Pediatrics 1 Neonatal Resuscitation Pediatric Assessment Airway Management. Neonatology. Topics. EMT Paramedic / Critical Refresher Session # 22

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1 EMT Paramedic / Critical Refresher Session # 22 Pediatrics 1 Neonatal Resuscitation Pediatric Assessment Airway Management 1 Neonatology 2 Topics Newborns & Neonates High Risk Newborn Patients APGAR Scoring Newborn Resuscitation 3 1

2 Introduction Neonate An infant from the time of birth to one month of age Newborn A baby in the first few hours of its life, also known as newly born infant 4 Epidemiology Approx. 6% of field deliveries require life support. The incidence of complications increases as the birth weight decreases. Approx. 80% of newborns weighing 1500g (3 pounds, 5 ounces) at birth require resuscitation. 5 Determine at risk newborns by considering antepartum and intrapartum factors that may indicate delivery complications. Antepartum before the onset of labor Intrapartum occurring during childbirth 6 2

3 Antepartum Risk Factors Multiple gestation Inadequate prenatal care Mother s age Less than age 16 or more than 35 History of perinatal morbidity or mortality Post term gestation Drugs/medications Toxemia, hypertension, diabetes 7 Intrapartum Risk Factors Premature labor Meconium stained amniotic fluid Rupture of membranes greater than 24 hours before delivery Use of narcotics within 4 hours of delivery Abnormal presentation Prolonged labor or precipitous delivery Prolapsed cord Bleeding 8 Assessment Assess the newborn immediately after birth. Ideally, one paramedic attends the mother while the other attends the newborn. Remember newborns will be slippery and require both hands. 9 3

Assessment Normal heart rate 150 180 per minute. Slowing to 130 140 thereafter. A pulse less than 100 indicates distress.

4 Assessment Normal heart rate per minute. Slowing to thereafter. A pulse less than 100 indicates distress. Normal respiratory rate per minute. Evaluate skin color as well. Use the APGAR score. 10 APGAR Scale 11 Treatment 12 4

Establishing an Airway Airway management is one of the most critical steps in caring for the newborn. Suction the baby s mouth to avoid risk of aspiration.

5 Establishing an Airway Airway management is one of the most critical steps in caring for the newborn. Suction the baby s mouth to avoid risk of aspiration. 13 Stimulate the newborn as required by flicking its feet or rubbing its back DO NOT spank or vigorously rub a newborn baby! 14 Prevention of Heat Loss Heat loss can be life threatening to newborns. Most heat loss results from evaporation. Core temp. can quickly drop 1 Celsius from its original temp. 15 5

To prevent heat loss Dry the newborn immediately. Maintain room/ambulance temperature at minimum 74 76 degrees. Close all windows and doors.

6 To prevent heat loss Dry the newborn immediately. Maintain room/ambulance temperature at minimum degrees. Close all windows and doors. Swaddle the infant in a warm, dry receiving blanket or other suitable material. In colder areas, use water bottles or rubber gloves filled with warm water. 16 Dry the infant to prevent loss of evaporative heat. 17 Cutting the Umbilical Cord AFTER you have stabilized the patient s airway and minimized heat loss, clamp and cut the umbilical cord. Do not milk or strip the cord. 18 6

7 THE DISTRESSED NEWBORN 21 7

Aspiration of meconium can cause significant problems and should be prevented.

8 The distressed newborn can either be full term or premature. The most common problems experienced by newborns during the first minutes of life involve the airway. Aspiration of meconium can cause significant problems and should be prevented. Of the vital signs, heart rate is the most important indicator of neonatal distress. A HR < 60 should be treated with chest compressions. 22 Evaluate heart rate 23 Inverted Pyramid for Resuscitation 24 8

9 Finger positions for infant sizes 27 9

10 Endotracheal intubation of a newborn should be carried out in the following situations: The BVM does not work. Tracheal suctioning is required. Tracheal administration of medications is required. Prolonged ventilation will be required. A diaphragmatic hernia is suspected. 28 ALS Resuscitation of the Newborn Ventilation is the most important step in correcting bradycardia before it progresses to cardiac arrest Medication administration is rarely necessary 29 ALS Resuscitation of the Newborn Medication administration is indicated if the heart rate remains less than 60 despite adequate ventilation with 100% oxygen and chest compressions 30 10

11 Insert a fresh tube for ventilation if necessary 32 Pediatrics 33 11

Topics General approach to pediatric: Emergencies Assessment Treatment 34 It is important to organize or participate in programs that educate children about injury prevention and health

12 Topics General approach to pediatric: Emergencies Assessment Treatment 34 It is important to organize or participate in programs that educate children about injury prevention and health care. 35 Emergency Medical Services For Children Federally funded program aimed at improving the health of pediatric patients who suffer from life threatening illnesses and injuries 36 12

13 General Approach to Pediatric Emergencies 37 Treatment begins with communication and psychological support. 38 Responding to Patient Needs The child s most common reaction to an emergency is fear of: Separation Removal from a family place Being hurt Being mutilated or disfigured The unknown 39 13

