Objectives. Objectives 9/11/2012. Chapter 17 Pediatric Emergencies. Name the narrowest part of the child's upper airway

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Chapter 17 Pediatric Emergencies Objectives Name the narrowest part of the child's upper airway Recall the characteristics of the various pediatric developmental stages and how the EMT-I should

1 Chapter 17 Pediatric Emergencies Objectives Name the narrowest part of the child's upper airway Recall the characteristics of the various pediatric developmental stages and how the EMT-I should approach the patient at each stage Objectives Recognize the signs and symptoms of increased respiratory effort in the infant or child Recognize the normal vital sign values for the various pediatric age groups Identify the type of endotracheal tube used in children younger than 8 years of age 1

2 Objectives List at least three techniques for bag-mask ventilation in the infant or child Recognize two characteristics of the following: croup, epiglottitis, asthma (reactive airway disease), and bronchiolitis Recognize the signs and symptoms of the infant or child with dehydration Objectives Describe the treatment of an infant or child in status epilepticus Identify the signs and symptoms of the infant or child with meningitis Define water rescue, submersion, and drowning Identify common poisons ingested by children Objectives List the causes of pediatric trauma from the most common to least common List the most important intervention for a child with head trauma Describe the process for pediatric immobilization List two signs of blunt trauma to the abdomen in the pediatric patient 2

3 Objectives Describe treatment for a child with hypothermia List five indicators of child abuse or maltreatment Recognize examples of cognitive and physical disabilities Objectives Describe treatment of an obstructed tracheostomy in an infant or child Identify family issues encountered when working with children who have special needs Epidemiology The Pediatric Patient Anatomic differences Infant: Birth to 1 yr Child: 1-8 yrs Weight is the key 3

4 Airway Smaller The Pediatric Patient Less than 8 y/o have larger tongue Large and floppy epiglottis Narrowest part is the cricoid cartilage area Tonsils and adenoids Weak muscles in the neck Vocal cords The Pediatric Patient Internal organs Larger in proportion Skeletal structure is smaller Most often injured organ is liver The Pediatric Patient Head, neck, and bones Large head Cervical injuries 4

5 Fontanelles Soft spots The Pediatric Patient Bulge with IICP Depressed with dehydration Bones Softer More pliable The Pediatric Patient Bend, rather than break Injured less frequently Underlying injuries The Pediatric Patient Nervous system Less developed 5

6 The Pediatric Patient Approaching the patient Psychologic aspect Do not have ability to understand Aware of pain Fearful of unfamiliar voices Parents need to be considered also Chronologic age Approximate weight Level of understanding Someone present whom the child knows and/or trusts Medical history Special circumstances General Assessment Initial and ongoing examinations Airway, breathing, and circulation Responsiveness AVPU Respiratory status General Assessment Respiratory status Distress can be life threatening 90% of cardiac arrests begin as respiratory problems First sign of distress in infants Tachypnea 6

7 General Assessment Respiratory status Other signs in infants and children Increased rate and effort Diminished breath sounds Decreased level of responsiveness Poor muscle tone Cyanosis General Assessment Respiratory status Effort increases Nasal flaring Intercostal, subcostal, and suprasternal retractions Head bobbing Grunting Stridor Prolonged expiration General Assessment Circulatory status Normally tachycardic Can result from hypovolemia, hypoxia, anxiety, fever, pain, heart failure Bradycardia No longer maintain adequate tissue oxygenation Precedes cardiopulmonary arrest Oxygen may increase heart rate 7

General Assessment Circulatory status Palpate brachial

General Assessment Infants Palpate brachial artery Children

Focused history and physical examination Vital signs vary

8 General Assessment Circulatory status Palpate brachial artery Evaluate Skin color Temperature Capillary refill General Assessment Infants Palpate brachial artery Children Palpate carotid or femoral artery General Assessment Focused history and physical examination Vital signs vary with age Evaluate abdomen Resuscitation tape Broselow resuscitation tape 8

9 General Assessment Focused history and physical Pelvis Check for pulse, motor and sensory Inspect back Pulse oximetry General Assessment Provides continuous monitoring Evaluates oxygen EMT-I should not rely solely on this tool Airway, Breathing, and Circulation Procedures and Equipment Opening the airway Chin-lift/jaw-thrust Sniffing position Suction 9

