INFANTS AND CHILDREN

							INFANTS AND
  CHILDREN
Objectives
• Understand the anatomic and
  physiologic characteristics of infants
  and children
• Adapt history-taking and assessment
  techniques
• Pediatric
Patients who have not yet reached the
  age of puberty
Puberty
• Female   breast development
• Male     hair on face, chest or
           underarm
Dealing with pediatric patients
Requires
• Specific knowledge
• Creativity
• Patience
• Be careful of sarcasm and joking
The adolescent
• 12 to 18 yrs
• Sensitive to their dignity
• Sensitive to being patronized
• When injured scared or anxious may
  act immature or act out
• May be embarrassed or intimidated
  by the attention
• Sensitive to their peers and what
  they think
• May be intimidated by those of
  authority
• Be discrete
• The young adolescent may be
  embarrassed by the changes to his /
  her body.
• A simple explanation of an exam
  before hand will ease the patient
• Inform and explain the exam to both
  parent and patient before performing
• Whenever possible an EMT of the
  same sex should be present when an
  exam is performed
Supporting the parents or other care
 providers

• A calming influence can make a
  difference in how a parent responds.
Reaction of parents to sudden life-
  threatening injury or illness
• Denial or shock
• Cry, scream, become angry
• Self-guilt, blame
     be calm, reassuring and supportive
If parents interfere:
• Try to persuade to assist in care
• If necessary, have friend or relative
  remove from scene
• Child may not live in traditional 2-parent
  home
      use tact
Gain confidence and calm all involved
Don’t distract from care of child
Assessing
• The condition of a sick/injured child
  can change rapidly
• Signs or symptoms can be subtle
Pediatric Assessment Triangle
• Appearance
     from the doorway
     Mental Status
     Body position
           sniffing position
           tripod
           refusal to lie down
           muscle tone
Breathing
  Include the airway
• Visible movement with breathing
• Effort
     retractions
     nasal flaring
     noisy
Circulation
• Skin color
• Pulse
• Subtle cyanosis
• Capillary refill
“Treat as you go care”
SCENE SIZE-UP & SAFETY
• Enter Slowly
• Observe for safety and mechanism
  of injury
INITIAL ASSESSMENT
General Impression
• Well or sick
• Mental status
      drowsy
      sleepy
      inattentive
• Effort of breathing
• Skin color
      pale
      cyanotic
      flushed
• Quality of speech
     strong cry
     speak only in short sentences
     grunts
• Interaction with the environment or
  others
     silence
     listlessness
     unconscious
• Emotional state
      withdrawn
      emotionally flat
• Response to you
      inattention to strangers
• Tone and body position
      limpness
      poor muscle tone
      position to indicate respiratory
  distress
• Mental status
        AVPU
        never shake
Airway
   depressed mental status
   secretions
   blood
   vomitus
   trauma
   infections

Do not hyperextend neck
Breathing
• Chest expansion
• Effort of breathing
• Sounds of breathing
• Breathing rate
• Color
Circulation
• Skin color
• Pulse
     radial in child
     brachial or capillary refill for
     infants or child <5
PRIORITY PATIENTS
• Poor General Impression
• Unresponsive or listless
• Does recognize parents or primary
  care   givers
• Not comforted when held by parent
  but becomes calm and quiet when set
     down
• Compromised airway
• Respiratory arrest or inadequate
  breathing
• Possibility of shock
• Uncontrollable bleeding
FOCUSED HISTORY AND PHYSICAL
  EXAM
• Get at eye level
• Ask simple questions
• Always explain what you are doing to
  a child
• Never lie
• Base-line vital signs
     low b/p may indicate imminent
     cardiac arrest
DETAILED PE
• Toe-to-head exam with infants and
  small children
• Unless injury/illness won’t permit,
  allow parent to hold child in lap
• Must be secured during transport
• Shelter from stares and onlookers
• Children loose heat quickly so recover
     quickly after exposing for exam
Specific considerations
• Head
     don’t apply pressure to fontanels
  in      infants
• Nose and ears
     if you observe blood or clear fluid,
     suspect skull fracture
• Neck
     be conscious of stiffness,
  soreness or swelling in medical
  emergencies
• Airway
     neutral position in infants
     sniffing or neutral-plus position in
     children
ON-GOING ASSESSMENT
• DON’T TAKE YOUR EYES OFF
  YOUR PEDIATRIC PAITENT FOR A
  MINUTE

