Pediatric Emergencies Lesson Goal Explain special characteristics of infants and children to become both comfortable & efficient in treating pediatric emergencies Lesson Objectives Identify physical & developmental differences between infants & children Recognize unique anatomic characteristics of pediatric airway and how pediatric and adult airway management differs 1
Lesson Objectives Identify & treat the following conditions in the pediatric patient: Respiratory distress Upper airway obstruction Shock Seizures Introduction Assessment and management of pediatric patients requires special knowledge Modify the approach to pediatric patients to meet their special needs Developmental Considerations Infants Limited ability to communicate Lose heat easily Stranger & separation anxiety Motor skills develop from head to toe and from trunk to extremities 2
Developmental Considerations Toddlers More independent More mobile & curious Separation anxiety Developmental Considerations Preschool children Good communication skills Generally cooperative Need for modesty Developmental Considerations School-age children Good understanding of their bodies May fear permanent injury or the sight of blood Need an explanation of procedures 3
Developmental Considerations Adolescents Independent Should be allowed to make as many choices as possible Legally still minors Pediatric Airway Shorter, smaller Narrowest at cricoid ring Larynx more superior & anterior Epiglottis long & floppy Respiratory Distress Noted by increase in work of breathing Signs Tachypnea Hyperpnea Nasal flaring Accessory muscle use Retractions 4
Upper Airway Always have suction readily available for removal of copious secretions Secretions can be sole cause of respiratory distress, especially in infants Upper Airway In larger child, rigid suction catheter may be applied to oropharynx In infant, bulb suction device may be more appropriate Upper Airway Crying increases respiratory distress Keep pediatric patient calm and comfortable If possible, child should stay with parent or guardian Use blow-by oxygen 5
Oxygen Delivery Systems Low flow Blow-by Nasal cannula Simple mask Oxygen Delivery Systems High flow Partial nonrebreather mask Complete nonrebreather mask Respiratory Failure If patient decompensates from respiratory distress to respiratory failure, take over management of airway and breathing 6
Signs of Respiratory Failure Decreased/decreasing responsiveness Does not recognize parents or caregivers Poor interactions with parents or caregivers Decreased muscle tone Use of accessory muscles for breathing Retraction of chest muscles Nasal flaring Cyanosis Head bobbing Airway Adjuncts Manual maneuvers Airway Adjuncts Simple adjuncts Nasopharyngeal airway Oropharyngeal airway 7
Airway Adjuncts Anatomic considerations Pad under shoulders of small children Pad under head of older children Avoid flexion & hyperextension Ventilation Select appropriate-size mask & bag Squeeze for ~1 sec (watch for chest rise) Ventilate 12-20/min Ventilation Use gentle cricoid pressure Provide 100% O 2 using reservoir bag Use pulse oximeter Persistent hypoxia? Troubleshoot equipment 8
Skill 31-1: Bag-Mask Ventilation 1. Kneel at patient s head. If no neck injury, place towel beneath head (for a child) or torso (for an infant) 2. If suspected neck injury, open airway with jaw thrust technique without head tilt 3. Apply mask to patient s face. Mask should reach from bridge of nose to cleft of chin without overlapping eyes 4. Apply E-C technique Skill 31-1: Bag-Mask Ventilation 5. Apply only force and volume needed to cause chest to rise visibly 6. 2-person bag-mask technique may be more efficient Open airway Check for breathing Look Listen Feel Infant & Child CPR Provide bag-mask ventilations for inadequate or absent breathing Consider obstruction if there is resistance chest does not rise 9
Infant & Child CPR If rescue breaths are successful, assess circulation Do not take >10 sec Begin compression for infants with a pulse <60 Compress at a rate of 100/min 3:1 ratio for newborns Children: 30:2 for 1 rescuer Children: 15:2 for 2 rescuer Skill 31-2: Child CPR 1. Shake patient gently and shout; if no response, call for help. Open airway using headtilt/chin-lift, jaw thrust, or tongue-jaw lift maneuver. Check for breathing: look, listen, and feel Skill 31-2: Child CPR 2. If respirations are present, place patient in recovery position; continue to monitor 3. If no breathing, deliver 2 rescue breaths. If resistance, reposition airway 10
Skill 31-2: Child CPR 4. Check for pulse <10 sec 5. If pulse present (>60 bpm), continue with rescue breathing (20bpm) Skill 31-2: Child CPR 6. If no pulse or <60 bpm, begin chest compressions. If pediatric AED is available & child meets the machine s requirements, attach pads and follow the AED protocol 7. Chest compressions should be 1/3 to 1/2 the depth of patient s chest Skill 31-2: Child CPR 8. Use age-appropriate compressions-to-ventilations ratio: Newborns: 3:1 Infants and children <8 y/o: 5:1 Children >8 y/o: 15:2 9. Reassess pulse after 20 cycles of compressions and ventilations (approximately 1 minute) and every few minutes thereafter 11
