BLS-2013-Pediatric Emergencies Print Version

Transcription

1 BLS-2013-Pediatric Emergencies BLS-2013-Pediatric Emergencies Print Version 2013 Seattle-King County Emergency Medical Services Division Public Health - Seattle/King County 401 5th Avenue, Suite 1200 Seattle, WA (206) Updated December 21, Seattle / King County EMS

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3 Navigation Pediatric Emergencies... 5 Introduction... 5 Terminology... 6 Anatomic Differences... 7 Smaller Airways... 7 Less Blood Volume... 7 Bigger Heads... 7 Vulnerable Organs... 8 Development... 8 Assessment SICK NOT SICK Patient Capacity Pediatric Triangle Breath Sounds M edical Emergencies Anaphylaxis Fever Respiratory Emergencies Seizures Meningitis SIRS Poisoning Trauma Submersion Injury Sudden Infant Death Syndrome Diabetes Burns Abuse and Neglect Injury Patterns Shock Pediatric Shock Signs of Shock Treatment Airway Management Choking Infant Choking Child Oxygen Therapy Seizures Seattle/King County EMS Page 3 of 28

4 Resources Recommended Reading Assessments Summary Practice Exam Final Exam Seattle/King County EMS Page 4 of 28

5 PEDIATRIC EMERGENCIES Introduction Children are not just "little adults" and should not be treated as such. Their bodies respond to significant injury and shock differently than adults. These differences may be subtle, but you must recognize them to provide the best possible care for an ill or injured child. You must recognize these differences if you are to provide the best possible care for an ill or injured child. Practical Skills and Course Objectives To receive credit for this course a trained skills evaluator must evaluate your ability to perform the following hands-on practical skills. Patient assessment of using the Pediatric Assessment Triangle (medical/trauma) Backboarding CPR/FBAO skills for pediatric patients Oxygen therapy and ventilation with a BVM Instructor Downloads Courses - Skills Checklists BLS-2013 Pediatric Emergencies is an EMT continuing education and recertification course. After completing this course you will be able to: 1. Identify the anatomic differences between adult and children. 2. Identify developmental considerations for pediatric age groups. 3. Identify the 3 elements of the Pediatric Assessment Triangle. 4. Identify the 7 aspects of the appearance element of the Pediatric Assessment Triangle. 5. Discriminate between the appearance of SICK and NOT SICK children. 6. Identify 4 indicators of increased work of breathing. 7. Distinguish between respiratory distress and respiratory failure. 8. Identify the 4 aspects of the circulation to the skin element of the Pediatric Assessment Triangle. 9. Identify the signs of shock in a pediatric patient and identify how shock is different in children compared (early vs. late). 10. Identify appropriate emergency care for a pediatric patient with a respiratory, medical or traumatic emergency (including airway management). Key Points 1. Appearance, work of breathing, and circulation to skin determines SICK/NOT SICK. 2. Understanding the PAT (Pediatric Assessment Triangle) 3. Understanding Pediatric Shock (sustained tachycardia) 4. Understanding Sick/Not Sick as it applies to the Pediatric Patient 5. Understanding TICLS (Tickles) as it applies to 'Appearance' and the PAT 6. Understanding Pediatric Respiratory Distress (tachypnea, bradypnea) 2013 Seattle/King County EMS Page 5 of 28

6 Terminology Test your knowledge of the following terms Cyanosis A condition where the skin, lips, nail beds and mucous membranes appears bluish in color due to insufficient air exchange and low levels of oxygen in the blood. Compensated shock An early stage of shock in which the body is able to compensate for inadequate tissue perfusion. It is characterized by sustained tachycardia, decreased skin perfusion and subtle changes in mental status. Decompensated shock A later stage of shock in which the body s compensatory mechanisms break down. The signs include decreased blood pressure, further tachycardia and an altered LOC with signs such as agitation, restlessness or confusion. Fontenelles - Any of the soft membranous gaps between the incompletely formed cranial bones of a fetus or an infant. Also called soft spot. Hypotension A blood pressure that is lower than the normal range. A systolic blood pressure below 70 + (2 x age in years) is considered hypotension in children. Occiput The base of the back of the head. Perfusion Circulation of blood within an organ or tissue in adequate amounts to meet cellular needs. Patient Capacity - The ability of the patient to understand and make an informed decision about their health care. Meningitis An inflammation of the meninges that covers the brain and spinal cord. Nasal flaring As a child breathes out, the nostrils widen. Seen in infants and toddlers an indicator of increased work of breathing. NOT SICK An assessment category for a pediatric patient who you believe is physiologically stable based on observation of appearance, work of breathing and circulation to the skin. Other terms for NOT SICK include stable, non-critical and nonurgent. Postictal An altered state of consciousness that occurs after a seizure. A postictal state usually lasts between 5 and 30 minutes and is characterized by confusion, drowsiness and nausea. Respiratory distress Occurs when a child is able to maintain adequate oxygenation of the blood but only by increasing work of breathing. Respiratory failure Occurs when a child cannot compensate for inadequate oxygenation and circulatory and respiratory systems begin to collapse. Retractions A visible sinking-in of the soft tissues in the chest wall or neck muscles seen during respiratory distress. SICK An assessment category for a pediatric patient who you believe to be physiologically unstable based on observation of appearance, work of breathing and circulation to the skin. Other terms for SICK include unstable, critical and urgent. SIRS Systemic Inflammatory Response Syndrome 2013 Seattle/King County EMS Page 6 of 28

