Chapter 33: Pediatrics Emergencies

Drowning

Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid, which may result in death, morbidity (illness or other adverse effects), or no morbidity

Follow these guidelines when ventilating the infant or child patient:

- Avoid breathing too hard through the pocket face mask or using excessive bag pressure and volume. Use only enough force to make the chest rise. Some pediatric bag-valve devices are equipped with pop-off valves. Familiarize yourself with these valves, and ensure that they are disengaged. These devices are designed for use by advanced providers who have expertise in controlling airway pressures. - Use properly sized face masks to ensure a good mask seal. - Flow-restricted, oxygen-powered ventilation devices are contraindicated for infants and children. - If ventilation is not successful in raising the patient's chest, perform procedures for clearing an obstructed airway. Then try to ventilate again.

These differences in respiratory anatomy pose several implications for the emergency treatment you provide to an infant or a child:

- Because infants are nose breathers, be sure to suction secretions from the nose as needed to help the patient breathe. - Hyperextension or flexion of the neck (tipping the head too far back or letting it fall forward) may result in airway obstruction. A folded towel under the shoulders of a supine infant or young child may help to keep the airway in a neutral in-line position. - "Blind" finger sweeps are not performed when trying to clear an airway obstruction in an infant or child because your finger might force the obstruction back and wedge it in the narrow trachea. An attempt to remove a foreign body airway obstruction should be done only when the obstruction is directly observed.

First Viewpoint: "from the doorway"

- Consider the child's mental status using the "AV" part of AVPU (alertness, verbal response). Is the child acting appropriately? How is the patient's muscle tone and general interactivity? Is the child consolable by a parent or caregiver? Is his look or gaze and speech or cry appropriate? - Observe the patient's breathing (including airway). Are there any abnormal airway/breathing sounds such as hoarseness, muffled speech, grunting, wheezing, stridor, or crowing? Is there any abnormal body position such as the sniffing position, tripoding, or refusing to lie down? Are there retractions, nasal flaring, "seesaw" breathing, or head bobbing? - Look at those signs that might indicate a circulation problem, such as pallor, mottling, or cyanosis (a gray-blue coloration).

Identifying Priority Patients: A patient who is a high priority for immediate transport is one who

- Gives a poor general impression - Is unresponsive or listless - Does not recognize the parent or primary caregiver - Is not comforted when held by a parent but becomes calm and quiet when set down - Has a compromised airway - Is in respiratory arrest or has inadequate breathing or respiratory distress - Has a possibility of shock - Has uncontrolled bleeding or has experienced significant blood loss before EMS arrival. Children have very little circulating blood volume, and as a result, it does not require much blood loss to raise concern for a child.

The following are some common groups of children with special challenges:

- Premature infants with lung disease - Infants and children with heart disease - Infants and children with neurological disease - Children with chronic disease or altered function from birth Often these children are able to live at home with their parents. This means that you may receive calls to care for children who have complicated medical problems and are dependent on various technologies. The children's parents will be familiar with the various devices used and can serve as a valuable resource. Common devices include tracheostomy tubes, home artificial ventilators, central intravenous lines, gastrostomy tubes and gastric feeding tubes, and shunts.

There can be certain indications that abuse may be occurring in or outside the home, with the family feeling they must not admit to the problem. Be on the alert for:

- Repeated responses to provide care for the same child or children in a family. - Indications of past injuries. This is one reason you must do a physical examination and remove articles of clothing. Pay special attention to the child's back and buttocks. Poorly healing wounds or improperly healed fractures. It is extremely rare for a child to receive a fracture, be given proper orthopedic care, and show angulations and large "bumps" and "knots" of bone at the "healed" injury site. - Indications of past burns or fresh bilateral burns. Children seldom put both hands on a hot object or touch the same hot object again. Some types of burns are almost always linked to child abuse, such as cigarette burns to the body and burns to the buttocks and lower extremities that result from the child being dipped in hot water. - Many different types of injuries to both sides, or to the front and back, of the body. This gains even more importance if the adults on the scene keep insisting that the child "falls a lot." - Fear on the part of the child to tell you how the injury occurred. - The parent or caregiver at the scene who does not wish to leave you alone with the child, tells conflicting or changing stories, overwhelms you with explanations of the cause of the injury, or faults the child. NOTE: Although parents or caregivers may call for help for the child, they may be reluctant to provide a history of the injury and refuse transport. Take note of any parent who refuses to have his child sent to the nearest hospital or to a hospital where the child has been seen before. This may indicate fear of the staff remembering or seeing a record of past injuries. You cannot transport without parental consent; however, you may be able to convince the parents the child needs to be seen by a doctor because of certain signs and symptoms that are "difficult to determine" in the field. Be the child's advocate, but do not accuse the parent.

