Chapter 42 Pediatrics Role of Paramedics in Pediatric Care Continuing Education and Training

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1 Chapter 42 Pediatrics Role of Paramedics in Pediatric Care Pediatric have become major concerns. Children are at higher risk of injury than adults. Children are more likely to be affected by the injuries they receive. Continuing Education and Training Pediatric Advanced Life Support ( ) Pediatric Trauma Life Support (PBTLS) Pediatric Life Support (APLS) Pediatric for Paramedics (PEP) It is important to organize or participate in programs that educate about injury prevention and health care. Emergency Medical Services For Children Federally-funded program aimed at improving the health of pediatric patients who suffer from life-threatening and injuries General Approach to Pediatric Emergencies Responding to Patient Needs The child s most common reaction to an emergency is fear of: Removal from a family place Being Being mutilated or disfigured The Responding to Parents or Caregivers Communication! One paramedic speaks with the. Introduce yourself and appear calm. Be and reassuring. Keep informed. Growth and Development Newborns First after birth Assessed with scoring system At 1 minute and 5 minutes after birth Neonates Birth to one. Tend to lose 10% of birth weight, but regain in 10 days. Development centers on. begins to form. Mother, occasionally father, can comfort child. 1

2 Neonates Common illnesses include, vomiting, and respiratory distress. Do not develop with minor illness. Allow patient to remain in lap. Infants Ages to months. Follow. Muscle development develops in cephalo-caudal (control begins at head and moves down) May stand or walk without assistance. Allow patient to remain in caregiver s lap. Toddlers Ages to years. Great strides in development. May stray from parents more frequently. are the only ones who can comfort them. Language development begins. Approach child. Toddlers Examine from head-to-toe. Avoid asking yes or no questions. Allow child to hold a favorite or item. Tell child if something will. Preschoolers Ages to years. Increase in fine and gross skills. Children know how to talk. Fear mutilation. Seek comfort and support from within home. Distorted sense of. Avoid baby talk Give child if possible School-Age Children Ages to years. Active and carefree age group. Growth are common. Give this age group responsibility of providing history. Respect. Adolescents Ages to. Begins with, which is very child-specific; are very body conscious. May consider themselves up. 2

3 Desire to be liked and included by peers. Are generally good historians. Relationships with parents may be. Anatomy and Physiology Airway Management In the supine position, an infant s or child s larger tips forward, causing airway obstruction Placing under the patient s back and shoulders will bring the airway to a neutral or slightly extended position Growth Plate The area just below the of the long bone in which growth in bone length occurs. During the stages of development, injuries to the growth plate by an intraosseous needle may disrupt bone growth. Respiratory System Infants and children require the metabolic oxygen as adults. They also have proportionately oxygen reserves. Cardiovascular System Infants and children their cardiac output by increasing their heart rate. They have a very capacity to increase their stroke volume. Cardiovascular A absolute volume of fluid/blood loss is needed to cause shock in infants and children. In pediatric patients, is an ominous sign of imminent cardiopulmonary arrest A child may be in despite a normal blood pressure. Suspect shock if is present. Monitor the pediatric patient carefully for the development of hypotension. Nervous System Neural tissue is more than in adults. The skull and spinal column offer less protection of the brain and spinal cord. Metabolic Differences Infants and children have a limited store of glycogen and. Pediatric patients are prone to because of their greater BSA-to-weight ratio. Significant volume loss can result from vomiting and. Newborns and neonates lack the ability to. General Approach to Pediatric Assessment 3

4 Basic Considerations Much of the initial patient assessment can be done during examination of the scene. Involve the or parent as much as possible. Allow to stay with child during treatment and. Scene Size-Up Conduct a quick scene size-up. Take BSI precautions. Look for to mechanism of injury or nature of illness. Allow child time to to you before approaching. Speak softly, simply, at level. Signs of Respiratory Distress AMS Flared Pale or bluish lips or mouth Stridor, grunting Breathing rate > 60/min of muscles Wheezing, increased work of breathing, or struggling to breathe Poor peripheral perfusion Decreased muscle tone Use of muscles Signs of Respiratory Distress Normal Pulse Rates Newborn: - Infant 0-5 months: Infant 6-12 months: Toddler (1 to 3): - Preschooler (3-5): School age(6-10): Early adolescence (11-14): - Respiratory Rates Newborn: - Infant 0-5 months: Infant 6-12 months: Toddler (1 to 3): - Preschooler (3-5): School age(6-10): Early adolescence (11-14): - Average Blood Pressures Systolic Average = Approximately X Diastolic Average = 2/3 4

