Chapter 32

32: Pediatric Assessment and Management

Cognitive Objectives

(1 of 3)

6-1.4 Indicate various causes of respiratory emergencies. 6-1.5 Differentiate between respiratory distress and respiratory failure. 6-1.6 List steps in the management of foreign body airway obstruction.

Cognitive Objectives

(2 of 3)

6-1.7

Summarize EMS care strategies for respiratory distress and respiratory failure.

6-1.8

Identify the signs and symptoms of shock (hypoperfusion) in the infant and child patient.

6-1.9

Describe the methods of determining end organ perfusion in the infant and child patient.

6-1.10 State the usual cause of cardiac arrest in infants and children versus adults.

Cognitive Objectives (3 of 3) 6-1.12 Describe the management of seizures in the infant and child patient. 6-1.14 Discuss the field management of the infant and child trauma patient. •

There are no affective objectives for this chapter.

Psychomotor Objectives (1 of 2) 6-1.21 Demonstrate the techniques of foreign body airway obstruction removal in the infant. 6-1.22 Demonstrate the techniques of foreign body airway obstruction removal in the child. 6-1.23 Demonstrate the assessment of the infant and child.

Psychomotor Objectives (2 of 2) 6-1.24 Demonstrate bag-valve-mask artificial ventilations for the infant. 6-1.25 Demonstrate bag-valve-mask artificial ventilations for the child. 6-1.26 Demonstrate oxygen delivery for the infant and child.

Additional Objectives* Cognitive 1. Describe the steps in positioning an infant and/or child to maintain an open airway. 2. Summarize neonatal resuscitation procedures. Affective None Psychomotor 3. Demonstrate the techniques necessary in neonatal resuscitation. *These are noncurriculum objectives.

Pediatric Assessment and Management • Caring for sick and injured children presents special challenges. • EMT-Bs may find themselves anxious when dealing with critically ill or injured children. • Treatment is the same as that for adults in most emergency situations.

Scene Size-up

• Take note of your surroundings. • Scene assessment will supplement additional findings. • Observe: – Position of the patient – Condition of the home – Clues to child abuse

Initial Assessment

• Begins before you touch the patient • Form a general impression. • Determine a chief complaint. • The Pediatric Assessment Triangle can help.

Pediatric Assessment Triangle • Appearance – Awake – Aware – Upright • Work of breathing – Retractions – Noises • Skin circulation

Assessing the ABCs • Ensure airway is open and position patient. • Breathing assessment – Effort – Obstructions – Rate • Circulation assessment – Rate – Skin color, temperature, and capillary refill

Transport Decision • Children under 40 lb should be transported in a child safety seat, if the situation allows. • Seat should be secured to the cot or captain’s chair. • Cannot be secured to bench seat • Child may have to be transported without a seat, depending on condition.

Focused History and Physical Exam

• Should be completed on scene unless severity requires rapid transport • Young children should be examined toe to head. • Focused exam on noncritical patients • Rapid exam on potentially critical patients

Vital Signs by Age Age

Respirations (breaths/min)

Pulse (beats/min)

Systolic Blood Pressure (mm Hg)

Newborn: 0 to 1 mo

30 to 60

90 to 180

50 to 70

Infant: 1 mo to 1 yr

25 to 50

100 to 160

70 to 95

Toddler: 1 to 3 yr

20 to 30

90 to 150

80 to 100

Preschool age: 3 to 6 yr

20 to 25

80 to 140

80 to 100

School age: 6 to 12 yr

15 to 20

70 to 120

80 to 110

Adolescent: 12 to 18 yr

12 to 16

60 to 100

90 to 110

Older than 18 yr

12 to 20

60 to 100

90 to 140

Respirations • Abnormal respirations are a common sign of illness or injury. • Count respirations for 30 seconds. • In children less than 3 years, count the rise and fall of the abdomen. • Note effort of breathing. • Listen for noises.

Pulse • • • •

In infants, feel over the brachial or femoral area. In older children, use the carotid artery. Count for at least 1 minute. Note strength of the pulse.

Blood Pressure • Use a cuff that covers two thirds of the upper arm. • If scene conditions make it difficult to measure blood pressure accurately, do not waste time trying.

Skin Signs • Feel for temperature and moisture. • Estimate capillary refill.

Detailed Physical Exam and Ongoing Assessment

• • • •

Status changes frequently in children. The PAT can help with reassessment. Repeat vital signs frequently. If child deteriorates, repeat the initial assessment.