In child physical abuse cases, you will find:

- Slap marks, bruises, abrasions, lacerations, and incisions of all sizes and with shapes matching the item used. You may see wide welts from belts, a looped shape from cords, or the shape of a hand from slapping. You may find swollen limbs, split lips, black eyes, and loose or broken teeth. Often the injuries are to the back, legs, and arms. - Broken bones are common and all types of fractures are possible. Many battered children have multiple fractures, often in various stages of healing, or have fracture-associated complications. - Head injuries are common, with concussions and skull fractures being reported. Closed head injuries occur to many infants and small children who have been severely shaken. - Abdominal injuries include ruptured spleens, livers and lungs lacerated by broken ribs, internal bleeding from blunt trauma and punching, and lacerated and avulsed genitalia. - Bite marks showing the teeth size and pattern of the adult mouth may be present. - Burn marks that are small and round from cigarettes; "glove" or "stocking" burn marks from dipping in hot water; burns on buttocks and legs (creases behind the knees and at the thighs are protected when flexed); and demarcation burns in the shape of an iron, stove burner, or other hot utensil are frequently found. - Indications of shaking an infant include a bulging fontanelle due to increased intracranial pressure from the bleeding of torn blood vessels in the brain, unconsciousness, and typical signs and symptoms of head and brain injuries. Injuries to the central nervous system from "the shaken baby syndrome" are among the most lethal child abuse injuries.

Airway and Respiratory System - There are several other special characteristics about infant's and children's respiratory systems that you should be aware of:

- The mouth and nose are smaller and more easily obstructed than in adults. - The tongue takes up more space proportionately in the mouth than in adults. - Newborns and infants typically breathe through their noses. Nasal obstruction can impair breathing. - The trachea (windpipe) is softer and more flexible in infants and children. - The trachea is narrower and is easily obstructed by swelling or foreign objects. - The chest wall is softer, and infants and children tend to depend more on their diaphragms for breathing than do adults. - The thorax is shorter than that of the adult and is located adjacent to a very full abdominal cavity. The normal degree of abdominal distention seen in a child can create a virtual obstruction to the downward movement of the diaphragm. When the child needs to take a deep breath to increase lung volumes, the abdominal contents can prevent the diaphragm from dropping far enough to promote increased lung capacities. - The neonatal ribs are more boxlike as compared to the adult. In an adult, the ribs are more oblong, allowing for greater lift on the chest to promote increased breathing depth. This variation limits the neonate's ability to take a deeper breath when needed.

Pediatric Airway Clearance Sequences

1. Conscious: Child (1 Year to Puberty): Ask, "Are you choking?" Perform subdiaphragmatic abdominal thrusts. Infant (Birth to 1 Year): Observe signs of choking (small objects or food, wheezing, agitation, blue color, not breathing). Series of 5 back blows, 5 chest thrusts. 2. Loses Consciousness during Procedure: Child (1 Year to Puberty): Assist the patient to the floor. Begin 30 chest compressions. Open the airway. Remove any visible objects (no blind sweeps). Attempt to ventilate. If unsuccessful, reposition the head and attempt to ventilate again. If unsuccessful, continue CPR. If alone, call for help after 2 minutes. Infant (Birth to 1 Year): Begin 30 chest compressions. Open the airway. Remove any visible objects (no blind sweeps). Attempt to ventilate. If unsuccessful, reposition the head and attempt to ventilate again. If unsuccessful, continue CPR. If alone, call for help after 2 minutes. 3. Unconscious When Found Child (1 Year to Puberty): Establish unresponsiveness. Open the airway. Attempt to ventilate. If unsuccessful, reposition the head and attempt to ventilate again. If unsuccessful, perform CPR, attempting compressions to ventilation at a 30:2 ratio. Remove any visible objects from the airway (no blind sweeps). Continue CPR until ventilations are successful. Infant (Birth to 1 Year): Establish unresponsiveness. Open the airway. Attempt to ventilate. If unsuccessful, reposition the head and attempt to ventilate again. If unsuccessful, perform CPR, attempting compressions to ventilation at a 30:2 ratio. Remove any visible objects from the airway (no blind sweeps). Continue CPR until ventilations are successful.