5 Blood Pressure Ranges Preschooler (3-5): Systolic: -, average of 98 Diastolic: average of 65 School age(6-10): Systolic: -, average of 105 Diastolic: average of 69 Early adolescence (11-14): Systolic: -, average of 114 Diastolic: average of 76 Anticipating Cardiopulmonary Arrest Respiratory rate greater than Heart rate greater than 180 or less than 80 (under 5 years) Heart rate greater than 180 or less than (over 5 years) Respiratory distress Trauma Burns Altered level of consciousness Seizures Fever with Transport Priority Urgent: perform trauma assessment on scene and remainder of assessment en route Non-urgent: complete focused history and physical exam at, and then transport Transitional Phase Allows patient to become familiar with you and your Depends on of patient s condition Intended for the ill patient History and Physical Exam History Nature of illness/injury Length of time ill or injured Presence of Effects of illness/injury on behavior Bowel/urine habits Presence of /diarrhea Frequency of Focused or Head-to-Toe Exam Capillary refill Pulse oximetry 5

6 sounds Signs of Increased Respiratory Effort : visible sinking of the skin and soft tissues of the chest around and below the ribs and above the collarbone Nasal flaring: widening of the nostrils Head bobbing: head lifts and tilts back as the child and then moves forward as the child exhales Signs of Increased Respiratory Effort : sound when infant attempts to keep the alveoli open by building back pressure during exhalation : most commonly upon expiration : course, abnormal bubbling sound heard in the airway. May indicate an open chest wound : abnormal, musical, high-pitched sound, most commonly heard on inspiration Glasgow Coma Scale Scoring Determines Severity GCS = GCS 9 12 = Moderate GCS < 8 = Glasgow Coma Scale Modifications for Infants Vital Signs Pulse Respirations Blood pressure (children over years of age) Taking the brachial pulse. Taking the femoral pulse. Other Monitoring Pulse oximetry Use appropriate Reassessment Reassess the patient since conditions can change rapidly. Reassess every minutes in stable patients. Reassess every minutes in unstable patients. General Management of Pediatric Patients Suctioning Decrease suction pressure to less than mm/hg in infants. Avoid excessive suctioning time less than 15 seconds per attempt. Avoid stimulation of the nerve. Check the frequently. Pediatric Suction Catheters 6

7 catheter catheter Oxygenation Adequate oxygenation is the of pediatric patient management. To overcome a child s fear of the non-rebreather mask, try it on yourself or have the patient try it on before attempting to place it on the child. OPA for Infants and Small Children In an adult, the airway is inserted with the tip pointing to the of the mouth, then rotated into position. In an infant or small child, the airway is inserted with the tip pointing toward the and pharynx, in the same position it will be in after insertion. In placing a mask on a child, it should fit on the of the nose and cleft of the chin. Ventilation Avoid excessive bag pressure and. Obtain chest rise and fall. Allow time for. Flow-restricted, oxygen-powered devices are contraindicated. Do not use BVMs with pop-off valves. Avoid pressure. Avoid of the neck. In maneuver, pressure is placed on the cricoid cartilage, compressing the, which helps bring the vocal cords into view. Advanced Airway and Ventilatory Management Needle Cricothyrotomy Needle cricothyrotomy in children is the same as for adult patients. The only indication for cricotyrotomy is to obtain an airway by any other method. Endotracheal Intubation in the Child Prehospital Tracheal Intubation vs Bag-Mask Ventilation Bag-mask ventilation may be as as intubation if transport time is short Tracheal intubation requires training and experience Confirmation of tracheal tube position strongly recommended Monitoring of improvement important The Pediatric Airway A blade is preferred for greater displacement of the tongue. The pediatric airway narrows at the cricoid cartilage. tubes should be used in newborns 7

