CHAPTER 31 Infants and Children. DevelopmentalCharacteristics

CHAPTER 31

Infants and Children

DevelopmentalDevelopmentalCharacteristicsCharacteristics

Classification of Children

Newborns/InfantsToddlersPreschoolSchool-agedAdolescents

Birth-11-33-66-1212-18

Age (yr.): Described as:

Tolerate parental separation poorly

Exhibit minimal anxiety over presence of strangers

Accept undressing, but want to feel warm

Can track movement visually

Do not tolerate oxygen masks

Newborns and Infants (birth to 1 year)

Behavioral Traits by Age

Assessment of Children

Have a parent hold the infant during the physical exam.

Keep hands & tools warm.

Observe breathing from a distance.

Examine the head last.

If listening to lungs, do it early

(before child is upset)

Newborns and Infants (birth to 1 year)

Do not tolerate parental separation

Do not like to be touched

May perceive illness as punishment

Sensitive about modesty

Easily frightened (i.e., by needles)

Tend to be perceptive, independent

Do not tolerate masks

Toddlers (1-3 years)


Toddlers (1-3 years)

Have a parent hold the child during the physical exam.

Explain that the child was not “bad.”

If clothing is removed, replace it.

Try to examine the head last. Trunk to toe exam.

Explain what you do in advance — but use a child’s terms.


Do not tolerate parental separation

Do not like to be touched


May perceive illness as punishment

Tend to fear blood, pain, and permanent injury or disfigurement

Curious, communicative, cooperative

Do not tolerate masks

Preschool (3-6 years)


Preschool (3-6 years)

Have a parent hold the child during the physical exam.

If clothing is removed, replace it.

Be calm, reassuring, and respectful.

Explain what you do in advance.

Allow the child to give the history.

Avoid fastening a face mask.


Cooperative, but expect to have opinions heard


Tend to fear blood, pain, and permanent injury or disfigurement

School Age (6-12 years)


School Age (6-12 years)

Allow the child to give the history.

Explain as you examine.


Respect the child’s modesty.


Expect to be treated as adults.

Generally act as though indestructible.

May fear lasting disfigurement.

Variable emotional and physical development may produce some insecurity about self-image.

Adolescent (12-18 years)


Adolescent (12-18 years)

Try to respect the emerging adult, yet reassure the remaining child.

Explain as you examine.


Respect the young adult’s modesty and need for privacy. May want to be assessed away from parent/guardians/adults


AnatomicalAnatomicalDifferencesDifferences

Airway Differences between Adults and Airway Differences between Adults and ChildrenChildren

Airway Differences betweenAdults and Children (Airway)

More anterior than the adult - less head tilt needed to open the airway.

Smaller airway than adult - blocked easily by secretions or blood

Large tongue in relation to jaw size - likely to cause obstruction when child is unresponsive.

Infants prefer to breathe through their nose - nasal obstruction can cause respiratory distress.

Bigger, softer.

Infants and small children have disproportionately larger heads (until about age 4). Note the effect of padding.

Head

Airway Differences betweenAdults and Children (Breathing)

Small children are dependent upon contraction of the diaphragm to breathe

Children in respiratory distress compensate rapidly by increasing their rate of breathing and using their accessory muscles, which causes fatigue.

Increased work of breathing is demonstrated by nasal flaring and intercostal retractions.

Slow pulse (Bradycardia) is a sign of hypoxia in the pediatric patient.

Airway Differences betweenAdults and Children (Circulation)

Children compensate rapidly in shock by increasing heart rate and vasoconstricting then decompensate rapidly.

Perfusion in the child is assessed by determining the heart rate, distal pulses, mental status, capillary refill and skin color and temperature.

Hypovolemia can develop from vomiting and/ or diarrhea in children.

Blood pressure is a poor indicator of perfusion status in the pediatric patient.