When dealing with pediatric patients, you should:

1. Identify yourself simply by saying, "Hi, I'm Pat. What's your name?" 2. Let the child know that someone has called or will call his parents. 3. Determine if there are life-threatening problems, and immediately treat them. If there are no problems of this nature, continue at a relaxed pace. Fearful children cannot take the pressure of a rapidly paced assessment and confusing questions fired at them by a stranger. 4. Let the child have any nearby toy that he may want. 5. Kneel or sit at the child's eye level. Ensure that bright light is not directly behind you and shining into the child's eyes. 6. Smile. This is a familiar sign from adults that reassures children. 7. Touch the child or hold his hand or foot. A child who does not wish to be touched will let you know. Do not force the issue; smile and provide comfort through your conversation. 8. Do not use any equipment on the child without first explaining what you will do with it. Many children fear the medical items that are familiar to the EMT, thinking they will cause pain. Always tell the child what you are going to do as you take vital signs and do a physical exam. Do not try to explain the entire procedure at once. Instead, explain each step as you do it. Use simple language and remember that children tend to take things literally. If you tell a young child, "I'm going to take your pulse," he may think you are going to take something away from him. Instead say, "I'm going to hold your wrist for a minute." If the child is older, explain why. 9. Let the child see your face, and make eye contact without staring at the child. (Staring makes children uncomfortable.) Speak directly to the child, making a special effort to speak clearly and slowly in words he can understand. Be sure the child can hear you. 10. Stop occasionally to find out if the child understands. Never assume the child understood you, but find out by asking questions if the child is old enough to respond. 11. Never lie to the child. Tell him when the examination may hurt. If the child asks if he is sick or hurt, be honest, but be sure to add that you are there to help and will not leave. Let the child know that other people also will be helping.

BLOOD PRESSURE NORMAL RANGES

1. Rough formula for all ages above 3 Approx. Systolic: 80 plus 2 × age Diastolic: Approx. ²⁄3 systolic 2. Preschooler (3-5 years) Systolic: Average 99 (78 to 104) Diastolic: Average 65 3. School age 6-12 years Systolic: Average 105 (80 to 122) Diastolic: Average 69 4. Adolescent (13-18 years) Systolic: Average 114 (88 to 140) Diastolic: Average 76

Anatomic and Physiologic Differences Compared to Adults & Potential Impact on Assessment and Care

1. Tongue proportionately larger - More likely to partially obstruct the airway 2. Smaller airway structures - More easily blocked 3. Abundant secretions - Can block the airway 4. Deciduous (baby) teeth - Easily dislodged; can block the airway 5. Flat nose and face; absence of teeth - Difficult to obtain a good face mask seal 6. Head heavier relative to the body and less-developed neck structures and muscles - Head may be propelled more forcefully than the body, creating a higher incidence of head injury 7. Fontanelle and open sutures (soft spots) palpable on top of young infant's head - Bulging fontanelle can be a sign of intracranial pressure (but maybe normal if the infant is crying); sunken fontanelle may indicate dehydration 8. Thinner, softer brain tissue that occupies less space in the cranium - Susceptible to serious brain trauma 9. Head larger in proportion to body - Head tips forward when supine, causing flexion of the neck, making neutral alignment of cervical spine and airway difficult 10. Shorter, narrower, more elastic (flexible) trachea - Can close off trachea with hyperextension of neck 11. Short neck - Difficult to stabilize or immobilize 12. Abdominal breathers - Reliant on the diaphragm to breathe; difficult to evaluate breathing 13. Faster respiratory rate - Muscles easily fatigue, causing respiratory distress 14. Newborns/infants typically nose breathers - Nasal obstruction can impair breathing 15. Larger body surface relative to body mass - Prone to hypothermia and increased injury because of higher proportions of energy transferred to their little bodies 16. Softer bones - More flexible, less easily fractured; traumatic forces may be transmitted to and injure internal organs without fracturing ribs or other bones 17. More flexible ribs - Traumatic forces may be transmitted to the chest cavity without fracturing ribs; lungs easily damaged with trauma 18. Spleen and liver more exposed - Injury likely with significant force to abdomen

The EMT and Pediatric Emergencies: Psychiatric effects on EMT

Pediatric calls are among the most stressful. May identify patient with own children May be anxious about dealing with children Most serious stresses over very sick, injured, or abused child, or child who dies during or after emergency care

Body Surface

A child's body surface area is larger in proportion to the body mass, making the child more prone to heat loss through the skin. For this reason, temperature should always be a concern when assessing and treating pediatric patients.