8 Cuffed tubes may be used on other pediatrics so long as cuff pressure is kept below 20cm H2O Intubation is likely to cause a response in children. Complications of Prehospital Tracheal Intubation Successful tracheal intubation rate: % Intubation attempts increased time at the scene by 2 to 3 minutes Unrecognized tube displacement or misplacement: 8% intubation: 2% Unrecognized : 6% Esophageal intubation or unrecognized extubation fatal (for 14 of 15 patients) Indications for Intubation Need for artificial ventilation Inadequate ventilatory support with a BVM Cardiac or respiratory Control of an airway in a patient without a cough or gag reflex Providing a route for drug administration Access to the airway for Pediatric Tube Size Formula (Patient s age in years + 16) 4 Confirmation of Tracheal Tube Placement tube through cords Assess breath sounds, chest rise bilaterally Primary confirmation: Oxygenation ( ) Exhaled CO 2 ( ) Exhaled CO 2 in Pediatrics With a Perfusing Rhythm Normal exhaled CO 2 should be approximately equal to PaCO 2 if airway is patent and unobstructed Normal CO 2 in esophagus is approximately Exhaled CO 2 detected from tube is sensitive and specific for tracheal tube placement if perfusing rhythm is present in patient weighing >2 kg Note: breaths recommended after intubation to wash out any CO 2 present in the stomach after bag-mask ventilation Note: Exhaled CO 2 will not detect or rule out intubation of mainstem Detection of ETCO 2 in Pediatrics in Cardiac Arrest Pulmonary blood flow stops in cardiac arrest, so exhaled CO 2 is approximately, even with correct tracheal tube position In cardiac arrest with CPR, pulmonary blood flow remains very low, so exhaled CO 2 is (much lower than PaCO 2) Thus, exhaled CO 2 may not be detected in victims of cardiac arrest despite tracheal tube placement Confirmation of ETT Position 8

9 No single confirmation device or examination technique is reliable under all circumstances Detection of exhaled CO 2 is reliable in patients weighing > kg with a perfusing rhythm Confirmation of tube position is particularly important after intubation and after any patient Continuous capnography is most reliable Nasogastric Intubation Nasogastric Intubation Indications: Inability to achieve adequate volume during ventilation due to gastric distention Presence of gastric distention in an patient Oxygenate and continue to, if possible. Measure the NG tube from the tip of the nose, over the ear, to the tip of the process. the end of the tube. Then pass it gently downward along the nasal floor to the stomach. Auscultate over the epigastrium to confirm correct placement. Listen for bubbling while injecting - cc of air into the tube. Use suction to stomach contents. the tube in place. Rapid Sequence Intubation Indicated in pediatric patients when intubation is difficult due to or clenched teeth. Neuromuscular compliance is gained by the use of a. Use local for guidance Circulation Two problems lead to cardiopulmonary arrest in children: failure Vascular Access Neck veins veins Arms Intraosseous infusion Intraosseous Infusion Indications Children less than years of age (Jamshidi) 9

10 Existence of shock, cardiac arrest, or other life threatening condition requiring administration of patient Unsuccessful IV Intraosseous Infusion Contraindications Fracture in the chosen for IO Fracture of the or extremity fracture of bone, proximal to the chosen site Intraosseous administration. Fluid Administration dosing is crucial Too much fluid can result in heart failure and pulmonary edema Use of microdrip or set is required Initial dose for hypovolemia is cc/kg of an isotonic crystalloid Bolus is repeated as needed Hypovolemic shock may require up cc/kg Septic shock may require up to cc/kg Drugs Used in Pediatric Advanced Life Support (PALS) Adenosine: 0.1 to 0.2mg/kg to a max of 6 or 12mg rapid IV push : 5mg/kg to a maximum of 150mg rapid IV push : 0.02mg/kg per dose with a minimum of 0.1mg to a maximum of 0.5mg in a child and 1.0mg in an adolescent rapid IV push Drugs Used in PALS Calcium Chloride: 20mg/kg per dose given slow IV push : 2-10mck/kg per minute IV drip Epinephrine (for ): IV/IO Push: 0.01mg/kg of 1:10,000 to a maximum of 1mg ET: 0.1mg/kg of 1:1,000 Drugs Used in PALS Epinephrine (for cardiac arrest) First dose IV or I/O: 0.01mg/kg of 1:10,000 First dose ET: 0.1mg/kg of 1:1,000 doses ET, IV or I/O: 0.1mg/kg 1:1,000 Epinephrine : initially at 0.1mcg/kg per minute IV drip Drugs Used in PALS : 1mg/kg rapid IV push Lidocaine Infusion: 20-50mcg/kg per minute IV drip Sodium Bicarbonate: 1mEq/kg per dose slow IV push if ventilation is adequate Electrical Therapy shock only; just as in adults Initial shock is joules per kilogram of body weight for V-fib and pulseless V- Tach. 10