Care of the Pediatric Airway (1 of 2) • Position the airway. • Position the airway in a neutral sniffing position. • If spinal injury is suspected, use jaw-thrust maneuver to open the airway.

Care of the Pediatric Airway (2 of 2) • Positioning the airway: – Place the patient on a firm surface. – Fold a small towel under the patient’s shoulders and back. – Place tape across patient’s forehead to limit head rolling.

Oropharyngeal Airways • Determine the appropriately sized airway. • Place the airway next to the face to confirm correct size. • Position the airway. • Open the mouth. • Insert the airway until flange rests against lips. • Reassess airway.

Nasopharyngeal Airways (1 of 2) • Determine the appropriately sized airway. • Place the airway next to the face to make certain length is correct. • Position the airway. • Lubricate the airway.

Nasopharyngeal Airways (2 of 2) • Insert the tip into the right naris. • Carefully move the tip forward until the flange rests against the outside of the nostril. • Reassess the airway.

Assessing Ventilation • Observe chest rise in older children. • Observe abdominal rise and fall in younger children or infants. • Skin color indicates amount of oxygen getting to organs.

Oxygen Delivery Devices • Nonrebreathing mask at 10 to 12 L/min provides 90% oxygen concentration. • Blow-by technique at 6 L/min provides more than 21% oxygen concentration. • Nasal cannula at 4 to 6 L/min provides 24% to 44% oxygen concentration.

BVM Devices • Equipment must be the right size. • BVM device at 10 to 15 L/min provides 90% oxygen concentration. • Ventilate at the proper rate and volume. • May be used by one or two rescuers

One-rescuer BVM Ventilation A

B

C

D

Airway Obstruction • Croup – A viral infection of the airway below the level of the vocal cords • Epiglottitis – Infection of the soft tissue in the area above the vocal cords • Foreign body airway obstructions

Signs and Symptoms • Decreased or absent breath sounds • Stridor • Retractions • Difficulty speaking

Signs of Complete Airway Obstruction • Signs and symptoms – Ineffective cough (no sound) – Inability to cry – Increasing respiratory difficulty, with stridor – Cyanosis – Loss of consciousness

Removing a Foreign Body Airway Obstruction (1 of 5) • In an unconscious child: – Place the child on a firm, flat surface. – Inspect the upper airway and remove any visible object. – Attempt rescue breathing. – If ventilation is still unsuccessful, position hands on the abdomen.

Removing a Foreign Body Airway Obstruction (2 of 5) • Give five abdominal thrusts. • Open airway again to try and see object. • Only try to remove object if you see it. • Attempt rescue breathing.

Removing a Foreign Body Airway Obstruction (3 of 5) • If unsuccessful, reposition head and attempt ventilation again. • Repeat abdominal thrusts if obstruction persists.

Removing a Foreign Body Airway Obstruction (4 of 5) • In a conscious child: – Kneel behind the child. – Give the child five abdominal thrusts. – Repeat the technique until object comes out.

Removing a Foreign Body Airway Obstruction (5 of 5) • If the child becomes unconscious, inspect the airway. • Attempt rescue breathing. • If airway remains obstructed, repeat thrusts.

Management of Airway Obstruction in Infants • • • • • •

Hold the infant facedown. Deliver five back blows. Bring infant upright on the thigh. Give five quick chest thrusts. Check airway. Repeat cycle as often as necessary.

Neonatal Resuscitation • Resuscitation measures include: – Positioning airway – Drying – Warming – Suctioning – Tactile stimulation

Neonatal Equipment

Additional Efforts • Deliver chest compressions at 120 per minute. • Coordinate chest compressions with ventilations at a ratio of 3:1. • If meconium is present, suction infant vigorously.

BLS Review • Cardiac arrest in children is commonly due to respiratory arrest. • Many causes of respiratory arrest • For purposes of pediatric BLS: – Infancy ends at 1 year of age. – Childhood extends to 8 years of age. – Children older than 8 years of age are treated as adults.

Determine Responsiveness • Gently tap on shoulder and speak loudly. • If responsive, place in position of comfort. • If you find an unresponsive child when you are not on duty: – Provide BLS for about 1 minute. – Call EMS system.

Airway • Airway may be obstructed by tongue. • Use head tilt-chin lift technique or jaw-thrust maneuver to open the airway. • Jaw-thrust maneuver is safer if possibility of neck injury exists.

Breathing • Look, listen, and feel. • Provide rescue breathing if needed. • Perform Sellick maneuver to prevent gastric distention.