7 Sniffing position A position of the head assumed by a patient who is attempting to maximally open his or her airway when an obstruction is present. Submersion Injury The process of experiencing respiratory impairment as a result of immersion in liquid, which may result in death. Sustained tachycardia A persistently fast heart rate of or greater depending on the clinical setting. Vasoconstriction Constriction of a blood vessel. Often leads to pale, dry skin. ANATOMIC DIFFERENCES A child s anatomy differs in four significant ways from an adult s. They differences are: Smaller airways Less blood volume Bigger heads Vulnerable internal organs SMALLER AIRWAYS There are several reasons why a child s airway is vulnerable to airway compromise. The reasons include: Large tongue in relation to a small oropharynx Diameter of the trachea is smaller Trachea is not rigid and will collapse easily Back of the head is rounder and requires careful positioning to keep airway open There are several reasons why a child s airway is more vulnerable to obstruction than an adult s. First, the tongue takes up a proportionately large amount of space in the mouth. This makes it easier for the tongue to block the airway. Next, the diameter of the trachea is smaller than in an adult. In addition, trachea is not as rigid and will collapse easily if the neck is flexed or hyperextended. Finally, the back of the head is rounder and requires more careful positioning to prevent closing of a child s smaller trachea. LESS BLOOD VOLUME Infants and children have a relatively smaller blood volume when compared to that of an adult. A good rule of thumb is that there is approximately 70 cc of blood for every 1kg (2 lbs) of body weight. This means a 20 pound child has about 700 cc of blood approximately the volume of a medium sized soda. Bigger Heads A child s head size is proportionally larger than an adult s. Infants and small children have a prominent occiput and a relatively straight cervical spine. When lying supine a child s head flexes forward which can collapse the airway Seattle/King County EMS Page 7 of 28

8 Another problem with a large head is that children do not have well developed cervical support. The neck and associated support structures aren t well developed in relation to their big heads. Also, a big head can make spinal immobilization and airway management more difficult. A final problem with a big head is that infants and small children are prone to falling because they are top heavy. View more information on head trauma emedicine (external Web site) VULNERABLE ORGANS The internal organs of a child are not well protected. The soft bones and cartilage and lack of fat in the rib cage make internal organs susceptible to significant internal injuries. Injury can be seen with very little mechanism and without obvious signs of injury. DEVELOPMENT A child goes through distinct development stages from newborn to adolescent. You should be familiar with a variety of considerations at each development stage. Text for interaction Infant: 1 to 12 months Active extremity movement Tracks object with eyes Obstruction of the nose may cause respiratory distress Separation anxiety later in this period Provide sensory comfort such as a warm stethoscope Toddler: 1 to 3 years Approach slowly & limit physical contact Many have stranger anxiety Sit down or squat next to and use a quiet voice Not good at describing or localizing pain Use play and distraction objects Have caregiver hold Get history from parent Preschool Age: 3 to 5 years Explain procedures in simple terms Use games or distractions Set limits on behaviors Praise good behavior Offer a stuffed animal or toy to hold School Age: 6 to 12 years Speak directly to the child Be careful not to offer too much information Explain procedures immediately before carrying them out Don t negotiate unless the child really has a choice Adolescent: 12 to 15 years Explain what you are doing and why 2013 Seattle/King County EMS Page 8 of 28

9 Show respect Get history from patient if possible Respect independence; address directly Allow parents to be involved in examination if patient wishes Consider asking questions about sexual activity, drug/alcohol use privately 2013 Seattle/King County EMS Page 9 of 28

10 ASSESSMENT SICK A SICK child is one who you believe is physiologically unstable based on observable clinical indicators. This means you see a significant abnormality in appearance, work of breathing or circulation to the skin. A SICK patient requires immediate and aggressive BLS and ALS care. You must recognize the SICK child within the first minute or so of contact. Much of the information you need to make a decision can be obtained without touching the patient. Pediatric SICK/NOT SICK The SICK/NOT SICK method of assessment for a pediatric patient is different from an adult. The adult clinical picture includes: Chief complaint, MOI or NOI Respirations Pulse Mentation Skin signs Body position or obvious trauma The pediatric clinical picture is based on the Pediatric Triad: Appearance Work of breathing Circulation to the skin We recommend completion of the BLS-2013 SICK/NOT SICK course before undertaking this course. NOT SICK The NOT SICK child is one who you believe is physiologically stable. He or she has no significant abnormality in appearance, work of breathing or circulation to the skin. They do not need immediate ALS intervention--but may require BLS care or an ALS evaluation. Don t Wait to Decide The most common mistake EMTs make when deciding SICK or NOT SICK is waiting for paramedics to arrive to make the decision and begin aggressive care. Another mistake is failing to recognize and respond to the decompensating patient or the patient who has changed from NOT SICK to SICK. Patient Capacity Patient capacity is the ability of the patient to understand and make an informed decision about their health care. The patient capacity can change based on the circumstances of the situation. The challenge for emergency responders is providing treatment for a minor when they refuse care and the parents are not present. Treatment of minors falls under implied consent when care is needed Seattle/King County EMS Page 10 of 28