11 If unsuccessful, all subsequent shocks are joules per kilogram If still unsuccessful, focus on correcting and acidosis. Transport to a pediatric critical care unit, if possible. Applying a Pediatric Immobilization System the patient on the immobilization system. Adjust the color-coded to fit the child. Attach the four-point system. Fasten the adjustable -support system. The patient fully immobilized to the system. Move the immobilized patient onto the stretcher and fasten the at both ends to connect to the stretcher straps. Emotional support of the infant or child continues during transport. Transportation Guidelines Children should be transported in a car seat if possible Never delay to perform procedures that can be performed en route if condition is serious Allow to ride in back if appropriate Consider need for specialized Consider need for transport Some Keys to Dealing with Pediatrics If time permits: Gain their Be patient Be truthful Never transport to perform a procedure that can be done en route to the hospital! If child has life threatening conditions, don t waste time trying to reason with an emotional child, and treat! Specific Medical Emergencies Infectious diseases account for the of pediatric illnesses Respiratory Emergencies Stages of Respiratory Compromise Respiratory Respiratory Respiratory 11

12 S/S of Respiratory Distress Irritability or Anxiety Retractions Nasal flaring (in infants) Good muscle tone Head bobbing that improves with supplemental oxygen Respiratory Failure Signs and symptoms: Irritability or deteriorating to lethargy Marked tachypnea later deteriorating to bradypnea Marked later deteriorating to agonal respirations Poor muscle tone Marked later deteriorating to bradycardia Central cyanosis Respiratory Arrest Signs and symptoms: Unresponsiveness deteriorating to deteriorating to apnea Absent chest wall motion Bradycardia deteriorating to Profound cyanosis Specific Respiratory Emergencies Upper airway distress Epiglottitis Foreign body aspiration Lower airway distress Bronchiolitis Pneumonia Foreign body lower airway obstruction Croup infection of the larynx Gradual onset Seal Bark cough grade fever: 100 to 101 degrees F. Treatment is to administer oxygen Epiglottitis infection of the epiglottis onset 12

13 No barking cough Drooling, pain upon swallowing fever: degrees F. Occasional Treatment is to administer humidified oxygen and rapid transport Do not visualize Croup and Epiglottitis Positioning of the child with epiglottitis. Often there will be excessive. The child with epiglottitis should be administered humidified oxygen and transported in a position. Asthma Chronic inflammatory disease of the lower respiratory tract cough Sitting up Presence of Management is to administer oxygen and bronchodilators and possibly epinephrine 1:1,000 Specific Medical Emergencies Shock heart disease Cardiomyopathy Neurological emergencies Meningitis Gastrointestinal emergencies emergencies Predisposing Factors of Pediatric Shock Dehydration (vomiting, diarrhea) Trauma Blood loss Allergic reactions Cardiac events (rare) S/S of Shock (Hypoperfusion) in a Child Absence of when crying Rapid respiratory rate Decreased Delayed capillary refill Pale, cool, clammy skin Weak or absent pulses Impaired mental status or unresponsiveness 13

14 Severity of Shock shock: body is able to compensate Decompensated shock: body is no longer able to compensate shock: treatment is inadequate or too late to prevent tissue damage and death Categories of Shock : failure of the heart : decreased blood or water volume : caused by obstruction that interferes with blood return to the heart Pulmonary embolism, tension pneumothorax, or cardiac tamponade : caused by abnormal distribution and return of blood resulting from vasodilation, vasopermiation, or both Septic, anaphylactic, or neurogenic Categories of Shock Another method of classifying shock is by 2 broad categories Cardiogenic Hypovolemic Distributive Hypovolemic Shock Loss of blood or body Common caused in pediatrics by blood loss,, vomiting/diarrhea S/S are the classic S/S of shock Treatment is fluid replacement at cc/kg repeated as needed after assessment and rapid transport Septic Shock within the blood stream S/S: very ill appearance, altered mental status,, capillary refill > 2 seconds, hyperventilation leading to respiratory failure, cool/clammy skin, inability to recognize Fluid bolus of cc/kg and rapid transport Anaphylactic Shock Due to severe reaction S/S include: tachycardia, tachypnea, wheezing,, anxiousness, edema, hypotension Treatment is to administer Epinephrine 1:1,000 and antihistamines Neurogenic Shock due to interruption of nervous control of the peripheral vascular system. Most commonly due to injury to the spinal cord 14

