Outdoor Emergency Care, Fourth Edition by WZ6DiLxl


									                            Outdoor Emergency Care, Fourth Edition


                                          Lesson Guide
                         Sheila C. Leeds, Brighton Ski Resort, Brighton, UT

Note: This lesson guide is provided in an electronic format in the OEC Instructor’s Tool Kit so
you can modify and customize it to fit your course.

     OEC Instructor’s Manual, 4th edition (lesson guides, activities, skill guides)
     OEC Instructors’ Tool Kit CD (lesson guides, PowerPoint presentations, activities,
      image bank)
     OEC Test Bank CD (questions, scenarios—generate quizzes, chapter tests, midterms,
     www.nsp.org, www.patrol.org/instructor, www.OECzone.com
     Activities section of this manual
     Skill Guides
          o Build on all Skill Guides presented previously
     Guest: Pediatrician or pediatric nurse practitioner
     Sample of airway and oxygen delivery devices in sizes appropriate for each age group
     Backboard with sample padding and c-collars for infant and child spinal immobilization
     Life-sized dolls, manikins, or actual child models

    Outdoor Emergency Care, 4th edition
    Student Workbook, 4th edition
    www.nsp.org, www.OECzone.com
    BSI devices; e.g. rubber (latex) gloves, mask, goggles
    Emergency care supplies

CORE OBJECTIVES for initial patrol training
Note: The objectives listed below are specific for first-time patroller training. All other
objectives identified in the textbook should be used when customizing your course for other
audiences and for continuing education purposes.

Cognitive (Information)
     Differentiate the response of the ill or injured infant or child (age specific) from that of an
     Discuss the field management of the child trauma patient.

Affective (Comprehension)

Psychomotor (Application)
     Demonstrate an assessment of an infant, toddler, and school-aged child.
     Demonstrate oxygen delivery for the infant and child.
     Demonstrate the techniques of foreign body airway obstruction removal in the child.

OEC Lesson Outline: Chapter 30                                                                          1

You are the rescuer
This activity deals specifically with pediatric patients and their problems. It provides you with an
opportunity to introduce students to the need for a thorough understanding of the issues that
arise while caring for infants and children.

You are alerted at the year-round resort medical clinic that a child has been injured on the
alpine slide.

     1.      How does the age of the child affect both your assessment and management? Give
             two age-specific examples.
              The toddler (1 to 3 years of age) may resist separation from caregivers and be
                 afraid to let others come near them. Toddlers have a hard time describing or
                 localizing pain, and examination may reveal tenderness throughout the body,
                 because he or she cannot tell the difference.
              The preschool age child (3 to 6 years of age) is able to use simple language
                 quite effectively, and have lively imaginations. They can understand directions,
                 be more specific in describing their sensations, and identify painful areas when
                 questioned. In both the toddler and preschool age child, use of a toy, game or
                 puppet may help in you examination.
     2.      Are there certain physical characteristics that make children more at risk when they
             are injured? What are they?
              The tongue is larger and more rounded compared with the size of the mandible,
                 which makes the tongue a greater risk for obstruction.
              The trachea is softer and narrower and can be occluded from compression.
                 Even during the head tilt-chin lift technique, the airway can be occluded if the
                 maneuver is performed too aggressively.
              Infants have little use of their chest muscles to make their chests expand during
                 inspiration, so anything that puts pressure on the abdomen can block the
                 movement of the diaphragm and cause respiratory compromise.
              The skeletal system contains growth plates at the ends of long bones, which
                 enables their bones to grow. Children’s fractures commonly occur in the growth
                 plate between the layer of new uncalcified bone cells, and the next layer of
                 calcified cells.
              Infants have two soft openings within the skull called fontanels. These usually
                 close within 18 months of age, before that time an infant’s head must be handled
                 with care.

These exercises will allow students an opportunity to refresh their knowledge of working with the
younger generations and their unique personalities and needs when injured or ill. The workbook
activities offer another tool to enhance your students’ knowledge and application of skills.