Shunts

A shunt is a drainage device that runs from the brain to the abdomen or to the atrium of the heart to relieve excess cerebrospinal fluid. There will be a reservoir on the side of the skull. If the shunt malfunctions, pressure inside the skull will rise, causing an altered mental status. An altered mental status may also be caused by an infection. These patients are prone to respiratory arrest. Your emergency care will include the following steps: - Maintaining an open airway - Ventilating with a pocket mask or bag-valve mask and high-concentration oxygen if needed - Transporting the patient

The EMT and Pediatric Emergencies: Dealing with stress

Communicating with and treating children can be learned. Care mostly consists of applying knowledge of adult patients and adjusting for children. Talk with other EMTs. Talk with your service's counselor. Unless you resolve the impact of stressful events, the problems created may compound and could lead to "burnout."

Physical Exam: Extremities

Perform an assessment with capillary refill and distal pulse, including a neurological component for motor function with a sensation check. With an infant or young child, you do not have to press on a nail bed. You can quickly check capillary refill by squeezing a hand or foot, forearm, or lower leg. Check for painful, swollen, and deformed injury sites.

Physical and Sexual Abuse

Abusers inflict almost every imaginable kind of injury and maltreatment. Physically abused children—often called "battered" children—are beaten with fists, hairbrushes, electric cords, pool cues, pots and pans, and almost any other object that can be used as a weapon. They are intentionally burned by hot water, steam, open flames, cigarettes, and other thermal sources. Battered children may be severely shaken, thrown into their cribs or down steps, pushed out of windows and over railings, and even pushed from moving cars. Sexual abuse ranges from adults exposing themselves to children to sexual intercourse or sexual torture. Cases in which abuse was only emotional or minor in nature are less reported.

The adolescent patient

Adolescents should be able to tell you exactly what happened and how they feel. However, in the presence of parents or peers, an adolescent patient may not be completely communicative or cooperative. Adolescents may also be intimidated by those in authority, such as parents or teachers. Therefore, it is important to be very discreet when asking sensitive questions about drug or alcohol use and medical issues such as a possible pregnancy. The young adolescent is often embarrassed or worried about the changes occurring to his or her body and uncertain if these changes are "normal." However, do not delay patient evaluation and care because you or the patient may be embarrassed. As a professional, you must put such feelings aside and act in a manner that will allow the patient to relax and understand that there is no need for embarrassment.

Other Pediatric Disorders: Altered mental status

Altered mental status may be caused by a variety of conditions, including hypoglycemia, poisoning, infection, head injury, decreased oxygen levels, shock, or the aftermath of a seizure.

Clearing an Airway Obstruction

An airway obstruction can be partial or complete. With many partial obstructions, the child is still able to breathe and get enough oxygen. With other partial obstructions or with complete obstruction of the airway, the supply of air is cut off.

Home Artificial Ventilators

Artificial ventilators in the home are becoming more common. Although the parents will be trained in the ventilator's use, they will call EMS when there is trouble. Regardless of the problem, your emergency care will include: - Maintaining an open airway - Artificially ventilating with a pocket mask or bag-valve mask with oxygen - Transporting the patient

Primary Assessment: Assessing Circulation

As with an adult, check for normal warm, pink, and dry skin and a normal pulse as indications of adequate circulation and perfusion. For assessment, check the radial pulse in a child and the brachial pulse in an infant. For basic life support, check the carotid pulse in a child and the brachial or femoral pulse in an infant. In infants and children five years old or younger, also check capillary refill.