14 Responding to Parents or Caregivers Communication! One paramedic speaks with the adults. Introduce yourself and appear calm. Be honest and reassuring. Keep parents informed. 40 The approach to the pediatric patient should be gentle and slow. 41 Anatomy and Physiology 42 14

15 Head Proportionally larger size Larger occipital region Fontanelles open in infancy Face is smaller in comparison to size of head Paramedic implications 43 Airway Narrower at all levels Infants are obligate nasal breathers Jaw is posteriorly smaller in young children Larynx is higher (C3 C4) and more anterior Cricoid ring is the narrowest part of the airway in young children Tracheal cartilage is softer Trachea is smaller in both length and diameter 44 Airway Epiglottis Omega shaped in infants Extends at a 45degree angle into airway Epiglottic folds have softer cartilage; more floppy, especially in children Paramedic implications 45 15

16 Chest and Lungs Ribs are positioned horizontally Ribs are more pliable and offer less protection to organs Chest muscles are immature and fatigue easily Lung tissue is more fragile Mediastinum is more mobile Thin chest wall allows for easily transmitted breath sounds Paramedic implications 46 Abdomen Immature abdominal muscles offer less protection Abdominal organs are closer together Liver and spleen are proportionally larger and more vascular Paramedic implications 47 Extremities Bones are softer and more porous until adolescence Injuries to growth plate may disrupt bone growth Site for IO access Paramedic implications 48 16

17 Skin and Body Surface Area (BSA) Skin is thinner and more elastic Thermal exposure results in deeper burn Less subcutaneous fat Larger surface area to body mass Paramedic implications 49 Respiratory System Tidal volume is proportionally smaller to that of adolescents and adults Metabolic oxygen requirements of infants and children are about double those of adolescents and adults Children have proportionally smaller functional residual capacity, and therefore proportionally smaller oxygen reserves Paramedic implications 50 Cardiovascular System Cardiac output is rate dependent in infants and small children Vigorous but limited cardiovascular reserve Bradycardia is a response to hypoxia Children can maintain blood pressure longer than adults Circulating blood volume is proportionally larger than adults Absolute blood volume is smaller than adults Paramedic implications 51 17

18 Nervous System Develops throughout childhood Developing neural tissue is more fragile Brain and spinal cord are less well protected by skull and spinal column Open fontanelles in early months Paramedic implications 52 Metabolic Differences Infants and children have limited glycogen and glucose stores Blood glucose can drop very low in response to stressors Significant volume loss can result from vomiting and diarrhea Children are prone to hypothermia due to increased body surface area Newborns and neonates are unable to shiver to maintain body temperature Paramedic implications 53 General Approach to Pediatric Assessment 54 18

19 Basic Considerations Much of the initial patient assessment can be done during visual examination of the scene. Involve the caregiver or parent as much as possible. Allow to stay with child during treatment and transport. 55 Scene Size Up Conduct a quick scene size up. Take BSI precautions. Look for clues to mechanism of injury or nature of illness. Allow child time to adjust to you before approaching. Speak softly, simply, at eye level. 56 General impression General impression of environment General impression of parent/guardian and child interaction General impression of the patient/pediatric assessment triangle A structure for assessing the pediatric patient Focuses on the most valuable information for pediatric patients Used to ascertain if any life threatening condition exists 57 19

20 Pediatric assessment triangle. 58 Triage Decisions Initial triage decisions Urgent proceed with rapid ABC assessment, treatment, and transport Non urgent proceed with focused history, detailed physical examination after initial assessment 59 Vital Functions Determine level of consciousness AVPU scale Alert Responds to verbal stimuli Responds to painful stimuli Unresponsive Modified Glasgow Coma Scale Signs of inadequate oxygenation 60 20

Glasgow Coma Scale Scoring Determines Severity GCS 13 15 = Mild GCS 9 12 = Moderate GCS < 8 = Severe 61 62 Airway and Breathing Airway determine patency Breathing should proceed with adequate chest

21 Glasgow Coma Scale Scoring Determines Severity GCS = Mild GCS 9 12 = Moderate GCS < 8 = Severe Airway and Breathing Airway determine patency Breathing should proceed with adequate chest rise and fall Signs of respiratory distress Tachypnea Use of accessory muscles Nasal flaring Grunting Bradypnea Irregular breathing pattern Head bobbing Absent breath sounds Abnormal breath sounds 63 21

22 Circulation Pulse Central Peripheral Quality of pulse Blood pressure Measuring BP is not necessary in children less than 3 years of age Skin color Active hemorrhage 64 Normal Vital Signs Group Breaths/min Beats/min Expected Mean for Blood Pressure (Systolic/diastolic) Newborn mm Hg/50-68 mm Hg Infant mm Hg/56-70 mm Hg Toddler mm Hg/50-70 mm Hg Preschool mm Hg/64-70 mm Hg School age (12-20)-30 (60-80) mm Hg/64-80 mm Hg Adolescent mm Hg/70-82 mm Hg 65 Transition Phase Used to allow the infant or child to become familiar with you and your equipment Use depends on the seriousness of the patient's condition For the conscious, non acutely ill child For the unconscious, acutely ill child do not perform the transition phase but proceed directly to treatment and transport 66 22