I.        Anatomy and Physiology
          A.    Adult—build on previously presented material as necessary–all adult human
                body anatomy and body systems as well as injuries to those systems should be

OEC Lesson Outline: Chapter 30                                                                         2
                reviewed as all are mentioned highlighting the differences presented by the
                pediatric patient.
        B.      Pediatric
                1.      Airway
                        a.      Tongue
                                i.       Larger, more rounded compared to mandible
                                ii.      Pulled forward and flattens as mandible grows
                        b.      Soft tissue in rear of mouth
                                i.       Tonsils, adenoids, soft palate plus tongue – smaller
                        c.      Upper respiratory infections more frequent
                        d.      Trachea
                                i.       Softer and narrower
                                ii.      Can be occluded from compression or aggressive head tilt-
                                         chin lift maneuver
                2.      Respiratory rate
                        a.      Decreases with age – lungs grow and develop better capability for
                                oxygen exchange
                        b.      Newborn – 40 to 60 breaths/min decreases to near adult by
                3.      Breathing
                        a.      Infants have very little use of chest muscles for chest expansion
                                during inspiration
                        b.      Use diaphragm – anything putting pressure on abdomen can
                                compromise respirations
                        c.      Muscle fatigue can lead to respiratory failure
                4.      Heart rate
                        a.      Compensatory mechanism for decreased oxygenation
                        b.      Infant’s can exceed 200 bpm if ill
                5.      Perfusion
                        a.      Children able to constrict blood vessels to maintain perfusion of
                                vital organs
                        b.      Signs of decreased perfusion: pale skin, weak distal pulses,
                                delayed capillary refill, and cool hands and feet
                6.      Skeletal system
                        a.      Presence of growth plates
                        b.      Bones weaker and more flexible
                        c.      Presence of fontanels in infants

II.     Growth and Development
        A.    Neonate or newborn – first month
        B.    Infant – 1 month to 1 year
              1.      Respond mainly to physical stimuli
              2.      Crying is main avenue of expression
              3.      Rapid progression to cooing, smiling, rolling over, recognition of parents
                      and/or caregivers
              4.      Usually not afraid of strangers progressing to crying if separated after
                      caregiver recognition
              5.      Develops
              6.      Begin assessment by observing from distance (infant held by caregiver)
              7.      Warm hands and end of stethoscope

OEC Lesson Outline: Chapter 30                                                                     3
                8.     Torso-to-head approach
                9.     Provide sensory comfort
                10.    Make procedures as fast as possible
        C.      Toddler – first to third year
                1.     Able to open doors, drawers, boxes, and bottles
                2.     Request permission of parent to render care
                3.     Stranger anxiety develops early
                       a.        Resist separation from caregivers
                       b.        Afraid to let others come near them
                4.     Develops independence
                       a.        Unhappy about being restrained or held for procedures
                       b.        Restrain for as short a time as possible
                       c.        Make as many observations as possible before touching child
                5.     Difficulty describing or localizing pain
                6.     Begin assessment at hands or feet
        D.      Preschool-age child – age three to six years
                1.     Use simple language
                2.     Active imaginations
                3.     Rich fantasy life
                       a.        Fearful about pain and change involving bodies
                       b.        Believe thoughts or wishes can cause injury to themselves or
                       c.        Can believe injury was due to a bad deed done earlier
                4.     Understand directions
                5.     Able to describe sensations and identify painful areas when questions
                6.     Use some form of distraction during examination
                7.     Avoid words that suggest invading the child’s body
                8.     Tell child what you are going to do immediately before you do it
                9.     Use adhesive bandage to cover site of injection or other small wound
        E.      School-age child – age six to 12 years
                1.     Able to think in concrete terms
                2.     Respond sensibly to direct questions
                3.     Help to care for themselves
                4.     Talk to child not just parent
                5.     Give appropriate choices and ask only questions that you can control the
                6.     Encourage cooperation by allowing child to handle equipment such as the
                7.     Understand difference between emotional and physical pain
                8.     Reward child after procedure but only at its completion
        F.      Adolescent – age 12 to 18 years
                1.     Able to think abstractly
                2.     Focus of their strength has moved from parents to peers
                3.     Very concerned about body image
                4.     May have strong feelings about being observed during procedures
                5.     Special problems
                       a.        Substance abuse
                       b.        Sexually transmitted diseases
                       c.        Pregnancy
                6.     Respect privacy at all times
                7.     Provide information as requested

OEC Lesson Outline: Chapter 30                                                                4
                8.      Have clear understanding of the purpose and meaning of pain
                        a.     Assess pain by facial and body expression and by asking
                        b.     Can be very stoic
                        c.     Use distraction talking about their interests
                9.      May regress into childlike behavior when injured or ill

III.    Assessment
        A.    Build on previously presented material as necessary
              1.     Scene size-up (emphasis on safety)
              2.     Initial assessment
              3.     History and physical exam
                     a.       Unresponsive patient – rapid
                     b.       Responsive trauma patient, no significant MOI – chief complaint
                              and focused physical exam as allowed
                     c.       Responsive medical patient – focused emphasis on medical
                              history (OPQRST)
              4.     Detailed physical exam
              5.     Ongoing assessment
        B.    Pediatric
              1.     Reason for specialized approach
              2.     Important to deal with and include parents in assessment and treatment.
              3.     Approach patients at their eye level
              4.     Be aware of compensatory mechanisms
                     a.       Work-of-breathing (WOB)
                              i.      Increased rate
                              ii.     Retractions
                              iii.    Position
                     b.       Heart rate
                     c.       Peripheral vasoconstriction
                     d.       Anxiety
                     e.       Level of responsiveness
                              i.      Use AVPU scale
                              ii.     Age-specific responses to verbal stimuli
                              iii.    Recognition of caregiver (parent)
              5.     Susceptibility to hypothermia