AirwayAirway

Airway Opening

Position to open airway is different – head-tilt/chin-lift = do not hyperextend

Jaw thrust with spinal immobilization if trauma is suspected

Opening the Airway Opening the Airway –– Use head-tilt, Use head-tilt,chin-lift chin-lift withoutwithout hyperextension. hyperextension.

Suctioning

Ensure small enough catheter.

Do not insert too deeply.

Suction as briefly as possible – no more than 10 seconds.

Signs of Partial AirwayObstruction

Stridor, 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.

Signs of Complete Airway Obstruction

No crying or speech

Initial difficulty breathing that worsens

Cough becomes weak and ineffective

Altered mental status, unconsciousness

Clearing Foreign BodyObstructions

INFANTS

Back blows &chest thrusts

CHILDREN

Abdominalthrusts

Remove visible foreign body.

Attempt artificial ventilation with BVM.

Oral Airways

Adjunct, not for initial artificial ventilation

Should not have gag reflex

Use correct size.

Use tongue depressor to hold down tongue.

Insert right-side-up (not upside-down).

Oral Airway InsertionOral Airway Insertion

• Insert tongue blade to the base of the tongue

• Push down against the tongue while lifting upward

• Insert oropharyngeal airway without rotation following oropharyngeal curvature

Nasal Airways

Adjunct not for initial artificial ventilation

Use proper size.

Insertion technique same as for adult.

Do not use if facial or head trauma exists.

OxygenOxygenTherapyTherapy

Nonrebreather MaskNonrebreather Mask

Blow-By Technique

Hold tubing no more than 2 inches from face OR

Insert tubing into paper cup.

Blow-By TechniqueBlow-By Technique

Do not usestyrofoam cup.

Artificial Ventilation

Use proper size mask and bag.

If trauma involved, use jaw thrust (not head tilt).

If unable to maintain mask seal with one hand, use two.

Mouth-To-Mask VentilationMouth-To-Mask Ventilation

Artificial Ventilation

Bag-Valve-Mask Use

Squeeze bag slowly/evenly until chest rises adequately.

If under 8 years old, ventilate 20 times a minute (1 breath every 3 seconds).

If over 8 years old, ventilate 10-12 times a minute (1 breath every 5 seconds).

Provide oxygen at 100% by using an oxygen reservoir

Head

Fontanelles (soft spots) exist until about 12-18 months old.

Sunken may indicate dehydration

Bulging may indicate crying or head injury

Chest & Abdomen

Increased elasticity of chest

Primarily abdominal breathers (infants primarily nose-breathers)

Less protection than adults for internal organs

Body Surface

Larger in proportion to body mass

Increased risk of hypothermia

Burn injuries calculated differently

Techniques ofTechniques ofPediatric CarePediatric Care

Assessment

Two methods:

Pediatric Assessment Triangle (PAT)

OR

Step-by-Step assessment

Pediatric Assessment Triangle

PAT General Impression

“From the Doorway”

Observe appearance:

Mental status

Body position/Muscle tone

Observe breathing effort.

Observe circulation (skin color).

PAT “Hands-On”

Assess and treat based on doorway assessment.

Provide interventions and assess for any further concerns.

Step-by-StepStep-by-StepAssessmentAssessment

General PrinciplesChildren differ from adults, but also differ from each other depending on age

Large amount of clinical information can be obtained by observation before approaching the child:

Child often anxious and scared by presence and examination of EMT as opposed to adults who are often relieved

General PrinciplesIt is important to maintain a calm and relaxed manner when dealing with a pediatric patient

Speak softly (It is a known fact that monsters and mean people speak loudly)

Use the child’s name

Adjust your height to the child’s (Monsters are most threatening when they tower over you)

Look before you touch, and touch gently (Monsters are rough)

Tell the child what you are going to do then do it immediately

Never lie to a parent or a child or you will lose their trust

Enlist the parent’s (care giver’s) help

Attempt to keep the parent and child together

General/Initial Impression

Ensure scene safety/Take BSI precautions.