Airway, Breathing, and Circulation Procedures and Equipment Airway

Crucial for BLS to be started immediately May buy time Airway,

airway Measure airway Use tongue depressor Airway, Breathing, and

10 Airway, Breathing, and Circulation Procedures and Equipment Airway obstruction Tongue Foreign objects Swelling Removal Magill Heimlich Crucial for BLS to be started immediately May buy time Airway, Breathing, and Circulation Procedures and Equipment Oropharyngeal airway Measure airway Use tongue depressor Airway, Breathing, and Circulation Procedures and Equipment Nasopharyngeal airway Proper size Measure Suction 10

11 Airway, Breathing, and Circulation Procedures and Equipment Airway adjuncts Suction equipment Flexible plastic catheter Avoid damage to airway Low suction setting Monitor heart rate Airway, Breathing, and Circulation Procedures and Equipment Airway adjuncts Endotracheal intubation Indications Loss of CNS control of breathing Airway obstruction Fatigue Need for higher pressures to maintain alveolar gas exchange Airway, Breathing, and Circulation Procedures and Equipment Considerations for endotracheal intubation Airway has more soft tissue and larger tongue Cricoid is narrower Monitor heart rate End-tidal carbon dioxide detector 11

Airway, Breathing, and Circulation Procedures and Equipment Bag-mask

ventilation A) One rescuer provides ventilation of infant B) One rescuer

mask seal Second delivers ventilations 12

12 Airway, Breathing, and Circulation Procedures and Equipment Bag-mask ventilation Mask inverted Rate: 20 breaths/min 450 cc volume No pop-off valve Airway, Breathing, and Circulation Procedures and Equipment Bag-mask ventilation A) One rescuer provides ventilation of infant B) One rescuer provides ventilation of child Airway, Breathing, and Circulation Procedures and Equipment Bag-mask ventilation Two-rescuer One uses airway and mask seal Second delivers ventilations 12

13 Airway, Breathing, and Circulation Procedures and Equipment Inadequate bag-mask ventilation Check for obstruction Reposition Check mask fit Lift jaw Suction airway Check equipment Provide adequate oxygen Airway, Breathing, and Circulation Procedures and Equipment Oxygen delivery devices Nasal cannula Oxygen masks Blow by method Airway, Breathing, and Circulation Procedures and Equipment Intravenous therapy Sites: hands, arms, external jugular, ankles, and scalp veins Contraindicated when: Delay for priority transport would result Epiglottitis or severe respiratory distress 13

inserted into a long bone of the leg Medications and fluids

cleanse area Insert needle perpendicular to bone with boring

14 Airway, Breathing, and Circulation Procedures and Equipment Intraosseous infusion Severe shock or cardiac arrest Needle inserted into a long bone of the leg Medications and fluids can be administered Intraosseous Infusion Identify and cleanse area Insert needle perpendicular to bone with boring motion Remove stylet Intraosseous Infusion Inject 10 ml normal saline 14

15 Intraosseous Infusion Connect infusion set Secure needle Video for Intraosseous Infusion Airway, Breathing, and Circulation Procedures and Equipment Fluid administration Initial bolus 20 ml/kg isotonic crystalloid solutions Monitor for improvement May repeat 15

16 Resuscitation Cardiac arrest usually results from respiratory arrest Hypoxia and acidosis Bradycardia and asystole Croup Age 3 mos-3 yrs Layngotracheobronchitis Viral infection Slow onset, usually follows a cold Signs and symptoms Hoarse Stridor Barking Croup Treatment Position of comfort May want to lie flat High-concentration oxygen Cool and humidified if possible Monitor for total airway obstruction 16

17 Epiglottitis Age: 3-7 y/o Bacterial infection Progresses rapidly True emergency, leading to total airway obstruction Epiglottitis Signs and symptoms Looks ill Tripod position Tongue protruding Drooling Stridor Respiratory distress Epiglottitis Treatment Do not attempt to visualize the airway Calm and comfort the child High-concentration oxygen Mask or blow by Humidified Be prepared to ventilate with bag mask Needle cricothyrotomy Intubation Only if cricothyrotomy or tracheostomy can be performed if intubation is not successful Priority transport 17

18 Asthma Reactive airway disease Acute attack Status asthmaticus Cannot be broken with bronchodilators Asthma Signs and symptoms Wheezing Silent chest Lethargic First-time case Treat as if it were anaphylactic shock Asthma Treatment High-concentration oxygen Mask or blow by Humidified Monitor vital signs and cardiac rhythm Pulse oximetry Local protocols regarding medications 18