IV.     Pediatric Airway
        A.     Positioning
               1.      Critical
               2.      Neutral sniffing position
               3.      Steps
                       a.       Firm surface
                       b.       1‖ padding beneath shoulders and back
                       c.       Tape across forehead
        B.     Airway adjuncts
               1.      Chose appropriately sized equipment
        C.     Assisting ventilation and oxygenation
               1.      Observe chest rise in older children
               2.      Observe abdominal rise in younger children and infants.
               3.      Skin condition indicates the amount of oxygen getting to the organs

OEC Lesson Outline: Chapter 30                                                                  5
                4.     Administer oxygen
        D.      Airway obstruction
                1.     Anatomy and physiology (see references above and previously presented
                2.     Assessment (see references above and previously presented material)
                3.     Causes
                       a.     Younger than 5 years, any object they can fit into their mouths
                       b.     Trauma – dislodged teeth, secretions
                       c.     Secretions – blood, vomitus, other
                       d.     Infections
                              i.      Croup
                              ii.     Epiglottitis
                4.     Signs and symptoms
                       a.     Upper airway
                              i.      Decreased or absent breath sounds
                              ii.     Stridor (high-pitched noise usually on inspiration)
                              iii.    Croup (bark of a seal on coughing expiration)
                       b.     Lower airway
                              i.      Wheezing (whistling sound)
                              ii.     Rales (crackling breath sound)
                              iii.    Auscultate at level of armpit
                       c.     Complete obstruction
                              i.      Ineffective cough (no sound)
                              ii.     Inability to speak or cry
                              iii.    Increasing respiratory difficulty, with stridor
                              iv.     Cyanosis
                              v.      Loss of consciousness
                5.     Emergency care
                       a.     Conscious child – partial obstruction
                              i.      If observed encourage cough
                              ii.     Provide supplemental oxygen
                       b.     Conscious – complete obstruction
                              i.      Perform Heimlich Maneuver on standing or sitting child
                              ii.     Finger sweep upper airway if object is visualized
                       c.     Unconscious – child
                              i.      Tongue-jaw lift to visually check for object in upper airway
                              ii.     Finger sweep if visualized
                              iii.    Abdominal thrusts
                                              Place child supine
                                              Inspect upper airway
                                              Attempt rescue breathing
                                              If unable to ventilate, kneel beside or straddle
                                               child’s hips
                                              Give five abdominal thrusts
                                              Open airway, visualize
                                              Remove object with finger sweep if visualized
                                              Attempt rescue breathing
                                              If obstruction remains, repeat abdominal thrusts
                       d.     Unconscious – infant
                              i.      No abdominal thrusts

OEC Lesson Outline: Chapter 30                                                                   6
                                 ii.    Hold infant face down on forearm, head lower than rest of
                                 iii.   Deliver five back blows between shoulder blades with heel
                                        of hand
                                 iv.    Place free hand behind infant’s head and back and turn
                                        face up while sandwiched between arms
                                 v.     Give five quick chest thrusts
                                 vi.    Check airway if object seen remove; if not repeat cycle
                                 vii.   If still unconscious after removal check for circulation and
                                        continue to CPR if necessary
                        e.       Transport in recovery position
                        f.       Have full vitals available
                        g.       Use pediatric resuscitation equipment if necessary
                        h.       Transport to pediatric specialty facility
                        i.       Take care never to hyperextend neck

V.      Vital Signs
        A.      Vary with age – Table 30-2
        B.      Approach to taking also varies with age
        C.      Warm equipment
        D.      Respirations
                1.      Abnormalities common sign of illness or injury
                2.      Count for at least 30 seconds
                3.      Observe abdomen not chest
                4.      Note effort, use of accessory muscles
                5.      Listen for noises
        E.      Pulse
                1.      May be difficult to palpate if markedly altered
                2.      In infants use brachial or femoral area
                3.      Older children use carotid – light pressure
                4.      Count for at lease one minute
                5.      Note strength
        F.      Blood pressure
                1.      Cuff must cover two thirds of upper arm
                2.      Value of same in field reduced for ages 3 and under
        G.      Skin signs
                1.      Note temperature and moisture with other vitals
                2.      Capillary refill