Oxygen Administration
• Consider blow-by method
CARING FOR SHOCK (hypoperfusion)
• Common causes
    diarrhea and/or vomiting with
    resulting dehydration
    infection
    trauma
         especially abdominal injuries
Blood loss
Body              blood volume
9 lb    newborn   12 oz coke can
60 lb    child    2 liter bottle
125 lb adult      2 2-liter
                    bottles
Less common causes
• Allergic reaction
• Poisoning
• Cardiac event

• Compensation
Signs and Symptoms
• Rapid respiratory rate
• Pale, cool, clammy skin
• Weak or absent peripheral pulses
• Delayed capillary refill
• Decreased urinary output
• Mental status change
• Absence of tears even when crying
Care
• Airway
     Oxygen
           always be prepared to deliver
           artificial ventilations
• Manage bleeding
• Elevate legs if no trauma
• Keep warm
     especially top of head
• Transport immediately
Hypothermia
• Larger proportional body surface
     this increases risk
• If active rewarming is necessary,
  consult medical control
• Avoid rough handling
PEDIATRIC MEDICAL EMERGENCIES
Respiratory Disorders
  differentiate upper airway obstruction from
  lower airway disorders
Respiratory Distress
• Nasal flaring
• Retraction
• Stridor (high-pitched, harsh sound)
• Wheezing
• Grunting
• Respiratory rate >60
Other signs of early respiratory
  distress
• Cyanosis
• Decreased muscle tone
• Capillary refill >2 seconds
• Altered mental status
• Decreased blood pressure (late sign)
Care
• O2
• If necessary ventilate
RESPIRATORY COMPRIMISE IS

THE PRIMARY CAUSE of CARDIAC
ARREST IN CHILDREN
RESPIRATORY DISEASES
Croup
• Viral
• 6 months to 4 yrs
• Inflammation of larynx, trachea and
  bronchi
• During the day mild fever and hoarseness
• At night “seal bark” cough, difficulty
  breathing, restlessness, and paleness with
  cyanosis
Care
• High concentration O2
• Position of comfort
• Rapid transport
Epiglottitis
• Bacterial
• Swelling of epiglottis and partial
  airway obstruction
• Can be life threatening
Signs
• Sudden onset of high fever
• Painful swallowing
• Tripod position
• Sitting still but muscles working hard
  to breathe
• Appears more ill than child with
  croup
Care
• Immediate transport with child on
  parents lap if possible
• High concentration of humidified
  oxygen
• Monitor airway; always be prepared
  for ventilations
DO NOT PLACE ANYTHING IN THE
  MOUTH
Fever
• Never blow off a fever as
  unimportant
• There are many causes of fever
• Fever with rash is a potentially
  serious condition
• Febrile seizures
Care
• Remove clothing (be cautious of
  hypothermia)
• If heat exposure, cover with towels
  soaked in tepid water (protocol)
• Monitor for shivering and
  hypothermia
• Give fluids by mouth or ice chips
  (protocol)
• A mild fever can quickly spike
     may be an indication of a serious or
     life-threatening problem
• Rapid transport if a child has had a seizure
     protect against extreme temperatures
• Do not submerge in cold water or cover
  with towels soaked in ice water
• Do not use rubbing alcohol as a means to
  cool
Meningitis
• Viral or bacterial
• Infection of brain lining and spinal cord
Signs/symptoms
• High fever
• Lethargy
• Irritability
• Headache
• Stiff neck
• Sensitivity to light
• Fontanelles may be bulging
• Movement is painful, child does not want to be touched
• Sudden excitement may cause seizures
• rash
Care
• Monitor ABCs and vital signs
• Be alert for seizures
• Care for fever
• Immediate transport