Primary Assessment: Forming a General Impression

As you approach and form your general impression, use the PAT to make the following observations: 1. MENTAL STATUS. The well child is alert. Alternatively, the sick child may be drowsy, inattentive, or sleeping. 2. INTERACTION WITH THE ENVIRONMENT OR OTHERS. The healthy child exhibits normal behavior for his age. He moves around, plays, is attentive, establishes eye contact, and interacts with his parents. The sick child may be silent, listless, or unconscious. 3. EMOTIONAL STATE. The well child's emotional state is appropriate to the situation. Crying may be his normal response to pain or fear. A withdrawn child or one who is emotionally flat is probably a sick child. 4. RESPONSE TO YOU. A well child may be interested in you or afraid of you. A sick child will give little attention to a stranger. 5. TONE AND BODY POSITION. A sick child may be limp, with poor muscle tone. Pediatric patients with respiratory distress often assume characteristic positions that seem to help them breathe (e.g., leaning forward with hands on knees, referred to as tripoding). 6. WORK OF BREATHING. The well child's breathing should be unlabored. The sick child will be making a visible effort to breathe, including use of flared nostrils and retractions, or pulling in of the tissues between the ribs. A change from visible effort to reduced effort could be the result of a significant intervention (e.g., a breathing treatment provided to an asthmatic). However, when the patient's effort to breathe slacks off in the absence of any significant intervention, the child should be considered to be getting sicker rather than better. Generally speaking, a child with compromised respiratory effort will not improve without intervention. 7. QUALITY OF CRY OR SPEECH. In general, a strong cry or normal speech indicates a well child with good air exchange. The child who can speak in only short sentences or grunts has significant respiratory distress. 8. SKIN COLOR. A sick child may be pale, cyanotic, or flushed.

Patient Assessment: Altered Mental Status

Assessment of the patient with altered mental status focuses on life-threatening problems discovered during the primary assessment: - Be alert for a mechanism of injury that may have caused the altered mental status, such as head injury. - Be alert for signs of shock. - Look for evidence of poisoning from ingested, inhaled, or absorbed substances. - Attempt to quickly obtain a history of any seizure disorder or diabetes.

Regression

At an emergency, if the child does not understand you or believes that you do not understand in return, his fear will increase. If the child is to communicate, he must remain calm. Putting the child at ease is a very important part of the care you must provide. Some children, when stressed, will act like a younger child. This is called regression.

Secondary Assessment

At times the child may be the only source of a history. He may be at school or another place where medical records are not kept or where adults who know his medical history are not present. In this case get as much history as you can from the child by asking simple questions that cannot be answered with a "Yes" or "No." A child who cannot tell you where it hurts can usually point to the area. Perform a physical exam for a medical patient and a rapid trauma assessment for a trauma patient, as you would for an adult. Explain to the awake child what you are doing, and do the exam in trunk-to-head order to avoid frightening the child. Take and record vital signs, assessing blood pressure in only children older than age three, using an appropriately sized cuff.

Protecting Against Hypothermia

Because children have a large surface area in proportion to their body mass and limited shiver ability, exposure to cool weather and water can result in hypothermia more easily than with adults. Therefore, hypothermia is always a concern with a pediatric patient. Other causes of hypothermia, in children as well as in adults, include ingestion of alcohol or drugs that dilate peripheral vessels and cause loss of body heat, metabolic problems such as hypoglycemia, brain disorders that interfere with temperature regulation, severe infection or sepsis, and shock. It is important to keep the patient warm, so cover the patient to avoid further loss of body heat. Pay special attention to covering the head, as the head is a major area of heat loss. Also, be aware of the temperature in the patient compartment of the ambulance. Avoid rough handling and inserting anything in the patient's mouth as these actions may cause ventricular fibrillation or cardiac arrest in the severely hypothermic child. Suction very gently if suctioning is necessary, and be alert to the possibility of cardiac arrest.

Central Intravenous Lines

Central lines are intravenous lines that are placed close to the heart. Unlike most peripheral IV lines, central lines may be left in place for long-term use. Possible complications of the use of central lines are: - Infection - Bleeding - Clotting-off of the line - Cracked line Your emergency care will include: - Applying pressure if there is bleeding - Transporting the patient

Child Abuse and Neglect

Child abuse can take several different forms, often occurring in combination: - Psychological (emotional) abuse - Neglect (Serious legal question as to what constitutes as neglect) - Physical abuse - Sexual abuse

Poisoning

Children are often the victims of accidental poisoning, frequently resulting from the ingestion of household products or medications. Certain poisons can quickly depress the respiratory system, cause respiratory arrest, and cause life-threatening conditions of the circulatory and nervous systems. The airway and gastrointestinal tract can also be burned by corrosive substances upon ingestion and with subsequent vomiting.

Physical Exam: Neck

Children are vulnerable to spinal cord injuries because of their proportionately larger and heavier heads. The neck offers less support because muscles and bone structures are less developed. In medical emergencies the neck may be sore, stiff, or swollen.