19 Bronchiolitis Age: 6-18 months old Viral infection Mild fever, cough, mucus, wheezing Bronchiolitis Treatment High-concentration oxygen Mask or blow by Humidified Monitor vital signs and cardiac rhythm Pulse oximetry May need to intubate Local protocols regarding medications Croup Usually caused by viral infection Usually occurs late fall/early winter 3 mos-3 yrs Slow onset Patient will either lie down or sit up Barking cough No drooling Temperature >104 F Epiglottitis Usually caused by bacterial infection No seasonal preference 3-7 yrs Rapid onset Patient will sit upright in tripod position No barking cough Drooling Temperature >104 F 19

Asthma Any age Winter and spring Response to allergy, exercise, or infection Family history Drugs reverse bronchospasm Bronchiolitis 16-18 months No seasonal preference Caused by virus No history of

20 Asthma Any age Winter and spring Response to allergy, exercise, or infection Family history Drugs reverse bronchospasm Bronchiolitis months No seasonal preference Caused by virus No history of asthma Drugs may not be effective Shock May lose <20% before signs and symptoms appear Assess Skin Color Pulse Mottling Leading cause Gastroenteritis with dehydration Burns Hypovolemia Rule of nines 20

21 Shock Signs and symptoms Altered level of responsiveness Hyperventilation Respiratory failure Tachycardia Normotension progressing to hypotension Cool or cold, clammy skin Diminished peripheral pulses Prolonged capillary refill Oliguria Acidosis Shock Treatment Control bleeding Position Can crash quickly Dehydration Loss of bodily fluids Vomiting, diarrhea, fever, burns, low intake Leads to drop in cardiac output Renal failure Shock Death Infants have a higher percentage of water 22 lb infant is approximately 14 lbs water 21

22 Dehydration Treatment for moderate to severe Oxygen Monitor vital signs and cardiac rhythm IV of isotonic crystalloid 20 ml/kg bolus; repeat every 5 min Priority transport Seizures/epilepsy Common complication of fever Result of epilepsy Medication Seizures/epilepsy Assessment Duration of seizure Presence of any aura Level of responsiveness Part of body involved Eye deviation and direction Postictal period Loss of bladder or bowel control 22

23 Seizures/epilepsy Treatment Position on side Protect from injury Maintain airway Possible IV line Status epilepticus Seizures lasting >30 min Life threatening Treatment Airway Cardiac monitor IV glucose Prompt transport Meningitis Inflammation of the membranes covering brain and spinal cord Viral or bacterial Bacterial is more serious 23

24 Meningitis Signs and symptoms Fever, dehydration Disorientation or lethargy Bulging fontanelle Irritability Loss of appetite and vomiting Seizures Respiratory distress, cyanosis Rash Stiff neck, Kernig s sign Headache Meningitis Treatment Support respiratory and vascular systems Monitor vital signs and cardiac rhythm IV lifeline 20 ml/kg bolus for shock Priority transport Use BSI procedures per protocol Water rescue Occurs when child had distress in water but is alert Submersion Swimming-related distress that requires care and transport Drowning Occurs when child dies after submersion 24

25 Drowning/submersion/water rescue Treatment Respiratory and cardiac status CPR Keep warm Rapid transport Do not perform invasive procedures on the hypothermic child Drowning/submersion/water rescue Assessment How long was the child submerged? Warm or cold water? Were there signs of a pulse or breathing on rescue? Was CPR started? Medical history Poisoning 18 mos-3 yrs account for 80% Household products Medications Toxic plants Contaminated foods 25

26 Poisoning School age to adolescence Alcohol Organic solvents Mind-altering drugs Narcotics CNS depressants CNS stimulants Poisoning Treatment Depends on type of poison ingested Trauma Fatal MOI in adolescents and children: Vehicular trauma Automobile, pedestrian, bicycle Drowning House fire Falls 26

27 Anatomic differences Trauma Smaller than adults, wider range of injuries Less body fat Connective tissue is more elastic Organs closer together Skeleton more resistant to injury Larger surface area Assessment Trauma Careful consideration of mechanism of injury Even in stable child Rapid transport if possibility of decompensation exists Head trauma Trauma Most common cause of death Ventilation is the most important intervention Rapid transport 27

28 Spinal trauma Trauma Serious injury to the cord can occur without signs of external injury Proper use of restraint systems in vehicles Trauma Initial assessment Careful evaluation of the mechanism of injury Can compensate better than adults Decompensate more rapidly Frequent reevaluation is important Airway, C-spine, breathing, circulation Quick neurologic exam Immobilization Helmet removal Trauma Chest and abdominal injuries Major internal injury without external signs of injury Assessment Bruising Distension, rigidity, tenderness Unexplained findings of shock 28