VI.     Specific Respiratory Emergencies
        A.      Assessment – general pediatric
                1.     Keep age-specific reference charts handy
                2.     Assess changes form the norm in relation to child’s activity level
                3.     Age-specific approach (see references above)
                4.     Observe abdomen not chest
                5.     To maximize air intake, work of breathing (WOB) increases
        B.      Croup
                1.     Anatomy and physiology (see references above)
                2.     Causative agent – virus (most common in ages 1-3)
                3.     Assessment (see references above)
                4.     Signs and symptoms

OEC Lesson Outline: Chapter 30                                                                     7
                        a.     Upper respiratory tract infection
                               i.       Rhinitis
                               ii.      Sore throat
                        b.     Hoarseness
                        c.     Characteristic barking cough
                        d.     Low grade fever
                5.      Emergency care
                        a.     Hydrate (administer fluids by mouth)
                        b.     Inhalation (cool mist nebulizer)
                        c.     Seek physician evaluation if fails to improve or stridor develops
        C.      Epiglottitis
                1.      Anatomy and physiology (see references above)
                2.      Causative agent – virus Haemophilus influenzae (most common in ages
                        18 month to 7 years)
                3.      Assessment (see references above)
                        a.     If suspected, use great care and calm in assessment
                               i.       Do not look in patient’s mouth
                               ii.      Do not put tongue blade in mouth or gag
                               iii.     Do not upset or frighten
                               iv.      Above can cause spasm and complete airway obstruction
                4.      Signs and symptoms
                        a.     Acute onset
                        b.     Fever (higher than croup)
                        c.     Difficulty swallowing
                        d.     Muffled voice
                        e.     Progressive stridor
                        f.     Increasing respiratory distress
                        g.     Preferred patient position – upright, tripod
                        h.     Breathes through mouth
                        i.     Drooling
                5.      Emergency care
                        a.     True pediatric emergency may quickly progress to complete
                               airway obstruction
                        b.     High-flow oxygen—use least upsetting method of delivery
                        c.     Immediately transport to medical facility
                        d.     Have caregiver hold patient to keep calm
                        e.     Give nothing by mouth in case of rapid deterioration
        D.      Asthma
                1.      Anatomy and physiology
                        a.     Build on previously presented material as necessary
                2.      Causative agent (see references above)
                        a.     Upper respiratory tract infections
                        b.     Cold
                3.      Assessment (see references above)
                4.      Signs and symptoms (see references above)
                        a.     Wheezing on inspiration
                        b.     Observable respiratory distress
                5.      Emergency care
                        a.     High flow oxygen—use least upsetting method of delivery
                        b.     Rapid transport

OEC Lesson Outline: Chapter 30                                                                     8
                        c.       Inhaler administration by patient or under direction of parent or
                      d.         Epi-Pen by patient or caregiver
        E.      Bronchiolitis
                1.    Anatomy and physiology (see references above)
                2.    Causative agent – usually viral of smaller air passages of lung (most
                      common ages 2 and under)
                3.    Assessment (see references above)
                4.    Signs and symptoms
                      a.       Respiratory distress
                      b.       Wheezing
                      c.       Cough
                      d.       In very young infants, first sign may be apnea
                5.    Emergency care
                      a.       High-flow oxygen – use least upsetting method of delivery
                      b.       Suctioning nostrils as needed
                      c.       Supporting breathing s necessary
                      d.       Immediate transport to medical care
        F.      Bronchitis and pneumonia
                1.    Anatomy and physiology (see references above)
                      a.       Bronchitis – infection of the large and small air passages
                      b.       Pneumonia – infection of the alveoli and spaces between them
                2.    Causative agent – usually viral (common in ages 2 and under)
                3.    Assessment (see references above)
                4.    Signs and symptoms
                      a.       Fever
                      b.       Respirator distress
                      c.       Cough
                      d.       In very young infants first sign may be apnea
                5.    Emergency care
                      a.       High-flow oxygen – use least upsetting method of delivery
                      b.       Suctioning nostrils as needed
                      c.       Supporting breathing s necessary
                      d.       Immediate transport to a medical facility

VII.    Other Emergencies
        A.     Cardiopulmonary arrest
               1.     Anatomy and physiology (see references above)
               2.     Assessment (see references above) – focus in pediatric BLS is airway
               3.     Cause
                      a.    Adult – abnormal cardiac rhythm due to underlying cardiac
                      b.    Children – usually healthy hearts
                            i.      Respiratory failure
                                          Injury
                                          Infections
                                          Foreign body in airway
                                          Near drowning
                                          Electrocution
                                          Poisoning or drug overdose

