PEDIATRIC PATIENTS

1. LESSON 21 PEDIATRIC PATIENTS

2. Introduction • 5-10% of emergency responses involve children • Children maybe unable to tell you what happened • Because parents, family members or caretakers are often frightened and worried, communication is particularly important • Size and anatomical difference make care different

3. Interacting with Infants, Children and Caretakers • Prevent anxiety and panic in child and caretakers • Tell child your name • Say you are there to help • Be especially sensitive to child’s feelings • Ensure a parent or caretaker has been called

4. Interacting with Infants, Children and Caretakers (continued) • Stay at child’s level, be friendly and calm • Observe child for clues about how best to be reassuring • Young child may be comforted by favorite toy or touch • Always be honest with child and caretakers • Keep patient and caretakers informed

5. Interacting with Infants, Children and Caretakers (continued) • Don’t separate child from caretaker • Approach slowly from a safe distance • Talk with both caretaker and child • Observe child and caretaker before touching child • Remain calm

6. Differences in Anatomyand Physiology • Infants and children are not small adults • Differences from adult anatomy and physiology in most body areas

7. Head and Neck • Smaller airway easily blocked • Tongue relatively larger, can easily block airway • When opening airway, don’t hyperextend neck • Pad beneath shoulders to prevent flexion of neck • Suctioning secretions from nose can improve breathing problems • Head of infant or young child relatively larger and heavier • “Soft spots” (fontanels) put head at greater risk

8. Chest and Abdomen • Children compensate for respiratory problems or shock for short periods • Compensation followed by rapid decompensation • Use of accessory muscles a clear sign of breathing problem • Slow pulse rate generally indicates hypoxia

9. Chest and Abdomen (continued) • More susceptible to hypothermia • Blood loss may be fatal • More easily dehydrated (diarrhea or vomiting) • Internal injuries are more likely with trauma

10. Extremities • Bones easily fracturedby trauma

11. Assessing Infants and Children • Assessment uses same steps as for adults • Correct problems threatening airway, breathing or circulation as soon as found • Assessment varies based on age and nature of problem • Reassess continuously until emergency care is transferred

12. Scene Size-Up • Begin by observing scene • Note how child and caretakers interact • Gather information from caretakers • Observe the environment • Note location and position in which patient is found

13. General Impression: Pediatric Triangle • You can often tell how ill or severely injured child is from a distance in 15-30 seconds • Remember 3 key elements: • Consider child’s general appearance • Assess child’s workof breathing • Assess skin color • These observations also help assess child’s mental status

14. Assess Mental Status • Quality of crying or speaking • Emotional state • Behavior • Response to caretakers • How attentive child is to you

15. Possible Causes of Abnormal Findings in Triangle Assessment • Respiratory distress or failure • Shock • Cardiopulmonary failure or arrest • Other abnormal conditions

16. Primary Assessment • Primary assessment follows same steps as adult

17. Responsiveness, Breathing, Circulation

18. Responsiveness • Responsive if purposively moving, crying or speaking, or coughing • Unless obviously responsive, tap child on shoulder and shout, “Are you OK?” or flick foot of infant • Unresponsiveness is potentially life-threatening condition  summon additional EMS resources • If child is responsive, assess level using AVPU scale • Assess pupil size, equality and reaction to light • Check whether all extremities are moving equally

19. Breathing • While assessing for responsiveness, look for normal breathing • Child who can speak, cough or make other sounds is breathing and has heartbeat • Reflex gasping (agonal respirations) is not normal breathing • Lack of breathing may be caused by cardiac arrest, an obstructed airway or other causes • If patient is not breathing normally, quickly check for pulse

20. If breathing, assess breathing adequacy: Respiratory rate Chest expansion and symmetry of movement Breathing (continued)

21. If breathing, assess breathing adequacy: Effort of breathing: nasal flaring, retractions, grunting Abnormal sounds: stridor, crowing Breathing (continued)

22. Circulation • If not breathing, check pulse for <10 seconds • Use femoral or carotid pulse in a child or brachial pulse in an infant • If no pulse, start CPR and use AED

23. Circulation (continued) • Assess pulse rate and strength • Assess skin color, temperature and condition • Reduced circulation indicated by: • Pale, ashen or cyanotic skin color • Cool, clammy skin • Capillary refill time ≥2 seconds • Begin CPR if the pulse is less than 60 beats/minute • Assess for signs of shock and treat

24. Check for Severe Bleeding • Decompensation can occur quickly in an infant or child with blood loss • Control external bleeding immediately with direct pressure

25. History • Communicate at level with child • Gather SAMPLE information from caretakers • Pay particular attention to signs and symptoms and their duration: • Fever • Activity level • Recent eating and drinking and urine output • Vomiting, diarrhea or abdominal pain

26. Vital Signs • Vital signs of infants and children are normally different from adults • Changes may occur quickly in infants and children, especially with decompensation • Falling blood pressure is a late sign of shock