29 Apply properly sized rigid cervical collar Trauma If collar not available, use other materials Trauma Logroll onto board; fasten torso to board Securely fasten head to board Trauma A B C A) Remove protection plate B) Pad open areas, especially around head and neck C) Secure seat for transport 29

Trauma Chest and abdominal injuries Signs of blunt trauma Bruising

30 Trauma Immobilizing child on backboard, place padding Under back Along torso Around both legs Helmets should be removed from children Trauma Trauma Chest and abdominal injuries Signs of blunt trauma Bruising Unstable pelvis Abdominal distension Rigidity or tenderness Unexplained levels of shock 30

31 Trauma Chest and abdominal injuries Treatment Definitive care at medical facility Oxygen Monitor vitals Rapid transport Hypothermia Trauma Large body surface area Compensatory mechanisms not as well developed Core temperature <35 C (95 F) Causes Environmental Metabolic disorders Sepsis Brain injury Alcohol/poisonings Trauma Hypothermia Assessment How long was exposure? Ingestions? Medical history 31

32 Trauma Signs and Symptoms of Hyperthermia MILD MODERATE SEVERE <28 Slurred speech Deteriorating responsiveness Unresponsive Mild uncoordination Cyanosis Dilated, fixed pupils Shivering Edema Ventricular dysrhythmia Decreased judgment Muscle rigidity, no shivering, bradypnea, bradycardia Respiratory arrest Modified from: Wertz, E. (2001). Emergency Care for Children, Delmar Publishing Pediatric Trauma Hypothermia Treatment Move to warm environment Immobilize as indicated Remove wet clothing, cover with dry blankets Maintain airway High-concentration oxygen CPR Rapid transport No invasive procedures Other Pediatric Problems Child abuse or maltreatment Physical abuse Injury intentionally delivered to the child Sexual abuse Any sexual activity between a child and an older child or adult Emotional or psychologic abuse Behaviors inflicted on the child that are Degrading Terrorizing Isolating Rejecting 32

33 Other Pediatric Problems Child abuse or maltreatment Indicators Obvious/suspected injuries <2 y/o Injuries in various stages of healing More injuries than normal Scattered injuries Bruise/burn patterns Suspected increased intracranial pressure in infant Suspected intraabdominal trauma in children Other Pediatric Problems Child abuse or maltreatment Indicators Injury does not fit description of cause given Accusation that child injured self Long-standing skin infections Extreme malnutrition Extreme lack of cleanliness Inappropriate clothing for situation Child withdraws from parent Child responds inappropriately to situation Children with Special Needs Cognitive disabilities Impaired adaptation in: Learning Social adjustment Maturation 33

34 Children with Special Needs Physical disabilities Type of limitation of mobility Hearing impairment Vision impairment Cerebral palsy Spina bifida Spinal cord injuries Children with Special Needs Chronic illnesses Condition that extends for prolonged period of time Asthma Diabetes Epilepsy Cancer Spinal cord injuries Congenital heart anomalies Children with Special Needs Technologic aids Tracheostomy Apnea monitor Gastrostomy tube 34

35 Children with Special Needs Tracheostomy Obstructed Suction tube Suction stoma Ventilate Manually occlude stoma Bag-mask over nose/face Children with Special Needs Gastrostomy tube Internal External Children with Special Needs Gastrostomy button 35

36 Children with Special Needs Family issues Include family during assessment Allow family to provide treatment Family frustration Siblings Summary Explain what is happening to child Provide simple distractions for young child In potential spinal injury, rule out lifethreatening injuries before attending to fullbody immobilization Use manual immobilization of head and cervical spine during airway assessment Summary Select best possible immobilization equipment EMT-I should be familiar with pediatric equipment Practice assessment on children whenever possible EMT-I must be adequately trained to deal with pediatric emergencies 36

37 Summary Concentrate on differences between adults and infants or children Pay attention to pediatric airway as respiratory distress usually precedes cardiac dysrhythmias Remember Infants/children can compensate longer in shock But can deteriorate rapidly Questions? 37

Pediatric Shock. Hypovolemia. Sepsis. Most common cause of pediatric shock Small blood volumes (80cc/kg)

Pediatric Shock. Hypovolemia. Sepsis. Most common cause of pediatric shock Small blood volumes (80cc/kg) Critical Concepts: Shock Inadequate peripheral perfusion where oxygen delivery does not meet metabolic demand Adult vs Pediatric Shock - Same causes/different frequencies Pediatric Shock Hypovolemia Most