OEC Lesson Outline: Chapter 30                                                                       9
                                               Sudden infant death syndrome (SIDS)
                                 ii.    Circulatory failure
                                               Illness
                                               Injury
                4.     Signs and symptoms – absence of respirations and pulse
                5.     Emergency care
                       a.      CPR – pediatric BLS
                       b.      High-flow oxygen
                       c.      Rapid transport to medical facility
        B.      Seizures
                1.     Anatomy and physiology (see references above)
                2.     Assessment (see references above)
                3.     General categories
                       a.      Generalized (grand mal) seizures
                               i.       Back-and-forth motions of upper and lower extremities
                               ii.      Unresponsive to verbal commands or painful stimuli
                       b.      Partial seizures
                               i.       Movement in one limb
                               ii.      Lip smacking
                               iii.     Eye deviation
                       c.      Absence (petit mal) seizures
                               i.       Unresponsiveness
                               ii.      With or without any movement
                4.     Signs and symptoms (see references above)
                       a.      Movements cannot be stopped on command or by holding an
                               extremity (duration varies from patient to patient)
                       b.      Postictal period
                               i.       Extreme fatigue or unresponsiveness from a few minutes -
                                        several hours after
                               ii.      Sleepy and/or confused, not able to interact appropriately
                       c.      Status epilepticus – continuous or multiple seizures without return
                               to consciousness in excess of 30 minutes
                5.     Causes
                       a.      Chemical – medications or poisons
                       b.      Abuse or neglect
                       c.      Fever
                6.     Febrile seizures (common between 6 months to 6 years of age)
                       a.      Typically occur on day 1 of fever
                       b.      Characterized by tonic-clonic seizure activity
                       c.      Last less than 15 minutes with short poetical phase
                       d.      Persistent fever can lead to another
                       e.      Require medical evaluation in hospital
                7.     Emergency care
                       a.      Scene safety
                       b.      ABC’s
                       c.      Brief history from caregivers regarding illnesses, medication, or
                       d.      Priority is securing and protecting airway
                       e.      Place in recovery position
                       f.      If trauma suspected observe spinal precautions
                       g.      Have suction available and use as necessary

OEC Lesson Outline: Chapter 30                                                                  10
                        h.      Do not place fingers inside mouth
                        i.      Be ready to support and assist ventilations
                        j.      Signs of inadequate breathing
                                i.       Very slow respirations
                                ii.      Very shallow breaths
                                iii.     Bluish tint to or very pale lips
                                iv.      Snoring respirations (snoring due to obstruction by tongue)
                       k.       Oxygen by mask or nasal cannula – BVM ventilation if no
                       l.       Note type of movement and position of eyes
                       m.       If febrile begin cooling with tepid water
                       n.       Protect patient from hitting sides of stretcher or nearby equipment
                       o.       Give all containers found at scene to EMS team
        C.      Altered level of consciousness
                1.     Anatomy and physiology (see references above)
                2.     Assessment (see references above)
                       a.       Common cause mnemonic – AEIOU-TIPS
                                i.       Alcohol
                                ii.      Epilepsy, endocrine, or electrolyte abnormalities
                                iii.     Insulin or low blood glucose levels
                                iv.      Opiates or other drugs
                                v.       Uremia
                                vi.      Trauma or temperature
                                vii.     Infection
                                viii.    Psychogenic or poison
                       b.       Shock, stroke, or shunt obstruction
                       c.       Assess ABC’s, provide care as needed
                       d.       Use AVPU scale
                       e.       Pupils, dilation and position
                       f.       Presence of posturing
                3.     Signs and symptoms (described in earlier chapter)
                       a.       Infants - nonverbal
                                i.       Tracking – following a person’s face or object
                                ii.      Babbling, cooing or crying
                       b.       Infants (verbal) and children
                                i.       Lack of response to vocal commands and pain
                                ii.      Combative behavior
                                iii.     Confusion
                                iv.      Thrashing about
                                v.       Drifting into and out of alert state
                                vi.      Change in pitch and nature of cry
                4.     Emergency care
                       a.       Secure airway
                       b.       Provide assisted ventilation with a BVM device
                       c.       Log roll if trauma suspected, use backboard and cervical collar
                       d.       Supplement oxygen with nasal cannula
                       e.       With active seizure activity provide care as previously stated
                       f.       Call ALS backup as necessary
        D.      Poisoning
                1.     Method of occurrence
                       a.       Ingestion – taking by mouth