Some forms of meningitis may be
 highly infectious
Diarrhea and Vomiting
• ABCs
     oxygen
     suction
• Monitor for shock
• Save samples of vomitus or rectal
  discharge
Seizures
  consider to be life-threatening
Fever is most common cause
Other causes
• Epilepsy
• Infections
• Poisons
• Hypoglycemia
• Trauma
• Decreased levels of oxygen
Assessment
• Prior seizures
     if yes:   was this a normal seizure
                    pattern?
               How long did it last?
               What part of the body
                    was seizing?
• Recent fevers
• Has the child taken/been given any
  anti-seizure medication or any other
  meds
• Assess for illness and injury
Care
• ABCs
     oxygen
     do not insert op or bite stick
• Watch for vomiting
     suction
• Transport
• Be aware of postictal state
Altered Mental Status
Causes
• Hypoglycemia
• Poisoning
• Infection
• Head injury
• Decreased oxygen levels
• Shock
• Postictal state
Assessment
• Mechanism of injury
• Shock
• Evidence of poisoning
• Obtain history
     seizure disorder
     diabetes
• Transport
Poisoning
Can depress the respiratory,
  circulatory and
nervous systems
Assessment
Aspirin
• Hyperventilation, vomiting, sweating
• Skin may feel hot
• In severe cases: seizures, coma or
  shock
Acetaminophen (Tylenol)
• Restless (early sign) or drowsy
• Nausea, vomiting, heavy perspiration
• Loss of consciousness is possible
Lead
• Nausea with abd pain or vomiting
• Muscle cramps/weakness, headache,
  irritability
Iron
• Within 30 minutes or several hours
     nausea, bloody vomiting, often
  with    diarrhea
• May develop shock
     up to 24 hrs
     child will appear to be getting
     better
Petroleum product poisoning
• Vomiting with coughing or choking
• Distinctive odor of a petroleum
  distillate
Care
• Contact medical direction or the poison control
  center
• Activated charcoal
• Oxygen
• Transport
If unresponsive
• Airway
• Oxygen
• Contact medical direction or the poison control
  center
• Rule out trauma as a cause for altered mental
  status
Drowning
• Water temperature may affect
  outcome
Assessment
• CPR
     if trauma related, CPR with
     considerations and precautions
• Consider alcohol as a contributing
  factor
Secondary drowning syndrome
• Deterioration after normal breathing
  resumes
• Minutes to hours after the event
Care
• CPR
• Suction
• Safe-guard against hypothermia
     remove wet clothing
     dry the skin
     cover with a blanket
• Treat any trauma
• Transport even if they seem to have
  recovered
SIDS
No cause has yet been identified
  do not diagnose
• CPR
  local protocol for obvious signs of death
      i.e. rigor mortis
• Make sure parent receive emotional support
      do not speak with suspicious tone or ask
      inappropriate questions
Maintain composure and professionalism
      you can fall apart afterwards
PEDIATRIC TRAUMA EMERGENCIES
Injuries are the number one cause of death
in infants and children
MVA
• Unrestrained
      head and neck injuries
• Restrained
     Abdominal and lower spine injuries
Struck by vehicle
• Triad of injuries
     Head injury
     ABD injury with possible internal
           bleeding
     Lower extremity injury

Features of head, neck, chest, ABD, and
  extremity trauma………
Head
• Proportionately larger and heavier
     leads to injury when propelled
  forward
• Respiratory arrest is a common
  secondary effect of head injury
• Signs of head injury
     altered mental status
     nausea and vomiting
Chest
• Less developed/immature respiratory
  muscles
• more elastic ribs make the chest
  more easily deformed
• tire easily therefore cannot maintain
  a rapid respiratory rate for long
• Injuries to structures beneath the
  ribs are common as elastic ribs rarely
  fracture
• If MOI is significant, suspect
  internal injuries even if there are no
  signs of chest trauma
Abdomen
• Infants and children are abdominal
  breathers
     observe to evaluate respiratory
  status
• ABD muscles offer less protection to
  organs
• Can be site of hidden injuries
Extremities
• Bones are more flexible
• Injuries are manages the same as
  adults
Burns
• Rule of nines
• Cover the burn with nonadherent dressing
      sterile sheets may be used
• Use precaution with moist dressings
      body surface proportionally larger to body
  mass, making them prone to heat     loss
  burned patients who become hypothermic have a
  higher death rate