Begin actively observing the child from the doorway

Much of the assessment can be performed prior to touching (thereby upsetting the child)

General/Initial Impression

Ensure scene safety/Take BSI precautions.

Begin actively observing the child from the doorway

Pay particular attention to Mental status

Skin Color

Effort of breathing

General Impression

The well versus sick child versus very sick

Mental Status

How is the child interacting with environment and parents (including eye contact)

What is the child’s behavior?

What is the child’s response to the EMT?

Tone/body position

Flaccid?

Is the child able to maintain an upright position?

Tripod Positioning?

General Impression

The well versus sick child versus very sick

Color

Pink?

Pale?

Cyanosis?

Respiratory rate and effort

What is the respiratory rate?

Is the chest rising and falling normally?

How much effort is the child making just to breathe?

Is the breathing noisy?

Primary Assessment

Detection of life threatening problems and treatment

Responsiveness

Stabilize cervical spine

Establish unresponsiveness

Primary Assessment

Airway

Is the child speaking or does the child have a vigorous cry? If not then position head

Trauma - Neutral with jaw thrust

Medical - Sniffing or Sniff Plus

OPA insertion as necessary

Primary Assessment

Airway cont’d…

Is stridor (indicates upper airway obstruction) or other evidence of upper airway obstruction present ?

Foreign body - FBAO procedure as per AHA guidelines

Swelling due to disease - Possibly croup or epiglottitis

Serious medical emergency

Do not agitate child

Maintain position of comfort

If necessary assist ventilations with a BVM

Primary Assessment

Airway cont’d…

Is gurgling / snoring present?

Excessive secretions require suctioning

Obstruction with the tongue requires repositioning of the head or insertion of OPA / NPA as indicated

Initial Assessment

Assess breathing:

What is the respiratory rate ?

Is chest rise adequate ?

What is the respiratory effort ?

Increased work of breathing

Retractions

Nasal flaring

What are the breath sounds ?

Listen at mid-axillary line for equality and abnormal breath sounds

Initial AssessmentAssess breathing cont’d…:

Is oxygenation / ventilation adequate ?

Cyanosis - Central versus peripheral

Altered Mental State

If oxygenation is inadequate provide supplemental oxygen

Non-Rebreather Mask (if tolerated) with 10-15 LPM flow rate

Blow-by Oxygen with oxygen tubing at 6 LPM flow rate

If ventilations are inadequate provide assisted ventilations

BVM with a reservoir

Are there signs of trauma to the chest ?

Seal holes

Stabilize fractures

Initial AssessmentAssess circulation:

Assess the rate and quality of peripheral pulses

Diminished or absent peripheral pulses indicates compensated shock especially in the presence of a strong central pulse.

Absence of central pulses (femoral or in children older than one year brachial) indicates decompensated shock

Absence of carotid pulse (brachial in infants) indicates cardiac arrest

Assess capillary refill

Normal is less than 2 seconds

Delayed (2-4 seconds) is seen with compensated shock

Absent (greater than 4 seconds) is seen with decompensated shock

Initial AssessmentAssess circulation:

Assess skin color and temperature

Pale and/or cool skin can indicate shock

Is shock present ? If present is it compensated or decompensated

Is their signs / symptoms of internal and/or external bleeding ?

Blood pressure is difficult to measure in pediatric patients and is of limited value

Support circulation as necessary

Control bleeding

Elevate the legs in the absence of trauma

Maintain body temperature

Initial AssessmentAssess disability:

Altered mental status is indicative of hypoxia or hypoperfusion

Assess the level of consciousness

Mental status evaluation is dependent on the patient’s age

AVPU scale

Assess pupils and ability to move all four extremities

If collar has not been applied and is indicated, apply a rigid extrication collar

Initial AssessmentExpose:

Attempt to locate all injuries

Maintain body temperature

CUPS Decision – Use pediatric CUPS status

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!