OEC Lesson Outline: Chapter 30                                                                    11
                        b.    Inhalation - lungs
                        c.    Injection – via needle, insect, arachnid, or reptile
                        d.    Absorption – skin
                2.      Assessment (see references above)
                        a.    Questions for caregiver
                              i.      What is substance involved
                              ii.     How much was ingested or exposed to
                              iii.    Time of incident
                              iv.     Any changes in behavior or level of consciousness
                              v.      Any choking or coughing after exposure
                        b.    Focus on ABC’s
                        c.    Level of consciousness
                3.      Emergency care
                        a.    Will be guided by how awake and alert the child appears
                        b.    Be prepared for rapid changes in child’s condition
                        c.    Support vital functions as necessary to include oxygen
                              administration if necessary
                        d.    If combative and/or agitated protect yourself from injury
                        e.    Do not administer syrup of ipecac unless directed to do so
                        f.    Attempt to find container
                        g.    Collect any vomitus and take to emergency department
                        h.    Focus immediately on ABC’s if unresponsive
                        i.    Arrange for rapid transport to emergency department
        E.      Shock
                1.    Anatomy and physiology
                      a.    Build on previously presented material as necessary
                      b.    Infants and children have smaller blood volume = shock with
                            smaller blood loss
                2.    Assessment (see references above)
                      a.    Focus on ABC’s taking immediate action – no waiting to complete
                            a detailed assessment
                      b.    Be aware drop in blood pressure is a very late (and ominous) sign
                            in pediatric shock
                      c.    Circulation – focus on:
                            i.      Pulse rate and quality
                                           Weak, ―thready‖ = problem
                                           Anything over 160 beats/min suggests shock
                            ii.     Skin signs
                                           Temperature
                                           Moisture
                            iii.    Capillary refill
                            iv.     Color
                      d.    Blood pressure
                            i.      Use appropriate sized cuff
                            ii.     May be normal = compensated shock
                            iii.    Low = decompensated shock, requires ALS care
                      e.    Other considerations to determine
                            i.      Any decrease in urine output (infants with less than 6 to 10
                                    wet diapers)
                            ii.     Absence of tears

OEC Lesson Outline: Chapter 30                                                                12
                              iii.    Changes in level of consciousness or behavior
                3.     Emergency care (see references above)
                       a.     Ensure an open airway
                       b.     Be prepared to assist ventilations
                       c.     Control bleeding if present
                       d.     Supplement oxygen as tolerated
                       e.     Position patient – feet above level of heart
                       f.     Keep warm
                       g.     Continue to monitor vital signs
                       h.     Contact ALS
                       i.     Allow caregiver to accompany
                       j.     Arrange for rapid transport
        F.      Dehydration
                1.     General
                       a.     Fluid losses exceed fluid intake
                       b.     Most common cause – vomiting and diarrhea
                       c.     Can lead to shock and death if not treated
                       d.     Infants and children at greater risk
                2.     Types
                       a.     Mild
                       b.     Moderate
                       c.     Severe
                3.     Assessment (see references above)
                       a.     Mild
                              i.      Dry lips and gums
                              ii.     Decreased saliva
                              iii.    Fewer wet diapers
                       b.     Moderate
                              i.      Very dry lips and gums
                              ii.     Eyes look sunken
                              iii.    Sleepy and/or irritable
                              iv.     Refusing bottles
                              v.      Skin tenting
                              vi.     Infants with sunken fontanels
                       c.     Severe
                              i.      Skin mottled, cool, clammy
                              ii.     Delayed capillary refill
                              iii.    Respirations usually increased
                              iv.     Blood pressure may remain normal until shock develops
                4.     Emergency care
                       a.     Careful attention to ABC’s with baseline vital signs
                       b.     ALS backup for severe dehydration cases for early IV access
                       c.     Rapid transport to hospital for all moderate to severe cases
        G.      Hyperthermia – build on previously presented material as necessary
                1.     Children produce more heat for their size than adults
                2.     Acclimatize more slowly
                3.     Avoid overdressing in hot weather
                4.     Older children and adolescents may develop exertional heat stroke
                5.     Emergency care
                       a.     Cool rapidly
                       b.     Transport to medical care immediately

OEC Lesson Outline: Chapter 30                                                                13
        H.      Hypothermia – build on previously presented material as necessary
                1.    Rapid heat loss in newborns and premature babies
                      a.       Large heads
                      b.       Lower proportions of body fat
                      c.       Poor thermal regulation
                      d.       Large ratio of body surface area to mass
                2.    Older children also more susceptible than adults
                3.    Prevention
                      a.       Dress properly in cold weather (warm hat)
                      b.       Keep dry
                      c.       Insulate and warm an injured or ill pediatric patient in cold
                               environment – blankets over and under patient
                      d.       Emergency care same as for adults
         I.     Severe infection (Sepsis)
                1.    Focus is on assessment – build on previously presented material as
                      a.       OPQRST
                      b.       Septic infant or child ―looks ill‖
                               i.      Irritable or lethargic
                               ii.     May fail to recognize caregiver
                               iii.    Skin pale, ashen or cyanotic may be hot or cool to touch
                               iv.     Capillary refill may be slow
                               v.      BP may be low
                               vi.     Heart and respiratory rates usually high until terminal, then
                               vii.    History of upper respiratory tract infection, fever, vomiting,
                                       diarrhea, lethargy, irritability or feeding problems
                      c.       Question whether recently exposed to sick people
                      d.       Take temperature
                2.    Emergency care
                      a.       High-flow oxygen via age-appropriate sized equipment
                      b.       Immediately transported to medical care
                      c.       Remove excess clothing but do not attempt to cool