15 S/S: warm/dry skin and Treatment is to administer fluids and/or (Dopamine) Cardiogenic Shock Inadequate output Normally caused by congenital heart disease or Congenital Heart Disease The cause of heart disease in children May result from holes in the walls of the heart or from abnormalities of the great vessels A common symptom is Treatment is to ensure oxygenation and ventilation Cardiomyopathy A disease or dysfunction of the muscle Results from congenital heart disease or S/S include fatigue, crackles,, engorgement of the liver, and peripheral edema Treatment is Dysrhythmias in children are the most common SVT is uncommon V-Tach is very uncommon SVTs Heart rate of or more Children can tolerate this rate well Treatment depends on clinical findings and of patient : 0.1mg/kg to a max of 6 or 12mg Synchronized cardioversion: J/kg (to a max of 100J) and J/kg (to a max of 360J) or biphasic equivalents (for sedation): 0.1mg/kg to a max of 2.5mg V-Tach With a Pulse Unstable patients should be aggressively treated : 2.5 to 5mg/kg to a max of 150mg repeated once : 0.5 to 1mg/kg repeated to a max of 3mg/kg Synchronized cardioversion: J/kg (to a max of 100J) and J/kg (to a max of 360J) or biphasic equivalents Bradydysrhythmias Perform chest compressions if: HR < on infants HR < on children 1-12 years of age 15

16 Epinephrine IV or I/O: 0.01mg/kg 1:10,000 to a max of.5mg ET 0.1mg/kg 1:1,000 to a max of 0.5mg Repeated every minutes as needed Bradydysrhythmias Atropine: 0.02mg/kg with a minimum dose of 0.1mg May be repeated once Not the drug of choice Cardiac Pacing in pediatrics Follow local protocols Asystole May be rhythm in cardiac arrest Epinephrine IV or I/O: 0.01mg/kg 1:10,000 to a max of.5mg ET 0.1mg/kg 1:1,000 to a max of 0.5mg Repeated every 3-5 minutes as needed is not indicated in pediatric asystole V-Fib or Pulseless V-Tach Defibrillation J/kg to a max of 360J on initial shock J/kg to a max of 360J on subsequent shocks Or biphasic equivalent Epinephrine IV or I/O: 0.01mg/kg 1:10,000 to a max of.5mg ET 0.1mg/kg 1:1,000 to a max of 0.5mg Repeated every 3-5 minutes as needed V-Fib or Pulseless V-Tach : 5mg/kg to a max of 300mg Repeated once if needed to a max of 150mg : 1mg/kg Repeated as needed to a total dose of 3mg/kg Sequence is same as adult PEA Main treatment is to identify and correct cause IV or I/O: 0.01mg/kg 1:10,000 to a max of.5mg ET 0.1mg/kg 1:1,000 to a max of 0.5mg Repeated every 3-5 minutes as needed Neurological Emergencies Seizures: in children 16

17 epilepticus seizures Common in children 6 months to 6 years Related to the of fever increase, not the temperature itself Normally seen during an illness Neurological Emergencies Management of seizures: IV of NS or LR Blood level 1 month to 5 years: 0.2mg to 0.5 mg slow IV push every 2-5 minutes to a max of 2.5mg (total dose) > 5 years: 1mg slow IV push every 2-5 minutes to a max of 5mg (total dose) Neurological Emergencies Management of seizures (cont d): or D25W if hypoglycemic 2cc/kg Febrile seizures Cool patient Avoid Consider giving antipyretic Neurological Emergencies Meningitis More in children High fever, lethargy,, stiff neck do not develop stiff neck Management: BSI (including respiratory protection) Oxygenation and airway control bolus of 20cc/kg if shock is present Rapid transport Gastrointestinal Emergencies Nausea and Vomiting Diarrhea Vomiting and diarrhea carry the potential for and electrolyte abnormalities serious conditions in the pediatric patient. Gastrointestinal Emergencies S/S of Severe Dehydration pulse Tachypnea Capillary refill > 2 seconds Lethargy Cool, dry, skin 17

18 Dry mucous membranes with no Treatment is fluid replacement Metabolic Emergencies Hypoglycemia Abnormally low concentration of in the blood It is a true medical emergency that must be treated immediately. Treatment is to administer D12.5W or D25W at 2cc/kg Hyperglycemia Abnormally high concentration of in the blood Treatment is IV bolus of 20cc/kg of NS or LR and rapid transport Poisoning and Toxic Exposure poisoning is a common childhood emergency. Leading cause of death in children. S/S would depend on type of poisons exposed to Treatment is manage airway, oxygenate, identify, and contact poison control Some of the poisons commonly ingested by children. Trauma Emergencies : the most common cause of traumatic injury in pediatrics Motor vehicle crashes Car vs. pedestrian injuries Drowning and near drowning injuries Physical abuse A deploying can propel a child safety seat back into the vehicle s seat, seriously injuring the child secured in it. Special Considerations Special Considerations Airway control Fluid Management Pediatric and Sedation Traumatic Brain Injury In the pediatric trauma victim, use the combination of /spine-stabilization maneuver to open the airway. Simultaneous cervical spine immobilization and in a pediatric patient. Immobilization 18