Skill 31-3: Infant Chest Compressions 2-Thumbs Encircling Hands Technique 1. Position yourself at infant s feet or side 2. Place thumbs side by side over lower half of infant s sternum (~1 2 apart, just below level of nipples). Support infant s back with fingers of both hands 3. Use both thumbs to depress sternum ~1/3-1/2 the depth of infant s chest 4. Deliver compressions at rate of at least 100/min (~2 compressions/sec) 5. Compression-to-ventilation ratio: 3:1 in newborns, and 5:1 in infants Skill 31-3: Infant Chest Compressions 2-Finger Compression Technique 1. Place2 fingers of 1 hand over lower sternum, about midline and ~1 2 below level of nipples (be careful not to compress over xiphoid process) 2. Deliver compressions at rate of >100/min 3. Use compression-to-ventilation ratio of 3:1 in newborns and 5:1 in infants Skill 31-4: Chest Compressions (1-8 yrs) 1. Place heel of 1 hand over lower sternum at nipple line. Be careful not to compress over xiphoid process. Lift fingers off chest 12
Skill 31-4: Chest Compressions (1-8 yrs) 2. Depress sternum ~1/3-1/2 depth of patient s chest 3. After delivering compression, release pressure to allow chest to return to normal position before beginning next compression. Do not lift your hand off chest during compressions Skill 31-4: Chest Compressions (1-8 yrs) 4. Compression rate: ~100/min 5. Compression-to-ventilation ratio: 5:1 NOTE: For children >8 y/o, use same CPR technique as for adults (compression-to-ventilation ratio: 15:2) Pediatric Airway Obstruction Causes of pediatric respiratory emergencies Foreign body Asthma Infectious illness Exhaustion due to respiratory failure Unresponsiveness 13
Upper Airway Obstruction Signs Universal choking sign Inability to speak or cry Stridor Accessory muscle use Retractions Cyanosis Upper Airway Obstruction Partial upper airway obstruction Conscious patient Maintain position of comfort Do not agitate patient Focus on transport to emergency facility Complete Airway Obstruction Infant Sequence: 5 back blows: 5 chest thrusts Visually inspect for dislodged object If unresponsive, attempt to ventilate If efforts are successful, assess breathing and circulation 14
Skill 31-5: FBAO Responsive Infant 1. Sit or kneel. Hold infant prone, with body resting on your forearm and head slightly lower than chest. Support infant s head with your hand under the jaw, taking care not to compress soft tissues of infant s mouth or throat. Rest your forearm on your thigh to support infant s weight Skill 31-5: FBAO Responsive Infant 2. With heel of your free hand, deliver 5 blows to infant s back between shoulder blades. Use enough force to attempt to expel foreign body Skill 31-5: FBAO Responsive Infant 3. After delivering 5 back blows, place your free hand over infant s occiput (back of head) and your forearm over middle of infant s back. This should cradle infant between both forearms, with 1 hand supporting face and jaw and other hand supporting occiput 15
Skill 31-5: FBAO Responsive Infant 4. Turn infant supine as a unit, supporting head and neck at all times. Place forearm supporting infant s weight on your thigh. Keep infant s head lower than trunk Skill 31-5: FBAO Responsive Infant 5. Using hand that was supporting infant s face and jaw, deliver <5 chest thrusts in same location as chest compressions (Skill 31-2) at a rate of about 1/sec. Use enough force to attempt to expel foreign body 6. Continue alternating back blows & chest thrusts until object is expelled or infant becomes unresponsive Skill 31-6: FBAO Unresponsive Infant 1. Open infant s airway using the tongue-jaw lift maneuver. Look for object in mouth and throat. If you see object, remove it. Never perform a blind finger sweep 16
Skill 31-6: FBAO Unresponsive Infant 2. If no object is visible, open airway with head-tilt chin-lift & attempt 2 rescue breaths. If breaths are ineffective, reposition head & reattempt rescue breaths 3. If breaths still are not effective, give <5 back blows & chest thrusts (Skill 31-5) Skill 31-6: FBAO Unresponsive Infant 4. Repeat steps 1-3 until foreign body is expelled and the airway is patent, or >1 min. If, at 1 min, patient is still unresponsive & airway is still obstructed, transport patient to nearest medical facility while continuing steps 1-3 5. If rescue breaths are effective, check for signs of circulation & continue CPR as needed (see Skill 31-2) Upper Airway Obstruction For children ages 1-8 Abdominal thrusts, rather than back blows & chest thrusts 17