VIII.   Injuries to Specific Body Systems
        A.      Head injuries
        B.      Anatomy and physiology
                1.     Common in children due to size of head
        C.      Signs and symptoms
                1.     Reference corresponding chapters on adults
                2.     Suspect head injury with nausea and vomiting following a traumatic event
                       with a child
        D.      Emergency care
                1.     Reference corresponding chapters on adults
                2.     Ensure open airway
                3.     Cervical spine immobilization using jaw-thrust maneuver to open airway
                4.     Avoid using sandbags to immobilize head
                5.     Do not hyperventilate head injured child until normal ventilations have
                       been established with a BVM device x several minutes
                6.     Be prepared for respiratory arrest
        E.      Chest injuries

OEC Lesson Outline: Chapter 30                                                                     14
                1.      Anatomy and physiology
                        a.      Ribs are very soft and flexible in children
                2.      Signs and symptoms
                        a.      Reference corresponding chapters on adults
                3.      Emergency care
                        a.      Reference corresponding chapters on adults
        F.      Abdominal injuries
                1.      Anatomy and physiology
                        a.      Reference corresponding chapters on adults
                2.      Signs and symptoms
                        a.      Reference corresponding chapters on adults
                        b.      May not be observable immediately
                        c.      Monitor very, very closely for shock
                                i.       Tachycardia
                                ii.      Poor capillary refill
                                iii.     Mental status changes
                3.      Assessment
                        a.      Reference corresponding chapters on adults
                        b.      Index of suspicion should be high following a high-energy trauma
                        c.      Abdominal distention in children may be due to swallowed air
                4.      Emergency care
                        a.      Reference corresponding chapters on adults
        G.      Injuries of the extremities
                1.      Anatomy and physiology – same as for adults
                        a.      Reference corresponding chapters on adults
                        b.      Potential weak spots exist – growth plates at ends of long bones
                        c.      Bones are more pliable – incomplete or greenstick fractures occur
                2.      Signs and symptoms – same as for adults
                3.      Assessment - common pediatric fractures
                        a.      Clavicle – most common
                        b.      Arm and wrist
                        c.      Elbow – true emergencies due to high degree of neurovascular
                        d.      Femur and tibia fractures require less force in pediatric population
                        e.      Ankle less common but when they do, fracture usually on outside
                                of same
                4.      Emergency care – same as for adults
                        a.      Splint deformed limbs as found except in absence of distal pulse –
                                realign only until pulse resumes
                        b.      Utilize splint or stabilization device appropriately sized for the
        H.      Burns
                1.      Anatomy and physiology – same as for adults
                2.      Signs and symptoms – same as for adults
                3.      Assessment – same as for adults
                        a.      Pediatric considerations
                                i.       Infections – sterile handling required
                                ii.      Consider possibility of child abuse in any burn situation
                                         and report information to hospital staff
                4.      Emergency care (see references above)
         I.     Submersion injury

OEC Lesson Outline: Chapter 30                                                                    15
                1.      Types
                        a.      Near drowning
                        b.      Drowning – second most common cause of unintentional death
                                among children in the U.S. ages 5 and under
                2.      Injuries sustained
                        a.      Anoxia
                        b.      Hypothermia
                        c.      Spinal cord injury with diving
                        d.      Secondary drowning – minutes or hours later due to pulmonary
                3.      Assessment
                        a.      ABCs – assess and reassess
                        b.      Care towards cervical spine if diving
                        c.      With ineffective ventilation suspect foreign body obstruction –
                                water won’t obstruct
                        d.      Have suction available
                4.      Emergency care
                        a.      Support ABCs
                        b.      High-flow oxygen as needed
                        c.      Suction as needed
                        d.      Immobilize on spine board if necessary
                        e.      Rapid transport to medical facility
                5.      Emergency care of the injured pediatric patient
                        a.      Always use size/age appropriate equipment
                        b.      When immobilizing on a spine board always place two-to-three
                                inches of padding beneath the trunk of a patient younger than
                                eight years of age to maintain neutral anatomical positioning
                        c.      Support family – calm parent helps contribute to a calm child
                        d.      Do not allow parent to hold child during a toboggan transport