NewbornNewbornAssessment andAssessment and

ManagementManagement

Newborn Assessment/ManagementImportance:

Newborn resuscitation needs to be provided immediately following delivery which is most likely to be provided by the first responder

Parents most likely will not have the skills or a good hold of the situation to perform the necessary skills

Newborn AssessmentRespiratory Effort

What is the respiratory rate?

Respiratory Effort

Are there retractions, nasal flaring, chest wall movement, etc…

Skin Color

Peripheral cyanosis is normal in the newborn

Central or persistent cyanosis is worrisome

Newborn AssessmentPerfusion

Heart rate

Assess by palpating umbilical cord or listening with stethoscope for heartbeat

Skin Color

Muscle Tone

The newborn should have a normal grasp and movement of all extremities

Newborn ManagementWarm and Dry

All newborns require warming and drying, this alone may stimulate breathing

Suctioning

All newborns require suctioning of the mouth and nose

Suctioning will stimulate the newborn to breathe

Always suction the mouth before the nose to prevent aspiration

Tactile Stimulation

After warming, drying and suctioning if the newborn has a poor or absent respiratory effort they may need to be stimulated

Tactile stimulation is accomplished by either rubbing the back or flicking the soles of the newborn

Blow-by Oxygen/Assisted VentilationsMost newborns do not require supplemental oxygen or assisted ventilations

Blow-by oxygen should be provided for the newborn who has either central cyanosis or prolonged peripheral cyanosis AND a normal respiratory effort and a heart rate above 100

If the indications for blow-by oxygen resolve the blow-by oxygen should be gradually withdrawn

Assisted ventilations should be provided to any newborn with either:

Heart rate below 100

Absent or poor respiratory effort despite warming, drying, suctioning and stimulating the newborn

Cyanosis which has not improved with blow-by oxygen

If the newborns indications for assisted ventilations resolve ventilations should be stopped and blow-by oxygen provided

Chest Compressions

Rarely does a newborn require chest compressions

If the newborn’s heart rate is either below 80 and not improving despite warming, drying, tactile stimulation and 30 seconds of BVM ventilation, begin, chest compressions

Common Medical Common Medical ProblemsProblems

Airway ObstructionsPartial Airway Obstruction – infant or child who is alert and sitting

Stridor, crowing, or noisy

Retractions on inspiration

Pink

Good peripheral perfusion

Still alert, not unconscious

Emergency medical care

Allow position of comfort, assist younger child to sit up, do not lay down. May sit on parents lap.

Offer oxygen

Transport

Do not agitate child

Limited exam. Do not assess blood pressure.

Airway Obstructions

Complete Airway Obstruction and altered mental status or cyanosis and partial obstruction

No crying or speaking and cyanosis.

Child's cough becomes ineffective

Increased respiratory difficulty accompanied by stridor

Victim loses consciousness

Altered mental status

Clear airway.

Infant foreign body procedures

Child foreign body procedures

Attempt artificial ventilations with a bag-valve-mask and good seal.

Respiratory Emergencies

Common causes are:

Aspiration of foreign objects

Respiratory diseases and infections

Near drowning or electrocution

Poisonings

SIDS


Upper Airway Obstruction

Stridor on inspiration

Lower Airway Disease Wheezing and breathing effort on exhalation

Rapid breathing without stridor

Know respiratory rates for age

Complete Airway Obstruction

No crying

No speaking

Cyanosis is present

No couging

Respiratory Assessment

Check respiratory rate

Rate can be affected by many factors such as fear, fever and age

Initial response to respiratory distress is an increased respiratory rate, followed by a drop in the respiratory rate as the child fatigues

Assess respiratory effort

Chest rise

Retractions

Nasal flaring

Respiratory AssessmentAuscultate breath sounds

Should be performed at the mid-axillary line

Sounds on inspiration usually indicate upper airway problems while sounds with expiration usually represent lower airway problems

