 of 6) • Anatomic differences • Heart is higher and lungs are smaller. • The opening to the trachea is higher.

23. The Airway (2 of 6) • Anatomic differences (cont.) • Larger tongue relative to the mouth • Less well-developed rings of cartilage in the trachea • Head tilt-chin lift may occlude the airway

24. The Airway (3 of 6) • A child’s airway differs from an adult’s in five ways: • Larger head • Larger tongue • Floppy U-shaped epiglottis • Higher larynx • Narrower airway at all levels

25. The Airway (4 of 6) • Is easily obstructed by secretions, blood, and swelling. • Trachea is easily collapsible. • Trachea tugging. • Intercostal muscles are not well developed. • Diaphragm dictates volume. • Belly breathers

26. The Airway (5 of 6) • Gastric distention is a more common and significant complication in pediatric patients. • Infants are obligate nosebreathers until the age of approximately 4-6 months. • If their nasal passages are blocked by secretions, they may not have the intuition to open their mouths to breath.

27. The Airway (6 of 6) • It is important for the EMT-I to remember: • Keep the nares clear in infants younger than 6 months. • Avoid hyperextension of the child’s neck; this may result in reverse hyperflexion and kinking of the trachea. • Keep airway clear of all secretions. • Use care when managing the child’s airway.

28. Chest and Lungs (1 of 3) • The tissues of the lungs are more fragile in children. • Significant compression to the chest may injure vital organs without obvious signs of external injury. • Rib fractures occur less frequently than in adults.

29. Chest and Lungs (2 of 3) • Barotraumas (pressure trauma) are the result of injury or overzealous ventilation. • The respiratory muscles are more immature in children and fatigue more quickly. • The chest wall is thin. • Breath sounds are easily transmitted to all areas of the chest.

30. Chest and Lungs (3 of 3) • The mediastinum is more pliable in children. • The EMT-I may see a more pronounced mediastinal shift as the result of a tension pneumothorax.

31. The Abdomen • Abdominal musculature is immature. • It offers less protection to solid, vascular organs such as the spleen and liver. • The abdominal organs are nearer to one another in children. • Pediatric patients are at higher risk for splenic and hepatic injuries than adults; multiple organ injuries are more common.

32. The Extremities • Bones are softer and more porous in children. • Incomplete fractures are common. • Injury to the epiphyseal plate during development can cause abnormalities in normal bone growth and development.

33. Skin and Body Surface Area • Children have thinner and more elastic skin than adults. • They have a larger body surface area (BSA)/weight ratio and less subcutaneous tissue. • These factors contribute to: • Increased risk of injury following exposure to temperature extremes • Increased risk of hypothermia and dehydration • Increased severity of burns

34. Respiratory System (1 of 4) • Proportionally, tidal volume in children is similar to adolescents and adults. • Their metabolic oxygen demand is doubled. • Their functional capacity is smaller, resulting in smaller oxygen reserves.

35. Respiratory System (2 of 4) • An infant needs to breathe faster than an older child. • Their lungs will grow and develop better abilities to handle oxygen exchange as the child ages. • A respiratory rate of 40 to 60 breaths/min is normal for a newborn. • Teenagers are expected to have rates closer to the adult range.

36. Respiratory System (3 of 4) • Infants have little use of chest muscles; they use their diaphragms. • Anything that puts pressure on the abdomen of a young child can block the movement of the diaphragm and cause respiratory compromise. • Young children also experience muscle fatigue much more quickly than older children. • Long, labored breathing may lead to respiratory failure.

37. Respiratory System (4 of 4) • During respiratory distress, infants and children are more susceptible to hypoxia because of: • Decreased oxygen reserves • Easily fatigued respiratory muscles

38. Cardiovascular System (1 of 5) • An infant’s heart rate can become as high as 200 beats or more per minute if the body needs to compensate for injury or illness. • Increasing the heart rate is the body’s primary method of compensating for decreased oxygenation.

39. Cardiovascular System (2 of 5) • It is important to know the normal heart rates for children.

40. Cardiovascular System (3 of 5) • Children have limited cardiac reserves. • They have a larger circulating volume compared with adults. • Because of these factors, injured children can maintain their blood pressure for longer periods than adults.

41. Cardiovascular System (4 of 5) • A larger volume of blood loss must occur in the child before hypotension develops. • Hypotension is an ominous sign and often indicates impending cardiopulmonary arrest. • The ability of children to constrict their blood vessels enables them to keep the vital organs well perfused. • Pale skin is an early sign that the child may be compensating for decreased perfusion. • Constriction of the vessels can be so profound that blood flow to the extremities can be diminished.

42. Cardiovascular System (5 of 5) • Signs of vasoconstriction include: • Weak distal pulses in the extremities (eg, radial) • Delayed capillary refill • Cool hands or feet

43. Nervous System • Continually develops throughout childhood. • Neural tissue is very fragile and easily damaged until fully developed. • Brain and spinal cord are less well protected by the developing skull and vertebrae. • As a result, it takes less force to cause brain and spinal injuries. • Brain injuries are more devastating when they occur in children. • Injury to the spinal cord may occur without injury to the spinal column itself.

44. Metabolic Differences • Children have limited stores of glycogen and glucose, which are rapidly depleted as a result of injury or illness. • Significant hypovolemia and electrolyte derangements are more common in children as a result of vomiting and diarrhea.

45. Pediatric Assessment • General considerations • Scene size-up • Initial assessment • Pediatric vital signs • Respirations

46. General Considerations • Young children are not able to provide the EMT-I with information needed to make treatment decisions and cannot tell you where they hurt. • Remember that when children are injured, you have several patients to treat.

47. Patient Assessment Process • Scene Size-up • Initial Assessment • Focused History and Physical Exam • Detailed Physical Exam • Ongoing Assessment

48. Scene Size-Up • Take BSI precautions. • Assess scene safety. • Determine mechanism of injury/nature of illness. • Determine number of patients. • Request additional assistance. • Consider c-spine immobilization.

49. Initial Assessment • Is accomplished by simple observation on first entering the scene or room. • The objective is to identify and treat immediate or potential life threats. • Begins by forming a general impression of the child’s condition and of the environment. • Note degree of interaction between child and parent or caregiver. • Determine if child is acting normally.

50. Pediatric Assessment Triangle (PAT) (1 of 4) • A structured assessment tool that allows the EMT-I to rapidly form a general impression • The PAT consists of three elements: • Appearance (muscle tone and mental status) • Work of breathing • Circulation to the skin