Circulation • Assess circulation after airway is open and two rescue breaths have been given. • Check for pulses. • Evaluate for other signs of circulation. • Do not spend more than 10 seconds trying to find a pulse.

Infant CPR (1 of 2) • Place infant on firm surface and maintain airway. • Place two fingers in the middle of the sternum. • Use two fingers to compress the chest about 1/2" to 1" at a rate of 100/min.

Infant CPR (2 of 2) • Allow sternum to return briefly to its normal position between compressions. • Coordinate rapid compressions and ventilations in a 5:1 ratio. • Reassess the infant for return of breathing and pulse after 1 minute, then every few minutes.

Child CPR (1 of 2) • Place child on firm surface and maintain airway with one hand. • Place heel of other hand over lower half of the sternum. – Avoid the xiphoid process. • Compress chest about 1" to 1 1/2" at a rate of 100/min.

Child CPR (2 of 2) • Coordinate compressions with ventilations in a 5:1 ratio, pausing for ventilations. • Reassess for breathing and pulse after about 1 minute and then every few minutes. • If the child resumes effective breathing, place child in recovery position.

AED Use in Children • Children over 8 should use the adult AED protocol. • Children ages 1-8: – 1 minute of CPR before AED – Use AED with pediatric capabilities. – Adult AED may be used in local protocols. • Do not use on an infant under 1 year old.

Trauma (1 of 2)

Extremity injuries in children are generally managed in the same manner as those in adults.

Trauma (2 of 2) • Be alert for airway problems on all children with traumatic injuries. • Give supplemental oxygen to all children with possible: – Head injuries – Chest injuries – Abdominal injuries – Shock • If ventilation is required, provide at 20 breaths/min.

Immobilization • Any child with a head or back injury should be immobilized. • Young children may need padding beneath their torso. • Children may need padding along the sides of the backboard.

Immobilization in a Child Safety Seat • Assess child for injuries and seat for visible damage. • If child is injured or seat is damaged, remove child to another transport device • Apply padding around child to minimize movement. • Move seat to ambulance and secure according to the manufacturer’s instructions.

Removing a Child from a Child Safety Seat • Remove both the child and the seat from the vehicle. • Place immobilization device behind the child. • Slide child into place on device.

Signs and Symptoms of Respiratory Emergencies • Nasal flaring • Grunting respirations • Use of accessory muscles • Retractions of rib cage • Tripod position in older children

Emergency Care • Provide supplemental oxygen in the most comfortable manner. • Place child in position of comfort. – This may be in caregiver’s lap. • If patient is in respiratory failure, begin assisted ventilation immediately. – Continue to provide supplemental oxygen.

Shock • Circulatory system is unable to deliver sufficient blood to organs. • Many different causes • Patients may have increased heart rate, respirations, and pale or mottled skin. • Children do not show decreased blood pressure until shock is severe.

Assessing Circulation • Pulse: Above 160 beats/min suggests shock • Skin signs: Assess temperature and moisture • Capillary refill: Is it delayed? • Color: Is skin pink, pale, ashen, or mottled?

Emergency Medical Care for Shock • • • •

Ensure airway. Give supplemental oxygen. Provide immediate transport. Continue monitoring vital signs en route. • Contact ALS for backup as needed.

Seizures • May present in several different ways • A postictal period of extreme fatigue or unresponsiveness usually follows seizure. • Be alert to presence of medications, poisons, and possible abuse.

Febrile Seizures • Febrile seizures are most common in children from 6 months to 6 years. • Febrile seizures are caused by fever. • Generally last less than 15 minutes • Assess ABCs and begin cooling measures. • Provide prompt transport.

Emergency Medical Care of Seizures (1 of 2) • Perform initial assessment, focusing on the ABCs. • Securing and protecting the airway is the priority. • Place patient in the recovery position. • Be ready to suction.

Emergency Medical Care of Seizures (2 of 2) • Deliver oxygen by mask, blow-by, or nasal cannula. • Begin BVM ventilation if no signs of improvement. • Call ALS for backup if appropriate.

Dehydration • Determine if child is vomiting or has diarrhea and for how long. • “How many wet diapers has the child had during the day?” (6 to 10 is normal) • “What fluids are the child taking?” • “What was the child’s weight before the symptoms started?” • “Has the child been normally active?”

Emergency Medical Care for Dehydration • Assess the ABCs. • Obtain baseline vital signs. • ALS backup may be needed for IV administration.