Look for asymmetry

Wheezes are a sign of small airway narrowing and reduced air flow

Inspect and palpate the chest

Are there any visible signs of trauma

Assess Skin Color

Central or peripheral cyanosis

Respiratory Distress

Recognize signs of increased effort or breathing – needs a NRB maskEarly respiratory distress is indicated by any of the following:

Nasal flaring

Intercostal Retractions (neck muscles), supraclavicular (above clavicles), subcostal retractions (below ribs)

Stridor

Neck and abdominal muscles – retractions

Audible wheezing

Grunting

Respiratory DistressThe presence of signs and symptoms of early respiratory distress and any of the following

Rate >60

Cyanosis

Decreased muscle tone

Severe use of accessory muscles

Poor peripheral perfusion and color


Alert, irritable, anxious

Grunting

Signs of Respiratory DistressSigns of Respiratory Distress

Respiratory Arrest/FailureNeeds assisted BVM assisted ventilations. Use the

patients as medical control (i.e. any pediatric patient who will tolerate a BVM needs a BVM)

Difficulty with breathing

Increased respiratory effort at sternal notch

Breathing rate less than 10 per minute

Retractions

Head bobbing

Grunting

Severe accessory muscle use

Absent or shallow chest wall motion

Respiratory Arrest/Failure

Needs assisted BVM assisted ventilations. Use the patients as medical control (i.e. any pediatric patient who will tolerate a BVM needs a BVM)

Difficulty with breathing cont’d…

Limp muscle tone

Decreased muscle tone or poor muscle tone (e.g. unable to maintain sitting position in infant > 4 months)

Change in Mental Status

Sleepy

Intermittently combative

Agitated

Unresponsive to voice or touch

Unconscious

Respiratory Arrest/Failure

Needs assisted BVM assisted ventilations. Use the patients as medical control (i.e. any pediatric patient who will tolerate a BVM needs a BVM)

Difficulty with breathing cont’d…

Slower, absent heart rate

Difficulty with color/perfusion

Central cyanosis

Marked tachycardia or bradycardia

Poor peripheral perfusion

Weak or absent distal pulses.

Respiratory ailments are the primary cause of cardiac arrest, not due to trauma


Maintain the airway

Provide high-concentration oxygen to all children with resp. emergencies

Provide oxygen and assist ventilations if respiratory distress is severe:


Cyanosis not improving with oxygen

Poor muscle tone

Respiratory failure

Respiratory arrest – apply oxygen and ventilate wit BVM

Viral inflammation of trachea & larynx

Usually affects ages 6 months to 4 years

Onset typically at night

Seal-like barking cough

Signs of respiratory distress

Croup

Place in position of comfort.


Cool air may provide relief.

Transport.

Treatment of Croup

A life-threatening emergency!

Bacterial inflammation of epiglottis

Usually affects ages 3 to 7

Sudden onset of high fever

Epiglottitis

Continued…

A life-threatening emergency!

Tripod positioning

Painful swallowing & respiratory distress

Epiglottitis

Place in position of comfort.


Transport immediately.

Do not increase child’s anxiety.

Do not place anything in patient’s mouth.

Treatment of Epiglottitis

Seizures

Seizures in children who have chronic seizure are rarely life-threatening. However, seizures, including febrile, should be considered life- threatening by the EMT-B

May be brief or prolonged

Assess for presence of injuries which may have occurred during the seizures

Seizures

Fever

Infection

Poisoning

Hypoglycemia

Trauma

Hypoxia

Idiopathic (Unknown Cause)

Causes

Assessing Seizures

History of Seizures:

Has child had seizures before?

If yes, is this the child’s normal seizure pattern?

Anti-seizure medication taken?

Any fever?

Treatment of Seizures

Assure patency of airway.

Position patient on side if no possibility of cervical spine trauma. Protect from injury.

Have suction ready.

Provide oxygen and if in respiratory arrest or severe respiratory distress, assure airway position and patency and ventilate with BVM.