11 Agencies are encouraged to develop protocols that are in alignment with local laws for dealing with minor patients. Pediatric Triangle There are three things that you need to assess in a pediatric patient in order to determine SICK or NOT SICK. They include appearance, work of breathing and circulation to the skin. You can make a SICK/NOT SICK decision based on these three things alone in many cases without touching the patient. These three clinical indicators reflect the overall status of a child s cardiovascular, respiratory and neurologic systems. Together they are called the Pediatric Assessment Triangle. Note: Most children with mild to moderate illness or injury, even when they are progressing to more severe degrees of distress, are alert and have a normal neurologic exam, although they have an abnormal appearance. Appearance is a much more sensitive indicator of degree of distress than the formal neurologic exam, or the AVPU (Alert, responsive to Verbal, Painful stimuli, or Unresponsive) neurologic assessment in the pediatric primary survey. Appearance Evaluating a child s appearance provides critical information about oxygenation, brain perfusion and central nervous system function that will allow you to make a SICK/NOT SICK decision. You can collect all the information you need about appearance through observation. Using the TICLS, pronounced tickles, pneumonic will allow you to easily assess the key characteristics of appearance: Tone, Interactiveness, Consolability, Look/Gaze, and Speech/Cry. TICLS Questions to Answer Tone Is the child moving and resisting vigorously and spontaneously? Is there good muscle tone? Interactiveness How responsive and interactive is the child with a stranger or other changes in environment? Is the child restless, agitated, or listless? (Children with mild to moderate illness or injury generally remain alert.) How readily does person, object, or sound draw child s interest or attention? Will the child play with toy or new object? Consolability Can the child be comforted by the caregiver or responder? Look /Gaze Does the child maintain eye contact with objects or people? Will the child fix her gaze on a face? Speech/Cry Is the speech / cry strong and spontaneous? 2013 Seattle/King County EMS Page 11 of 28

12 Weak and muffled? Hoarse? Color Is the child pink? Or is the child pale, dusky, blue or mottled? Does the skin coloring or the trunk differ from the extremities? Work of Breathing Work of breathing is the second side of the Pediatric Assessment Triangle. An abnormal position, abnormal breath sounds, retractions and nasal flaring are signs of increased work of breathing. Watch the child from a distance and observe for four indicators of increased work of breathing: abnormal position (e.g., tripod position), abnormal breath sounds, retractions and nasal flaring. Abnormal position, abnormal breath sounds, retractions or nasal flaring = high flow oxygen and ALS intervention! Abnormal Positions A child in the sniffing position is attempting to maximally open his or her airway when an upper airway obstruction is present, for example, in cases of epiglottitis. The patient in the tripod position is attempting to recruit all of the breathing muscles to move air in and out of the lungs. In addition to the sniffing and tripod positions, look for signs of extra effort to move air in or out such as head bobbing where the head draws back during inspiration and falls forward during expiration. Nasal flaring is seen in infants and toddlers as an indicator of increased work of breathing. As the child breathes out, the nostrils widen. Retractions Observe the chest and abdomen for movement. Retractions in the chest wall or neck muscles mean that the child is using greater muscle effort in order to move air. Retractions are a visible sinking-in of the soft tissues. Abnormal Breath Sounds Listen for audible sounds such as rales, rhonchi, stridor or wheezing. Rales sound like crackles or bubbles. They are created by air bubbles moving through fluids in the airways. They are usually associated with pulmonary edema or pneumonia. Stridor is a harsh, high-pitched sound heard without a stethoscope on inspiration. It is caused by spasms of the larynx and swelling that contract the vocal cords and narrow the airway. Stridor is common in croup which sounds like the bark of a seal. It can also indicate a life-threatening condition such as epiglottitis or foreign body obstruction. Circulation to Skin 2013 Seattle/King County EMS Page 12 of 28