23 Focused History Approach For infant, toddler, and preschool age patient, obtain from parent/guardian For school age and adolescent patient, most information may be obtained from the patient For older adolescent patient question the patient in private regarding sexual activity, pregnancy, illicit drug and alcohol use 67 Focused History Content Chief complaint Nature of illness/injury How long has the patient been sick/injured Presence of fever Effects on behavior Bowel/urine habits Vomiting/diarrhea Frequency of urination Past medical history Infant or child under the care of a physician Chronic illnesses Medications Allergies 68 Detailed Physical Examination Should proceed from head to toe in older children Should proceed from toe to head in younger children (less than 2 years of age) Depending on the patient s condition, some or all of the following assessments may be appropriate: Pupils Capillary refill Hydration Pulse oximetry ECG monitoring 69 23

24 On Going Assessment Appropriate for all patients Should be continued throughout the patient care encounter Purpose is to monitor the patient for changes in: Respiratory effort Skin color and temperature Mental status Vital signs (including pulse oximetry measurements) Measurement tools should be appropriate for size of child 70 General Management of Pediatric Patients 71 Suctioning Decrease suction pressure to less than 100 mm/hg in infants. Avoid excessive suctioning time less than 15 seconds per attempt. Avoid stimulation of the vagus nerve. Check the pulse frequently

25 Pediatric size suction catheters. Top: soft suction catheter. Bottom: rigid or hard suction catheter Oxygenation Adequate oxygenation is the hallmark of pediatric patient management

Oxygenation NON REBREATHER MASK BLOW BY IF MASK NOT TOLERATED UTILIZE PARENT OR GUARDIAN IF PATIENT CONDITION ALLOWS 76 Measurement and insertion of an oropharyngeal airway in a child with the use of

26 Oxygenation NON REBREATHER MASK BLOW BY IF MASK NOT TOLERATED UTILIZE PARENT OR GUARDIAN IF PATIENT CONDITION ALLOWS 76 Measurement and insertion of an oropharyngeal airway in a child with the use of a tongue blade. 77 Ventilation Avoid excessive bag pressure and volume. Obtain chest rise and fall. Allow time for exhalation. Flow restricted, oxygen powered devices are contraindicated. Do not use BVMs with pop off valves. Apply cricoid pressure. Avoid hyperextension of the neck

27 In placing a mask on a child, it should fit on the bridge of the nose and cleft of the chin. 79 In Sellick s maneuver, pressure is placed on the cricoid cartilage, compressing the esophagus, which reduces regurgitation. 80 Advanced Airway and Ventilatory Management 81 27

28 The Pediatric Airway A straight blade is preferred for greater displacement of the tongue. The pediatric airway narrows at the cricoid cartilage. Uncuffed tubes should be used in children under 8 years of age. Intubation is likely to cause a vagal response in children. 82 Pediatric Endotracheal Tube Size Use a resuscitation tape that estimates ET tube size based on height. Estimate the correct diameter, based on the child s little finger. 83 Pediatric Tube Size Formula (Patient s age in years + 16)

Indications Need for prolonged artificial ventilation Inadequate ventilatory support with a BVM Cardiac or respiratory arrest Control of an airway in a patient without a

29 Indications Need for prolonged artificial ventilation Inadequate ventilatory support with a BVM Cardiac or respiratory arrest Control of an airway in a patient without a cough or gag reflex Providing a route for drug administration Access to the airway for suctioning 85 Placement of the laryngoscope. 86 Endotracheal Intubation in the Child 87 29

30 Hyperoxygenate the child. 88 Position the head. 89 Insert the laryngoscope and visualize the airway

31 Insert the tube and ventilate the child. 91 Confirm tube placement. 92 USE A COLORMETRIC DEVICE FOR SECONDARY CONFIRMATION AS OF JANUARY 1, 2008 CAPNOGRAPHY IS MANDATORY TO CONFIRM CORRECT PLACEMENT OF AN ENDOTRACHEAL TUBE IN ALL PATIENTS 93 31

32 Nasogastric Intubation 94 Nasogastric Intubation Indications: Inability to achieve adequate tidal volume during ventilation due to gastric distention Presence of gastric distention in an unresponsive patient 95 Oxygenate and continue to ventilate, if possible

Measure the NG tube from the tip of the nose, over the

33 Measure the NG tube from the tip of the nose, over the ear, to the tip of the xiphoid process. 97 Lubricate the end of the tube. Then pass it gently downward along the nasal floor to the stomach. 98 Auscultate over the epigastrium to confirm correct placement. Listen for bubbling while injecting cc of air into the tube

34 Use suction to aspirate stomach contents. 100 Secure the tube in place. 101 Nasogastric tube

35 SUMMARY QUESTIONS

Pediatric Patients. BCFPD Paramedic Education Program. EMS Education Paramedic Level

Pediatric Patients. BCFPD Paramedic Education Program. EMS Education Paramedic Level Pediatric Patients BCFPD Program Basic Considerations Much of the initial patient assessment can be done during visual examination of the scene. Involve the caregiver or parent as much as possible. Allow