Transport. Although brief seizures are not harmful, there may be a more dangerous underlying condition.

Seizures

Can be caused by head injury

Inadequate breathing and/or altered mental status may occur following a seizure.

Hypoglycemia

Poisoning

Post-seizure

Infection

Head trauma

Hypoxia

Shock

Causes

Altered Mental Status

Emergency Care ofAltered Mental Status

Establish airway.


Be prepared to artificially ventilate and suction as needed.

Consider spinal precautions.

Transport.

Poisonings

Common reason for infant and child ambulance calls

Identify suspected container through adequate history. Bring container to receiving facility if possible.

Emergency medical care

Responsive patient

Contact medical control.

Provide oxygen.

Transport.

Continue to monitor patient - may become unresponsive.

Poisonings

Emergency medical care cont’d…

Unresponsive patient

Assure patency of airway.

Be prepared to artificially ventilate.

Provide oxygen if indicated.

Call medical control.

Transport.

Rule out trauma, trauma can cause altered mental status.

Fever

Common reason for infant or child ambulance call

Many causes – rarely life-threatening. A severe cause is meningitis

Fever with a rash is a potentially serious consideration

Transport and be prepared for seizures.

Diarrhea and dehydration

Trauma

Vomiting

Blood loss – The loss of any amount of blood in an infant or child can be life-threatening

Infants = 50ml

Infection

Abdominal injuries

Common

Causes

Shock (Hypoperfusion)

Blood VolumeBlood Volume

Allergic reactions

Poisoning

Cardiac problems

UncommonCauses

Shock (Hypoperfusion)

Assessment of Shock

Different than for adults

Blood pressure hard to measure and unreliable, especially true when < 3 years old, don't even obtain BP measurement

Key assessment is peripheral perfusion and mental status

Be aware that shock in a child can rapidly deteriorate

Diminished or absent peripheral pulses indicates compensated shock especially in the presence of a strong central pulse.

Signs and Symptoms of Shock

Compensated Shock

Altered Mental Status

Rapid pulse (tachycardia)

Cool extremities

Weak/absent peripheral pulses

Delayed capillary refill

Continued…

Decompensated Shock

Weak or impalpable central pulses

Extensive cyanosis of all extremities

Absence of tears even when crying

Systolic BP less than 70mmHg

Signs and Symptoms of Shock

Signs of Shock

TreatingTreatingShockShock

1. Assure airway/oxygen

2. Provide supplemental oxygen

3. Be prepared to artificially ventilate

4. Manage bleeding if present

5. Immobilize the patient as indicated

6. Elevate legs if no indication of trauma

7. Keep warm

8. Transport.

***Rapid transport form infant/child with secondary exam en route***

Emergency Care forNear Drowning

Artificial ventilation is top priority

Consider possibility of trauma

Consider possibility of hypothermia

Consider possible ingestion, especially alcohol

Protect airway, suction if necessary

Secondary drowning syndrome - Deterioration after breathing normally from minutes to hours after event. All near drowning victims should be transported to the hospital.

Sudden Infant DeathSyndrome (SIDS)

Key Term

Sudden death without identifiable cause Sudden death without identifiable cause in infant < 1 year old. Cause is not well in infant < 1 year old. Cause is not well understood. Most common time of understood. Most common time of discovery is early morning.discovery is early morning.

Emergency Care of SIDS

Resuscitate if indicated - unless rigor mortis is present.

Parents will be in agony from emotional distress, remorse and imagined guilt.

Avoid comments that blame parents.

TraumaTrauma

In the United States, injuries kill more children and infants than any other cause of death.