13 Skin signs reflect the overall status of the circulatory system. Pink tones point to NOT SICK. Pale, bluish or mottled skin point to SICK. Skin signs include: Color Temperature Capillary refill time Pulse quality A child in shock will maintain blood pressure longer than an adult. A child can lose up to one-third of blood volume before there are significant changes in blood pressure. Skin Color and Temperature Normal skin and mucus membrane color should be pink. When the body shuts down blood flow to the skin, in order to maximize flow to the vital organs in conditions such as shock, skin color will change. Abnormal skin colors (mottled - non-uniform color, pale, grayish and blue) indicate inadequate tissue perfusion or inadequate oxygenation. Cyanosis, a late sign, indicates impending respiratory failure. Assess skin temperature by feeling the skin of the child s calf or forearm. Coolness is an early sign of shock. Capillary Refill Time Capillary refill is an indicator of adequate perfusion. Check capillary refill time (CRT) by blanching a distal extremity such as a hand, nail bed or foot and then releasing it. Normal CRT is two seconds or less. A CRT greater than two seconds can indicate that blood is being shunted to the vital organs due to shock or other causes. Pulse Quality Check the pulse at the wrist or elbow. An absent, weak, or strong pulse at either of these sites may indicate a problem with circulation. Carry a reference card with you to determine if vital signs are within normal range for specific age groups because they are difficult to interpret since pediatric anatomy and physiology vary greatly. Heart rates range from 170 to 60 BPM (infant to 12 years) Minimum blood pressure ranges from 60 to 94 mm HG (infant to 12 years) Breath Sounds Listen to breath sounds Auscultation Assistant (external Web site) Listen to stridor R.A.L.E. Repository (external link) Wheezes are musical high-pitched noises and are described as a whistling sound. They are caused by narrowing of the airways due to bronchospasm, edema or foreign matter. You can hear wheezes in patients with asthma, COPD and anaphylaxis. Listen to wheezes R.A.L.E. Repository (external Web site) View more information on breath sounds Wikipedia (external Web site) Seattle/King County EMS Page 13 of 28

14 Medical Emergencies Anaphylaxis Anaphylaxis is a growing pediatric clinical emergency that is difficult to diagnose because until recently, a consensus definition was lacking. Intramuscular epinephrine is the acknowledged first-line therapy for anaphylaxis, both in the hospital and in the community, and should be given as soon as the condition is recognized. Additional therapies such as volume support, nebulized bronchodilators, antihistamines or corticosteroids are supplementary to epinephrine. There are no absolute contraindications to administering adrenaline in children. Allergy assessment is mandatory in all children with a history of anaphylaxis because it is essential to identify and avoid the allergen to prevent its recurrence. A tailored anaphylaxis management plan is needed, based on an individual risk assessment, which is influenced by the child's previous allergic reactions, other medical conditions and social circumstances. Collaborative partnerships should be established, involving school staff, healthcare professionals and patients' organizations. Absolute indications for prescribing self-injectable epinephrine are: Prior cardiorespiratory reactions Exercise-induced anaphylaxis Idiopathic anaphylaxis and persistent asthma with food allergy Relative indications include: Peanut or tree nut allergy Reactions to small quantities of a given food Food allergy in teenagers Living far away from a medical facility Children who have received a dose of epinephrine should be transported to a medical facility for further evaluation and observation. Fever Fever in the pediatric patient is a common presentation to the emergency department. Most often these fevers are due to infections. The evaluation should include: History Duration and onset Maximum temperature and the method Is anyone else sick Recent immunizations Pediatric Triangle Food and consumption Urination and bowel movements Medications Prenatal and Birth History Physical Exam Rash. Bulging Fontenelle Sunken Fontenelle Abdominal Masses 2013 Seattle/King County EMS Page 14 of 28

15 Fever in very young patients is very concerning. Generally, if emergency services were contact for a fever, the patient deserves a follow up examination. In patients <28 days and a fever >= 38C or 100.4F the patient will generally be admitted to the hospital. Do not allow the parents to give the child any Tylenol, Aspirin, or other fever reducer. In patients 28 days to 3 months and a fever >=38C or the patient will be examined and blood, urine, and spinal fluid test will be preformed. Possible admission to the hospital, if not then a 24-hour re-evaluation. Do not allow the parents to give the child any Tylenol, Aspirin, or other fever reducer. In patient 91 days to 3 years and a fever >=39C or the patient will be examined and blood and urine tests will generally be preformed. If discharged the patient will receive close follow up. Respiratory Emergencies A fever is always a higher concern in a patient with an underlying medical condition. Acute obstructive respiratory emergencies are a common cause of EMS calls for children. Their severity ranges from mild to life threatening. These include croup, asthma, bronchiolitis, foreign body airway obstruction and inhalation injuries. Infants and young children pose a particular challenge because decreased activity and an altered level of consciousness may be the only noticeable signs of an impending life-threatening emergency. Evaluating appearance, work of breathing and circulation to the skin will tell you whether or not a child is SICK. An altered LOC, respiratory distress, respiratory failure and poor color all warrant aggressive treatment and rapid transport. Tachypnea is an early sign of a respiratory problem in children and is an indication that they are experiencing and increased work of breathing. Respiratory Distress and Failure Respiratory distress is a state where a child can maintain adequate oxygenation of the blood only by increasing work of breathing. Signs of respiratory distress include: extra effort to move air, tachypnia and tachycardia. The varying degrees of respiratory distress are mild, moderate and severe. Respiratory failure occurs when a child cannot compensate for inadequate oxygenation and the circulatory and respiratory systems begin to collapse. Signs of respiratory failure include a poor appearance, significant work of breathing, poor tidal volume or apnea. When you see signs of respiratory distress or respiratory failure, immediately choose the SICK category and provide aggressive care including an ALS response. Seizures Seizures are a result of abnormal electrical discharges of neurons in the brain resulting in the alteration of behavior or function. Physical signs can include shaking, twitching, staring or a loss of consciousness. Many seizure patients experience a postictal period of fatigue or unresponsiveness Seattle/King County EMS Page 15 of 28