19 may not fit the small child Use of towels or rolls If in a car seat, in the car seat Fluid Management Use as bore catheter as possible Don t delay to establish IV Utilize I/O if unable to establish peripheral IV on an unstable patient Consider Lidocaine mg/kg up to 50mg for pain management Initial fluid bolus of 20cc/kg repeated as needed Pediatric Analgesia & Sedation An often aspect of prehospital pediatric care is pain control. Many pediatric injuries, such as, long bone fractures, dislocations, and others, are painful and analgesics are indicated. analgesics and Nitrous Oxide are effective Consult for dosages and indications Traumatic Brain Injury Pediatric head injuries can be classified as follows: Glasgow coma score is Glasgow coma score is 9-12 Glasgow coma score is less than or equal to 8 management is most important Transport to appropriate facility Specific Injuries Head, face, and neck Chest and abdomen Extremities Burns Head, Face, and Neck Injuries to the head are the most common cause of death in pediatric trauma victims. The most common facial injuries are lacerations secondary to. injuries in children are not as common in adults, but the cervical spine is more susceptible to injury. Chest and Abdomen Chest injuries are the most common cause of pediatric trauma deaths. Children tend to develop pulmonary, sometimes, massive, following blunt trauma to the chest. Significant blunt trauma to the abdomen can result in injury to the or liver. Both splenic and hepatic injuries can cause life-threatening internal hemorrhage. Injuries to the Extremities Fractures and are most common 19

20 Falls are most common cause Of special concern are fractures involving the growth plate Consider use of for lower extremity fractures and pelvic fractures Burns Second leading cause of traumatic death in children under 14 Estimation of burn is different from adults Rule of 9 s Rule of : the size of the patient s palm is roughly % of TBS Aggressive airway control, maintain body heat, fluid therapy using the formula Rule of Nines Sudden Infant Death Syndrome (SIDS) SIDS is the sudden death of an infant during the first year of life from an illness of etiology. Leading cause of death between 2 weeks and 1 year of age Peak incidence occurring at months Sudden Infant Death Syndrome (SIDS) Typical history is a normal healthy baby that was put to bed and found dead the next morning Consider value of efforts Support members can appear to be bruising from child abuse Child Abuse and Neglect Types of Abuse abuse Physical abuse abuse Neglect (either physical or emotional) Treatment is to obtain, treat the injury, and transport The stigmata of child abuse. Burn injury from placing a child s buttocks in hot water as a punishment The effects of child abuse, both physical and mental, can last a. Infants and Children with Special Needs Common home-care devices Tracheostomy tubes monitors Home artificial ventilators Central lines Gastric feeding and gastrostomy tubes Shunts 20

21 Tracheostomy Tubes Complications Site bleeding Air leakage Dislodged tube Management is to maintain airway, tube as needed, administer oxygen, assist ventilations as needed Apnea Monitors Monitor breathing status of infant Some signal changes in rate: bradycardia or tachycardia Most of the time, the patient only requires and is breathing adequately when EMS arrives Be patient and if requested to Home Ventilators Two complications: failure failure Management: Maintain airway Ventilate with appropriate sized Transport to hospital until home ventilator is working Central IV Lines Possible complications: lines Place a clamp between the crack and the patient Position on left side with head lowered if AMS Transport Transport Loss of (such as clotting) Stop infusion, control bleeding, and transport Central IV Lines (may be considerable) control bleeding through direct pressure and transport Air If a large amount of air is in the line, use a syringe to withdraw the air Position on left side with head lowered and transport Gastric Feeding Tubes Used on children who cannot Possible complications: Bleeding tube 21

22 175 Possible respiratory distress with aspiration due to missed feedings Treatment is to support ABCs with possible suctioning to prevent aspiration Shunts Surgical connection that runs from the brain to the to remove excess CSF Occlusion causes S/S of increased Treatment is to maintain ABCs and transport 22