Trauma – General Considerations

Most pediatric trauma is blunt trauma and arises from falls and motor vehicle accidents

Blunt trauma has less overt signs and has a later deterioration than penetrating trauma, therefore rely on the mechanism in the absence of overt signs and / or symptoms of serious trauma

Children have relatively large liver and spleen and have poor muscle protection of these organs making them extremely susceptible to injury

Trauma – General Considerations

Head trauma is more prevalent in children because of the larger head to body ratio when compared with adults

Infants can lose enough blood in their head to develop decompensated shock

Pediatric head injury patients usually die from airway and ventilatory problems and not the actual head injury. As such control the airway and ventilation

Pelvic fractures can cause enough blood loss in the pediatric shock to cause hypovolemic shock

What may seem like a small blood loss may be relatively extensive when compared to the child’s smaller blood volume

Blunt TraumaMost Common Type of Injury

Pattern of Injury will be different from adults:

Motor vehicle crashes:

Unrestrained passenger (head and neck injuries)

Restrained passenger (abdominal and lower spine injuries)

Blunt Trauma

Motor vehicle impacts:

Struck while riding bicycle (head, abdominal, spinal injuries)

Pedestrian struck by vehicle (abdominal injury with internal bleeding, possible painful, swollen, deformed thigh, head injury)

Blunt Trauma

Falls from height, diving into shallow water

Head and neck injuries

Burns

Sports injuries – head and neck

Child abuse

Blunt TraumaSpecific Types of Injuries

HeadThe single most important maneuver is to assure an open airway by means of the modified jaw thrust combined with a neutral head position.

Children are likely to sustain head injury along with internal injuries. Signs and symptoms of shock (hypoperfusion) with a head injury should cause you to be suspicious of other possible injuries.

Respiratory arrest is common secondary to head injuries and may occur during transport.


Head cont’d…Common signs and symptoms are nausea and vomiting.

Most common cause of hypoxia in the unconscious head injury patient is the tongue obstructing the airway. Jaw-thrust is critically important.

Do not use sandbags to stabilize the head because the weight on child's head may cause injury if the board needs to be turned for emesis.


Pediatric Cervical Spinal Stabilization and Immobilization

Manual stabilization

Initially provide manual stabilization while maintaining an adequate airway

Cervical Collars

Initially assure that the head is in a neutral position

Choose a collar of appropriate size based on manufacturers recommendations

Towels can be used in place of a cervical collar for infants that do not fit in the available collars.


Spinal Immobilization

Immobilization of pediatric patients should account for their anatomical differences

Children are shorter than adults - use backboards which have strap holes at multiple locations or use a short backboard.

Children are narrower than adults - it may be necessary to pad along the sides to insure a snug fit of the straps.

Small children have a large occiput - pad under the upper torso to insure neutral alignment of the cervical spine.


Spinal Immobilization cont’d…

Assure that a cervical collar is in place prior to moving patient to the backboard.

Place a child on the backboard using standard patient moves for a spinal injury patient

Secure the chest, pelvis and knees and then the head

Chest

Children have very soft pliable ribs

There may be significant injuries without external signs


Abdomen

More common site of injury in children than adults

Often a source of hidden injury

Always consider abdominal injury in the multiple trauma patient who is deteriorating without external signs

Air in stomach can distend abdomen and interfere with artificial ventilation efforts



Extremities

Managed in the same manner as adults

TraumaOther Considerations

Burns

Cover with sterile dressing (non-adherent, if possible, sterile sheets may be used).

Follow local protocol with regard to transport to burn center.

Emergency Care of Trauma

Maintain an adequate airway while manually stabilizing the cervical spine

Assure airway position and patency. Use modified jaw thrust.

Suction as necessary with large bore suction catheter.

Provide oxygen.

Assist ventilations for severe respiratory distress and ventilate with a bag-valve-mask for respiratory arrest.

Support circulation

Provide spinal immobilization.

Transport immediately.

Child AbuseChild Abuse and Neglectand Neglect

Abuse

Key Term

Improper or excessive action so as to injure or cause harm

Neglect

Key Term

Giving insufficient attention or respect to someone who has a claim to that attention

EMT–B must be aware of condition in order to recognize it.