16 Complications can include brain damage due to hypoxia or even cardiac arrest. Seizures can be caused by: Infection Head trauma Epilepsy Electrolyte imbalance Hypoglycemia Toxic ingestion or exposure Birth injury A child s medical history can help identify a cause. It is not uncommon for patients with seizures to be prescribed a medicine called Diastat. This is a gelled form of Valium that is delivered rectally. In these cases you may find that the parents have administered it prior to your arrival. You may also find that this medication is stored at school for the patient. The school nurse may or may not have administered it. Follow local protocols for dispatching ALS response to administer medication. Febrile Seizure Most seizures in children 6 months to 6 years of age are due to fever; however, a seizure can indicate a serious problem such as meningitis. A febrile seizure is characterized by a generalized tonic-clonic seizure less than 15 minutes in length with a short postictal period. You will often find these patients alert and oriented when you arrive. If the patient is under 6 months or over 6 years of age this may not be a febrile seizure. A short seizure is usually not in itself harmful, but a long seizure or multiple seizures without a return to consciousness is a medical emergency. View more information on febrile seizures Wikipedia (external Web site) Meningitis Meningitis is an inflammation of the meninges that covers the brain and spinal cord. If not treated, it can cause permanent brain damage and death. The signs and symptoms vary according to age, but an altered level of consciousness and fever are common in all patients. Signs and symptoms can include: Altered LOC Fever Seizures Stiff neck Pain on moving of the head Small, red spots or purplish rash Irritability in infants Bulging fontenelles SIRS Systemic Inflammatory Response Syndrome (SIRS) is a systemic response to a condition, i.e., trauma or infection, that provokes and inflammatory reaction. In adults, SIRS is defined has having two or more of the following conditions present: Fever greater than38 C (100.4 F) or less than 36 C (96.8 F). Patient may be hot or cold to touch. Heart rate greater than 90 beats per minute Respiratory rate greater than 20 breaths per minute respiratory failure requiring intubation Seattle/King County EMS Page 16 of 28

17 Children, in addition to an abnormal temperature, will have one or more of the following: Heart rate above normal for their age (greater than 2 standard deviations above normal for their age). Hyperthermia or hypothermia. Increased respiratory rate (greater than 2 standard deviations above normal for their age). Sepsis is the presence of a known or suspected infection plus SIRS. For additional information on SEPSIS, please refer to CBT940-EMT12 Sepsis. Add link. ( Poisoning Poisoning occurs through ingestion, inhalation, injection or absorption. Ingestion is the most common form of poisoning. Poisoning by mouth can produce immediate effects such as burns from a cleaning solution or the effects may be delayed for several hours, for example, with some plant ingestions. Common sources of poisons include: Alcohol Pills Cleaning products Houseplants Vitamins TRAUMA Trauma kills more children and young adults than all other causes combined. It includes submersion injury, burns, abuse, neglect and trauma from firearm injuries, motor vehicle passenger injuries, pedestrian injuries and bicycle injuries. Your ability to rapidly assess and begin treatment can have an enormous impact on survival and recovery for an injured child. Use appearance, work of breathing and circulation to the skin as the basis for your assessment. Also, mechanism of injury is an important factor. Submersion Injury Submersion Injury, also referred to as drowning, is a leading cause of injury death of infants and younger children. Children are attracted to water and easily become submerged in swimming pools, lakes, bathtubs and buckets among other hazards. A brief submersion in water robs the lungs of oxygen causing respiratory arrest, permanent brain damage, cardiac arrest and eventually death. Hypothermia can occur in cold water settings, but is very rare. The most important factors in submersion injuries are the duration and severity of hypoxia. View more information on near drowning emedicine (external Web site) View more information on submersion injury emedicine (external Web site) View more information on Pediatric Submersion Injuries: New Definitions Seattle/King County EMS Page 17 of 28