27. Normal Vital Signs

28. Physical Examination • Maintain spinal immobilization in trauma or unresponsive patient • Support head when moving infant • Expose skin to look for injuries, but promptly cover child to prevent hypothermia; cover infant’s head • Assess anterior fontanel on top of skull • Examine from toe to head

29. Physical Examination (continued) Especially assess: • The head for bruising or swelling • The ears for drainage suggestive of trauma or infection • The mouth for loose teeth, identifiable odors and bleeding • The neck for abnormal bruising • The chest and back for bruise, injuries and rashes • Extremities for deformities, swelling and pain on movement

30. Airway Management • Opening airway • Suctioning • Using airway adjuncts

31. Opening the Airway of Pediatric Patients • Be careful not to hyperextend neck when using head tiltchin lift to open airway of infant • Put folded towel under back and shoulders for better positioning of airway • Look inside mouth of an unresponsive infant for obstructing object • Use jaw thrust technique for trauma patients • Suction airway if needed

32. Suctioning • Using gauze pad sweep mouth or suction • Don’t insert tip of rigid catheter deeper than baseof tongue • For newborn, don’t suction longer than 3-5 seconds at a time • With an older infant or child, don’t suction longer than 10 seconds at a time

33. Airway Adjuncts • Use oral airway if no gag reflex • Remove airway if child gags, coughs, etc. • Oral airway not for initial ventilations • Device keeps airway open • Select proper size • Nasal airways are not usually inserted in children by EMRs

34. Oral Airway Insertion • Insert oral airway in upright position – do not rotate 180 degrees as for adult • Open child’s mouth • Use tongue blade to press base of tongue down • Insert airway in upright (anatomic) position • If tongue blade not available, use index finger to press base of tongue down

35. Respiratory Emergencies

36. Respiratory Emergencies • Airway obstructions • Respiratory distress and arrest • Respiratory infections • Asthma

37. Signs and Symptoms of Mild Airway Obstructions • Infant or child is alert and sitting • Hear stridor, crowing, noisy breathing • Retractions on inspiration • Skin pink with good peripheral perfusion • Strong pulse

38. Emergency Care for Mild Airway Obstructions • Allow child to assume position of comfort • Assist a younger child to sit up, not lie down • Do not agitate child • Encourage continued coughing to dislodge object • Follow local protocol for oxygen administration

39. Signs and Symptoms of Severe Airway Obstructions • No crying or speaking • Weak and ineffective cough • Cyanosis • Cough that becomes ineffective • Increased respiratory difficulty and stridor • Altered mental status; unresponsiveness

40. Emergency Care for Severe Airway Obstructions • Attempt to clear airway (finger sweep and suctioning) • Use alternating back blows (slaps) and chest compressions in responsive infant • Use abdominal thrusts in responsive child • Give CPR to unresponsive infant or child

41. Emergency Care for Severe Airway Obstructions (continued) • Check for object in mouth before giving a breath • Remove any object you see • Never perform blind finger sweep • Attempt artificial ventilations with mouth-to-mask technique

42. Respiratory Distress and Arrest • Respiratory distress is difficulty breathing • Respiratory distress frequently leads to respiratory arrest

43. Signs and Symptoms of Respiratory Distress • Gasping, speaking in shortened sentences • Respiratory rate <30 or >60 breaths/minute in infants • <20 or >30-40 breaths/minute in children • Nasal flaring • Intercostal, supraclavicular, subcostal retractions • Stridor, grunting or noisy breathing • Cyanosis, or pale or ashen skin • Altered mental status

44. Emergency Care for Respiratory Distress • Perform standard patient care • Allow child to assume position of comfort • Ensure appropriate position of head and neck • Follow local protocol for oxygen administration

45. Blow-by Oxygen • Responsive infant or child may resist mask on face • Use blow-by oxygen delivery technique • Have caretaker hold mask about 2 inches from face

46. Signs and Symptoms of Respiratory Arrest • Breathing rate: • <20 breaths/minute in an infant • <10 breaths/minute in a child • Limp muscle tone • Unresponsiveness • Slow or absent pulse • Weak or absent distal pulses • Cyanosis

47. Emergency Care forRespiratory Arrest • Perform standard patient care • Provide ventilations by mouth or mask • Follow local protocol for oxygen administration • Monitor pulse and provide CPR if needed

48. Respiratory Infections • Common in childhood • Range from minor to life threatening • May affect upper or lower airways • Result from infection, foreign bodies, allergic conditions

49. Signs and Symptoms of Respiratory Problems • Rapid breathing • Noisy breathing • Retractions • Mental status changes

50. Croup • Viral infection of upper/lower airway • More frequently occurs in winter months and in evening • More common in younger children • Often preceded by being ill 1-2 days with or without fever • Generally not life-threatening