Physical abuse and neglect are the two forms of child abuse EMT–B is most likely to suspect.

Signs of Abuse

Multiple bruises in various stages of healing

Injury inconsistent with mechanism described

Repeated calls to the same address

Continued…

Fresh burns

Parents seem inappropriately unconcerned

Conflicting stories

Fear on the part of the child to discuss how the injury occurred

Signs of Abuse

Lack of adult supervision

Child appears malnourished

Unsafe living environment

Untreated chronic illness (i.e. asthmatic with no medications)

Signs of Neglect

Handling Abuse and Neglect

CNS injuries are most lethal.

Shaken baby syndrome

Do not accuse anyone in the field.

Accusation and confrontation delays transportation

Bring objective information to the receiving facility

Handling Abuse and Neglect

Required Reporting

Follow state laws and local regulations.

Document objective information (what you SEE and HEAR, NOT what you THINK).

Infants and ChildrenInfants and Childrenwithwith

Special NeedsSpecial Needs

Children with Special Needs

This can include many different types of children:

Premature babies with lung disease

Babies and Children with heart disease

Infants and children with neurologic disease

Children with chronic disease or altered function from birth

Technologically DependentChildren (“High-Tech Kids”)

Tracheostomy tube

Central intravenous lines

Gastrostomy tubes

Shunts

Tracheostomy TubeComplications

Obstruction

Bleeding

Air leak

Dislodged tube

Infection

Tracheostomy Tube

Managing the Tracheostomy Tube

Maintain open airway.

Suction.

Maintain a position of comfort.

Transport.

Home Artificial Ventilation

Parents are usuallyfamiliar withequipment.

Home Artificial Ventilation

Assure airway.

Artificially ventilate with high-concentration oxygen.

Transport.

Central Intravenous Lines

IVs that are placed near the

heart for long term use

Complications

Cracked line

Infection

Clotting off

Bleeding

Care of Central IntravenousLines

If bleeding is present, apply pressure.

Transport.

Tube placed directly into stomach for feeding. Comes in many shapes. These patients usually cannot be fed by mouth.

Gastrostomy Tubes

Key Term

Managing GastrostomyTubes

Assure adequate airway.

Have suction available.

If a diabetic patient, be alert for altered mental status. Infant will become hypoglycemic quickly if they cannot be fed.

Provide high-concentration oxygen.

Transport patient sitting or lying on right side with head elevated.

Shunt

Key Term

Device running from brain to abdomen to drain excess cerebrospinal fluid. Will find reservoir on side of skull.

Managing Shunts

Prone to respiratory arrest

Manage airway.

Assure adequate artificial ventilation.

Transport.

Family ResponseFamily Response

A child cannot be cared for in isolation from the family; therefore, you have multiple patients.

Family Response

Striving for calm, supportive interaction with family will result in improved ability to deal with the child.

Calm parents = calm child; Agitated parents = agitated child.

Anxiety arises from concern over child’s pain; fear for child’s well-being

Worsened by state of helplessness

Family Response

Parent may respond with anger/hysteria toward EMT–B.

Parents should remain part of the care unless child is not aware or medical conditions require separation.

Parents should be instructed to calm child; can maintain position of comfort and/or hold oxygen.

Parents may not have medical training, but they are experts on what is normal or abnormal for their children and what will have a calming effect.

ProviderProviderResponseResponse

Anxiety from lack of experience with treating children as well as fear of failure.

Skills can be learned and applied to children.

Stress from identifying patient with their own children.

Provider should realize that much of what they learned about adults applies to children; they need to remember the differences.

Provider Response

Infrequent encounters with sick children; advance preparation is important (practice with equipment and examining children).

Encounters with sick or injured children may result in adverse emotional response by the EMT-B.

Critical Incident Stress Management (CISM) programs have been helpful in assisting EMS personnel to manage their normal response to these stressful situations.

Provider Response

Documents

CHAPTER 31 Infants and Children. DevelopmentalCharacteristics