18 Sudden Infant Death Syndrome Sudden infant death syndrome is the sudden, unexplained death of children under 1 year of age, usually occurring while the child is sleeping. There is currently no definitive cause for this syndrome, which occurs in children who are typically healthy and otherwise receiving proper care. While the rate of SIDS has decreased in the last decade, thousands of babies, continue to die from SIDS in the United States each year. As the emergency provider, a SIDS patient will be presenting as a respiratory or cardiac arrest and should be treated appropriately by providing basic and advanced life support. Part of your role will also be to provide emotional support to the parents who will be dealing with intense feelings of guilt and remorse. Assure them you are doing everything you can for the child, and be prepared to call in additional family support or refer them to additional resources. It is extremely important that EMT s involve law enforcement in all cases of suspected SIDS. Only after law enforcement and medical examiner investigation can a determination be made as to whether or not a death can be classified as SIDS. Other causes of death must be ruled out, such as asphyxia, congenital defects, neglect or abuse. Diabetes Diabetic emergencies in pediatric patients are treated the same as adults. Use the pediatric assessment triangle to determine patient condition, and check glucose levels on any patient with altered level of consciousness. Most recent information from the Centers for Disease Control indicates the occurrence of diabetes in children and adolescents is increasing. Each year 13, 000 young people are diagnosed with type 1 diabetes and the incidence of Type 2 diabetes also appears to be increasing in the pediatric population. Type 1 Glucose is the basic fuel for the cells in the body. Insulin allows glucose from the blood to enter the cells. In type 1 diabetes, the pancreas does not produce insulin so glucose cannot enter the cells. Since the glucose does not enter the cells, it builds up to a dangerous level in the blood. Type 1 diabetics receive insulin through an injection or pump. Type 2 In type 2 diabetes, either the body does not produce enough insulin or the cells become resistant to the insulin that is produced. While type 2 diabetes is the most common form of diabetes, accounting for nearly 90 percent of all cases, type 1 remains most prevalent in children. Type 2 diabetes can be controlled by diet and exercise, oral medication or injected insulin. The oral medications prescribed for this type of diabetes stimulate the pancreas to produce more insulin. Some type 2 diabetics must use injected insulin to help control their glucose level. Patient Care - Hypoglycemia The most common diabetic emergency is hypoglycemia. A patient with hypoglycemia needs sugar immediately and often responds quickly after eating or a drinking sugary food or liquid. The key treatment principles for a hypoglycemic episode in the pediatric patient include: Request medic unit, if indicated Maintain airway Administer oxygen Use pediatric assessment triangle to determine patient condition Use glucometry per local protocol to determine glucose level If able to swallow, give oral glucose Monitor vital signs and LOC Repeat glucometry 5-10 minutes after providing oral glucose 2013 Seattle/King County EMS Page 18 of 28

19 Patient Care - Hyperglycemia Your primary care for the hyperglycemic diabetic is to maintain the airway and provide rapid transport. Burns Burn injuries result from thermal, electrical or chemical sources. Scald burns and contact burns are common. Be aware of suspicious burn patterns in children. Assessment and management of burns are the same as for an adult patient. Be certain to check for possible involvement of the airway. Make a quick estimate of the burned body surface area. Administer high flow oxygen to all patients with burns that are not localized scald or contact burns. Cover the burned areas with dressings according to your local protocol. A common problem related to burns is infection. Take care to avoid further contamination of burn injuries by wearing gloves and carefully dressing the wounds. Abuse and Neglect The term child abuse includes physical injury, emotional injury, negligent treatment, maltreatment and sexual exploitation of a child. In many cases, it is done by someone related to the child 90% of the time the abuser is the person who provides primary care to the child. Consider family members and other adults who know the child. Child abuse is seen in all socioeconomic classes. There are many general signs of abuse. Some are harder to detect than others. Take the time to observe the child s behavior and the environment where the injury occurred, as well as his or her physical injuries. The general indicators of abuse include: Passive and withdrawn behavior Bruises on soft parts of body Burns in patterns or unusual locations Facial or head injuries Multiple injuries at various stages of healing Poor hygiene (physical, dental) or poor nutrition Drug/alcohol abuse In all cases of suspicious nature, follow local protocols for mandatory reporting for care providers and involve law enforcement. Child Abuse HelpGuide (external Web site) Behavior of the Parents How a child s parents act may give you a clue about when to suspect abuse or neglect. Be suspicious when parents do not want their child to go to the hospital or to a hospital where the child has been seen before. Also, you should be wary of incompatible or changing explanations of the child s injury or a history that does not account for injury. Ask the parent to describe in detail how the injury occurred. Watch the parent s reaction to your questions. Observe the environment or mechanism of injury where the child was hurt. The parents story can later be compared to that told to hospital staff. Suspicious situations include: 2013 Seattle/King County EMS Page 19 of 28

20 Delay in seeking medical treatment Suggestion by the child that someone hurt them intentionally Anger, hostility or lack of appropriate concern by a parent Immaturity, quick temper and rigid behavioral standards demonstrated by a parent Never voice your suspicions to the parents or accuse them of anything. If the parents do not want the child transported, insist that the child s injury cannot be evaluated in the field. Remember, you cannot legally take a child against a parent s wishes. Injury Patterns Injury patterns can suggest if a child s injuries were accidental. Accidental Injury Patterns Injury usually on bony prominence One injury or set of injuries usually occurs with resolution rather than repeatedly the same injury Lacerations more common One body plane usually affected Intentional Injury Patterns Injury usually on soft parts of body Pattern injury (finger, bite marks, cord and strap marks) Injuries at various stages of healing Lacerations uncommon Injuries on multiple body planes Signs of Physical Abuse Suspicious injuries include those scattered on several areas of the body, bruises or burns in patterns that suggest intentional injury, fractures in children under age two and injuries at various stages of healing. Look for three types of suspicious injuries: Suspicious Bruises Buttocks or back Genital or thigh Swollen ear due to slapping Bruises resembling finger or hand marks Human bite marks Bruises over soft tissue areas Suspicious Burns* Palms, soles of feet or belly Genital or thigh Scalding of hands, feet or buttocks (often involves both extremities or buttocks) *Burn pattern is a more important indicator of intentional injury than location. Suspicious Welts 2013 Seattle/King County EMS Page 20 of 28