Keep covered to prevent drop in body temperature
Trauma Care
• ABCs
      jaw thrust to open airway
      suction if necessary
• Oxygen administration
  high concentration
• Spinal immobilization
• Transport immediately
• On-going assessment
• Assess and treat other injuries en route if time
  permits
CHILD ABUSE AND NEGLECT
No race, creed, ethnicity, or economic
  background is exempt
May include
• Psychological abuse
• Nelgect
• Physical
• Sexual
Physical and sexual abuse
• “battered children”
  children are beaten with anything
  that can be used as a weapon
  children are intentionally burned
  may be severely shaken, thrown,
  pushed down steps, to the extreme
  of being thrown from a car
     shot, stabbed, electrocuted, or
          suffocated
• Sexual abuse ranges from adults
  exposing themselves, to sexual
  torture
Assessment
You may see
• Slap marks
• Bruises
• Abrasions
• Lacerations
• Incisions
• Broken bones
     in various stages of healing
• Head injuries
           shaken baby syndrome
• Abdominal injuries
     ruptured spleens, livers and lungs that
     have been lacerated by broken ribs
• Internal bleeding
     blunt trauma
     punching
     lacerated and avulsed genitalia
• Bite marks
• “Glove” and “stocking” burn marks
     dipping in hot water
• Demarcation burns
     in the shape of utensils used
• Bulging fontanelle
     ICP from shaking
Be on the alert for
• Repeated responses to the same
  child or     children
• Indications of past injuries
• Poorly healing wounds or improperly
      healed fractures
• Past burns or fresh bilateral burns
• Many different types of injuries
  bilaterally or anterior/posterior
• Responses such as “he/she falls a lot”
• Child seems to expect no comfort
  from parents
• No apparent reaction to pain
• Parent or care-giver does not want
  you to be alone with the child
• Conflicting or changing stories or
     overwhelms with explanations
Pay attention to the adult as you treat the
  child
• Inappropriately unconcerned
• Feeling there could be an emotional
      explosion at any moment
• Deep state of depression
• Indications of alcohol/drug abuse
• Voicing suicide or seeking mercy for the
      unhappiness of the child/children
• Refuses to have child transported to the
  nearest hospital or where the child has
  been seen      before
BE THE CHILD’S ADVOCATE BUT
 DO NOT ACUSE THE PARENT
Assessment-Sexual abuse
• Rearrange or remove clothing only as
     necessary to determine and treat
     injuries. helps to preserve
     evidence
• Examine genitalia only if there is
  obvious       injury or the child tells
  you of a recent injury.
• Be as calm and reassuring as possible
Signs include
• Obvious sexual assault
• Unexplained genitalia injury
    bruising
    lacerations
    bloody discharge from genitalia
    orifices
• Try to talk to the child separately
• Control emotions and hold back
     accusations
• Report (protocol)
     obligated
Maintain patient and family
  confidentiality
• Only share information with agencies
     involved
• Use terms such as “suspicion” and
     “possible”
• Remember the suspected abuser
  needs help
• Your suspicions may turn out to be
  unfounded
SUSPICIONS SHOULD BE AROUSED
NOT BY INDIVIDUAL INJURIES
 BUT BY PATTERNS OF INJURIES
 AND BEHAVIORS
Infants and Children with Special
              Needs
Emergency Information Form
• Form kept with patient that contains
     up-to-date information
          medical condition
          history
          precautions needed
          specific management plans
If available, bring form with you
Special Needs include:
• Premature babies with lung disease
• Babies and children with heart
      disease
• Infants and children with neurological
      disease
• Children with chronic disease or altered
      function from birth
Often cared for by parents at home,
  technologically dependent
Tracheostomy tube
• Complications
       Obstruction
       Bleeding from or around the tube
       air leak
       dislodged tube
Care:
• Maintain an open airway
• Suction
• Position of comfort
• Transport
Ventilators
Parents well trained but will call if
  complications
Care:
• Maintain an open airway
• Pocket mask or BVM with O2
• Transport
Central Lines
Complications:
• Infection
• Bleeding
• Clotting
• Cracked line
GI Tubes and Gastric Bleeding
• Tubes placed through the abdominal
    wall directly into the stomach
• Used when Pt. can’t feed orally
• Most dangerous potential problem
    Respiratory Distress
Care:
• Be alert for AMS in diabetic patients
• Protect/maintain the airway
• Suction
• Transport
      sitting
      right side with head elevated
Shunts
• Drainage device that runs from the
     brain to the ABD to drain CSF
Complications:
ICP resulting in AMS
Infection resulting in AMS
Care:
• Patients are prone to respiratory
     arrest
• Maintain/protect airway
• Ventilate if needed
• Transport
• Stress
Blood Pressure
• Not taken in children <3
• Systolic          80 + 2(age)
• Diastolic         2/3 systolic

• Or tables, charts you may have
  access to
Examples:
• 5 yr. old    80 + 2(age)    90
               2/3 systolic   60

• 11 yr. old   80 + 2(age)    102
               2/3 systolic   68