IX.     Child Abuse
        A.     Types
               1.    Physical abuse
               2.    Sexual abuse
               3.    Neglect
               4.    Emotional abuse
        B.     Assessment
               1.    Mnemonic for assessing: CHILD ABUSE
                     a.     Consistency of injury with developmental age
                     b.     History inconsistent with injury
                     c.     Inappropriate parental concerns
                     d.     Lack of supervision
                     e.     Delay in seeking care
                     f.     Affect
                     g.     Bruises of varying ages
                     h.     Unusual injury patterns
                     i.     Suspicious circumstances
                     j.     Environmental clues
               2.    Bruises
                     a.     Color and location
                     b.     Bruises to back, buttocks, or face are usually inflicted by a person

OEC Lesson Outline: Chapter 30                                                                    16
                3.      Burns
                        a.     Burns to penis, testicles, vagina, or buttocks are usually inflicted
                               by a person
                        b.     Circumferential burns about hands, feet or a child’s body
                        c.     Cigarette burns or grid pattern burns
                4.      Fractures
                        a.     Humerus and femur fractures usually do not occur without major
                               trauma such as a fall from a high place or MVA
                5.      Shaken baby syndrome
                        a.     Evidenced by intracranial bleeding
                        b.     Damage to the cervical spine
                        c.     Found unconscious often without external trauma
                6.      Neglect
                        a.     Dirty
                        b.     Too thin
                        c.     Developmentally delayed
                7.      Other symptoms and indicators
                        a.     Child withdrawn, fearful or hostile
                        b.     Suspicious if child refuses to discuss how injury occurred
                        c.     Parent or caregiver reveals history of several ―accidents‖ – be
                               alert for conflicting stories
                        d.     Marked lack of concern
                8.      Emergency care
                        a.     Treat injuries
                        b.     Transport all suspected abuse cases
                        c.     Report all suspicions and observations
                        d.     Allow law enforcement to deal with the problem


Assessment in Action
This activity is designed to assist students in gaining a further understanding of issues
surrounding pediatric airway management. The activity incorporates both critical thinking and
application of OEC knowledge.

While patrolling at a cross-country ski area, you are called to the chalet halfway around the 6-
mile course. There is a 12-year-old girl sitting with her hands on her knees having difficulty
breathing. ―I can’t get enough air.‖ It is 0°F outside. Her mother says she has exercise-induced

Answers to Multiple-Choice Questions
      1.     A
      2.     B
      3.     B
      4.     C
      5.     A
      6.     B
      7.     C
      8.     D

OEC Lesson Outline: Chapter 30                                                                        17
         9.       D
         10.      A

Points to Ponder
This activity enables you to help students probe the more difficult situations that they may face.
Use this as an opportunity to allow them to express differences of opinion and approach, while
directing them to be thorough and decisive in their answers. Encourage challenges.

You arrive at the scene of a collision involving a 5-year-old girl and an adult. The adult appears
to be fine physically, but is very stressed and anxious about the condition of the child. Your
assessment finds the child to be unresponsive, with multiple small wounds and abrasions. You
suspect a spinal injury. You do not have any pediatric spinal stabilization equipment in the top
dispatch nor is there any on either of the toboggans coming to the scene. You feel this situation
warrants a load and go. What are the risks of using equipment that is too large? What are the
risks of waiting for proper equipment to come from the base medical clinic?

        Decision-making skills
        Problems without clear answers
        Alternative resources
        Calming excited participants
        Duty to transport
        Scene investigation/risk management

               1. You do not have any pediatric spinal stabilization equipment, what is the risk of
                  using equipment that is too large?
                       If equipment is used that is too large for the patient, you will have poor
                         stabilization and risk further injury to the patient. An alternate method
                         should be used such as towel or blanket rolls.
               2. What are the risks of waiting for proper equipment to come from the base
                  medical clinic?
                       Because pediatric patients have a relatively large head size, a greater
                         body surface mass area-to-mass ratio, and a less stable system for
                         regulating body temperature, they are more prone to heat loss and
                         therefore more susceptible to hypothermia. Therefore, transport should
                         not be delayed.

Online Outlook www.OECzone.com

This activity requires students to have access to the Internet. This may be accomplished
through personal access, employer access, or through a local educational institution. Some
community colleges, universities, or adult education centers may have classrooms with Internet
capability that will enable this activity to be completed in class. Check out local access points
and encourage students to complete this activity as part of their on-going reinforcement of the
EMT-B knowledge and skills.

OEC Lesson Outline: Chapter 30                                                                        18

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