21 Strap marks Bizarre shaped marks (e.g., shoe) Choke marks, bite marks Welts caused by a rope or cord Swelling around the cheek or eye SHOCK Pediatric Shock Shock is circulatory failure that results in the inadequate delivery of blood to the body s tissues. This lack of blood flow inhibits delivery of oxygen and removal of waste products from the body s organs. A hypotensive pediatric patient is one who is approaching cardiac arrest and must be treated aggressively. Never wait for a drop in blood pressure to begin treating for shock. Hypotension in a child is a late sign of shock. Signs of Shock In adults, the progression of shock usually includes a steady loss of blood pressure with an increase in heart rate. By contrast, children maintain blood pressure by increasing their heart rate and vasoconstriction--even with a significant loss of blood volume. This means that blood pressure does not drop until much later in the progression of shock. A child can lose up to one third of blood volume before a significant drop in blood pressure occurs. Use appearance and circulation to the skin to assess for shock. Text for interaction Early Signs of Shock sustained tachycardia ** delayed capillary refill > 2 seconds tachypnea anxiousness, combativeness, agitation peripheral constriction, cold clammy extremities ** May be the only suggestive finding. Late Signs of Shock weak or absent peripheral pulses decreased LOC unconsciousness hypotension (a very late and ominous sign) TREATMENT Airway Management 2013 Seattle/King County EMS Page 21 of 28

22 A leading cause of preventable death in children is airway obstruction. Airway management requires you to position the child to keep the airway open. You must protect the airway from obstruction. You may need to position the head in a neutral position with a towel under the shoulders. Take care to not flex or extend the head, which can easily collapse the trachea. Use the head tilt-chin lift maneuver when there is no trauma involved. Use the jaw-thrust maneuver in cases where trauma was involved. Be prepared to suction the airway to remove foreign objects or fluids. Choking Infant Obstructions from a foreign body range from mild to severe. When an airway obstruction is mild, the infant should be able to cough and make sounds. Do not interfere with an infant s efforts to clear the obstruction. Responsive Infant Severe Obstruction 1. Kneel or sit with the infant in your lap and bare the infant s chest. 2. Hold the infant prone with the head slightly lower than the chest. Support it with your arm. Support the head with your hand. 3. Deliver up to 5 backslaps with the heel of your hand, between the shoulder blades. 4. Place the infant face up supporting it with your arm. 5. Deliver up to 5 quick chest thrusts just below the nipple line. 6. Do steps 3 5 repeatedly until the object is expelled or the infant becomes unresponsive. View video of procedure Unresponsive Infant Severe Obstruction If the infant is unresponsive: 1. Open the airway. 2. Remove the object only if you see it. (No blind finger sweeps) 3. Begin CPR with an airway check. 4. Look for the obstruction each time you open the airway to ventilate. Mild vs. Severe A mild airway obstruction has these signs: Adequate air exchange Responsive and can cough forcefully May wheeze between coughs A severe airway obstruction has these signs: Poor or no air exchange Weak or ineffective cough No cough High-pitched noises while inhaling 2013 Seattle/King County EMS Page 22 of 28

23 No noises Unable to cry Choking Child It is important to recognize an airway obstruction quickly and distinguish it from a seizure, syncope, cardiac arrest or overdose. When an airway obstruction is mild, a victim should be able to talk, cough or make sounds. Do not intervene when an obstruction appears to be mild. Responsive Child Severe Obstruction (age 1 and older) If the obstruction is severe and the child is responsive, perform abdominal thrusts. Unresponsive Child Severe Obstruction If the obstruction is severe and the child is unresponsive, perform the same procedure as for an adult: 1. Open the airway. 2. Remove the object if you see it (No blind finger sweeps). 3. Begin CPR with an airway check. 4. Look for the obstruction each time you open the airway to ventilate. Oxygen Therapy Every child with a respiratory emergency or significant trauma should receive high flow oxygen. Use the appearance, work or breathing and circulation to the skin as a guide for determining a child s oxygen needs and which delivery device to use. You may need to assist respirations. Delivery device options are: Blow-by oxygen Pediatric non-rebreathing mask (NRM) Bag-valve mask (BVM) Healthcare providers often deliver excessive ventilation during CPR, particularly when an advanced airway is in place. Excessive ventilation is detrimental because it impedes venous return and therefore decreases cardiac output, cerebral blood flow and coronary perfusion. It also increases the risk of regurgitation and aspiration. Do not over-ventilate. BMV Effectiveness Bag-valve mask ventilation can be as effective as endotracheal intubation. However, it requires mastery of the following skills: Selecting the correct mask size Selecting the correct airway adjunct and size Opening the airway Making a tight seal between the mask and face Delivering effective ventilation Assessing the effectiveness of that ventilation 2013 Seattle/King County EMS Page 23 of 28