Skill 31-7: FBAO Responsive Child 1. Stand or kneel directly behind child. Put your arms under axillae (armpits), encircling the chest 2. Place flat, thumb side of one fist against victim s abdomen in midline, slightly above navel and well below tip of xiphoid process Skill 31-7: FBAO Responsive Child 3. Grasp fist with other hand and deliver series of <5 quick, inward & upward thrusts 4. Deliver each thrust as separate, distinct movement with enough force to attempt to expel obstruction. Continue series of 5 thrusts until object is expelled or child becomes unresponsive Skill 31-8: FBAO Unresponsive Child 1. Lay child on flat surface; position yourself near child s head 2. Open airway using tongue-jaw lift and look for foreign body. If object is visible, remove it. Never do blind finger sweep 3. If no visible object, open airway with head-tilt/chin-lift & provide 2 rescue breaths. If breaths are not effective, straddle child s hips & prepare to perform abdominal thrusts 18
Skill 31-8: FBAO Unresponsive Child 4. Place heel of 1 hand on child s abdomen at midline, slightly above navel and well below xiphoid process. Place other hand on top of first 5. Press both hands into abdomen with series of <5 quick, inward & upward thrusts. Each thrust should be separate & distinct movement with enough force to attempt to expel obstruction Skill 31-8: FBAO Unresponsive Child 6. Repeat steps 1-5 until foreign body is expelled and the airway is patent, or >1 min. If, at 1 min, patient is still unresponsive & airway is still obstructed, transport patient to nearest medical facility while continuing steps 1-5 7. If rescue breaths effective, check for signs of circulation & continue CPR as needed (Skill 31-2) Shock Hypovolemic Inadequate vascular volume Cardiogenic Uncommon, due to cardiac problems Distributive Abnormal distribution of blood flow Sepsis, anaphylaxis, spinal injury 19
Shock Compensated shock Heart rate Respiratory rate Decompensated shock Hypotension Assessment Weak pulses Cool, clammy skin Delayed capillary refill Altered mental status Decreased urinary output Dry mucous membranes Management Make sure airway is patent; provide 100% O 2 Artificial ventilation if needed Control bleeding Elevate legs & keep patient warm Rapid transport required 20
Pediatric Cardiac Arrest Primary cardiac arrest is rare Respiratory failure most common cause Respiratory failure must be corrected before it progresses to cardiac arrest Pediatric Cardiac Arrest Attempt resuscitation unless obvious signs of death Consider that family may need to witness resuscitative attempt Avoid comments that may be accusatory or insensitive Seizures Most pediatric seizures are tonic-clonic May be isolated event or recurrent Seizures may be followed by postictal period Repeated seizures without regaining consciousness life-threatening emergency 21
Seizures Some patients have diagnosed seizure disorders (epilepsy) New-onset seizures or change in pattern suggests new problem Assume seizures with trauma are due to brain injury Seizures Seizures with fever May be febrile seizure May be due to CNS infection May be metabolic causes Hypoglycemia most common Consider toxic ingestion Management Airway 1 st priority Consider secretions, emesis, tongue Use manual maneuver Suction Simple adjunct Recovery position 22
Management Breathing If necessary, assist with bag-mask Supplemental O 2 Mechanisms MVC (most common) Falls Bicycle accidents Child abuse Mortality Pediatric Trauma Head injuries (most common) Thoracic injuries Abdominal injuries Head & neck injuries Large head Pediatric Trauma Weak neck muscles Abdominal injuries Small pelvis Small rib cage Weak abdominal musculature Relatively large solid organs 23
Pediatric Trauma Manage immediate life threats from problems with ABCs Transport to appropriate facility Watch for signs of intracranial injury Consider c-spine injury; immobilize if necessary Child Abuse Behaviors destructive to normal growth, development, & well-being Physical abuse Sexual abuse Neglect Emotional abuse Child Abuse Physical abuse Centrally located injuries Chest Back Buttocks Abdomen Bruises in various stages of healing Pattern injuries Burns Bite marks 24
Physical abuse Child Abuse Broken bones with history that does not match findings Femur fractures, esp. in young children, are rare & highly suspicious for abuse Other fractures Skull Ribs Sternum Pelvis Vertebrae Physical abuse Child Abuse Injuries to mouth Torn frenulum in infants Dental trauma in older children Brain injuries Shaken-baby syndrome Child Abuse Neglect Most prevalent form of child abuse Giving insufficient attention or respect to someone who has a claim to it Difficult to diagnose Common findings Failure to thrive, lack of food, & feeding skills Signs of malnutrition Medical neglect 25
Child Abuse Abandonment Total absence of supervision Difficult to define EMTs are in unique position to see child s surroundings & situation Child Abuse Legal responsibility EMTs have responsibility to report suspected child abuse Follow state laws Report findings objectively Do not make accusations at scene Document carefully Summary EMTs need specific knowledge & skills to effectively assess & treat pediatric patients Specific concerns Airway and respiratory problems Shock Trauma Seizures 26