24 Seizures Your main objective in care of a seizure patient is protection of the airway. This means assessing for adequate respirations, maintaining an open airway, preparing to suction and proper positioning. Other care may include: Protecting the actively seizing patient from trauma Administering oxygen therapy Assisting ventilations Monitoring vital signs Cooling measures ALS response Recovery Position For children who are actively seizing or in a postictal state, consider using the recovery position. This will help prevent the tongue from blocking the airway Seattle/King County EMS Page 24 of 28

25 Management of Submersion Injuries When attempting to rescue a drowning victim, you should get to the victim as quickly as possible using a safe method such as a boat, raft, surfboard or flotation device. Once you are in position to safely do so: 1. Open the airway and begin rescue breathing as soon as possible. 2. Next, begin chest compressions on a victim with no pulse. 3. If vomiting occurs, tilt the victim s head to the side and remove the vomitus using your finger or suction. Management of Submersion Injuries 1. Open the airway and begin rescue breathing as soon as possible. There is no need to drain or clear the airway of water, because most drowning victims ingest little water and it is rapidly absorbed into the central circulation. Provide rescue breathing even before the victim is pulled from the water if possible. 2. Next, begin chest compressions on a victim with no pulse. Once the victim is out of the water, if the victim is unresponsive and not breathing, pulseless and after delivery of 2 rescue breaths, attach an AED and attempt defibrillation. 3. If vomiting occurs, tilt the victim s head to the side and remove the vomitus using your finger or suction. In situations where there is a potential spinal cord injury, logroll the victim so that the head, neck, and torso are turned as a unit Seattle/King County EMS Page 25 of 28

26 Changes in Emphasis of C-Spine Care in Submersion Injury Recent evidence indicates that routine cervical spine stabilization is not necessary unless the circumstances leading to the drowning indicate trauma. Manual cervical spine stabilization and spine immobilization may impede maintenance of the airway and delay the delivery of rescue breaths. Use cervical spine stabilization under the following circumstances: History of diving Use of a water slide Signs of injury Signs of alcohol intoxication Follow your local protocols in such situations. RESOURCES Recommended Reading Chapter 31 Pediatric Emergencies Emergency Care and Transportation of the SICK and Injured 9th ed. (AAOS) Chapter 33 Pediatric Assessment and Management Emergency Care and Transportation of the SICK and Injured 9th ed. (AAOS) Websites Emergency Management of Pediatric Patients with Fever (external site - Emergency Medical Services for Children National Resource Center website US DHHS (external Web site) Pediatric Education for Prehospital Professionals website American Academy of Pediatrics (external Web site) Systemic Inflammatory Response Syndrome (external website - ASSESSMENTS Summary The anatomic differences between adult and children are smaller airways, less blood volume, bigger heads and vulnerable internal organs. The 3 elements of the Pediatric Assessment Triangle are appearance, work of breathing and circulation to the skin. The 7 aspects of the appearance element of the Pediatric Assessment Triangle are: 2013 Seattle/King County EMS Page 26 of 28

27 Alertness Distractibility Consolability Eye contact Speech/cry Spontaneous motor activity Color The SICK child is one who you believe is physiologically unstable based on observable clinical indicators. Physiologic instability means that you see a significant abnormality in either appearance, work of breathing or circulation to the skin. The NOT SICK child is one who you believe is physiologically stable and has no significant abnormality in appearance, work of breathing or circulation to the skin. The appearance of a SICK child Motionless Mottled, dusky Cyanotic Fixed gaze Limp and listless Weak cry Hoarse, stridor The appearance a NOT SICK: Restless and agitated Alert Interactive Attentive Playful, active Screaming Consolable by caregiver Maintains good eye contact Good muscle tone, pink skin color Indicators of increased work of breathing include: Abnormal position Abnormal breath sounds Retractions Nasal flaring Signs of respiratory distress include: Signs of respiratory failure include: Alert Limp Good muscle tone Motionless Agitated Diminished LOC Use of accessory muscles Absent respirations Grunting Slowed breathing Retractions Exhausted Nasal flaring Poor air exchange Pink Paleness Cyanosis 2013 Seattle/King County EMS Page 27 of 28

28 Signs of early shock include: Signs of late shock include: Sustained tachycardia Weak or absent peripheral pulses Delayed capillary refill > 2 seconds Decreased LOC unconsciousness Tachypnea Anxiousness, combativeness, agitation Hypotension (a very late and ominous sign) Peripheral constriction, cold clammy extremities For a responsive infant with a severe obstruction, give 5 backslaps, 5 chest thrusts, repeat For a responsive child with a severe obstruction, deliver abdominal thrusts Unresponsive Infant or Child with a Severe Obstruction 1. Open the airway 2. Remove the object if you see it (No blind finger sweeps) 3. Begin CPR 4. Each time you open the airway, look for the obstruction in the back of the throat 2013 Seattle/King County EMS Page 28 of 28