Patient Care: Fever

Children can tolerate a high temperature, and only a small percent will have a seizure due to fever (febrile seizure). It is a rapid rise or fall in temperature rather than the temperature itself that causes seizures. If you find an infant or child has a high fever, take the following steps: 1. Remove the child's clothing, but do not allow him to be exposed to conditions that may bring on hypothermia. If the child objects to having clothing removed, let the child keep on light clothing or underwear. 2. If the condition is a result of heat exposure, and if local protocols permit, cover the child with a towel soaked in tepid (not cold) water. This will quickly cool the child. 3. Monitor for shivering and avoid hypothermia. If shivering develops, stop the cooling activities and cover the child with a light blanket. 4. If local protocols permit, give the child fluids by mouth or allow him to suck on chipped ice. This may not prevent dehydration but will increase his comfort. 5. Be aware that a mild fever can quickly turn into a high fever that may indicate a serious, if not life-threatening, problem. If the infant or child feels very warm or hot to the touch, then prepare the patient for transport. Transport all children who have suffered a seizure as quickly as possible, protecting the patient from temperature extremes. NOTE: There are also some "do nots" in treating an infant or child with fever: - Do not submerge the child in cold water or cover with a towel soaked in ice water (which can rapidly cause hypothermia). - Do not use rubbing alcohol to cool the patient. (It can be absorbed in toxic amounts and is a fire hazard.)

Pediatric Hypovolemic Shock

Compensatory changes will begin immediately inside the body of a child who is losing blood. For example, the heart will beat faster to improve blood circulation. The child's blood vessels will constrict to move blood toward the body's core to support the function of essential organs. To compensate for hypoxia, the respiratory rate will increase. If hypoxia persists, brain function may be disrupted. Outside the child's body, there will be evidence of these compensatory changes. Increased heart rate will be seen as an increased pulse rate (if it can be found peripherally). Vessel constriction will be seen in the form of pale skin and delayed capillary refill. Disrupted brain function will show as altered mental status.

Primary Assessment: Assessing the Airway

Consider not only whether the airway is open but whether it is endangered. A depressed mental status, secretions, blood, vomitus, foreign bodies, face or neck trauma, and lower respiratory infections may all compromise the airway. Be careful not to hyperextend the child's neck, which may cause the airway to become occluded.

Trauma: Extremities

Despite the more flexible bones in the pediatric patient, the extremity injuries are managed the same way as those in adults.

Physical Exam: Head

Do not apply pressure to an infant's fontanelles ("soft spots"). It may bulge naturally when the infant cries or be abnormally sunken if the infant is dehydrated. Meningitis and head trauma cause the fontanelle to bulge due to increased intracranial pressure. Collisions involving infants and children can often produce head injuries.

Patient Assessment: Croup

During the day, the child with croup will usually have these signs: - Mild fever - Some hoarseness At night, the child's condition will worsen, and he will develop: - A loud "seal bark" cough - Difficulty breathing - Signs of respiratory distress including nasal flaring, retraction of the muscles between the ribs, the child tugging at his throat - Restlessness - Paleness with cyanosis

Second Viewpoint: "next to the patient"

During the hands-on primary assessment, the triangle again looks at appearance, breathing (including airway), and circulation—but with more precision. - For appearance, you look at mental status using the "PU" part of AVPU (response to pain or unresponsiveness). - For breathing, you start by ensuring that the airway is open and closely observing the quality of the patient's breathing. - For circulation, you check for pulse, subtle cyanosis, and capillary refill.

Psychological and Personality Characteristics

Each age group has its own general characteristics of psychology and personality. Some children may cry when they see you since you are a stranger to them. Never let the potential of upsetting a child prevent you from delivering appropriate treatment.

Other Pediatric Disorders: Vomiting and Diarrhea

Either one can cause dehydration that worsens whatever other condition the child may have and may lead to life-threatening shock.

Patient Care: Poisoning

Emergency care for a responsive poisoning patient includes the following steps: 1. Contact medical direction or the poison control center. 2. Consider the need to administer activated charcoal (where protocols allow). 3. Provide oxygen. 4. Transport. 5. Continue to monitor the patient. The patient may become unresponsive. Emergency care for an unresponsive poisoning patient includes the following steps: 1. Ensure an open airway. 2. Provide oxygen. 3. Be prepared to provide artificial ventilation. 4. Transport. 5. Contact medical direction or the poison control center. 6. Rule out trauma as a cause of altered mental status.

Patient Care: Diarrhea and Vomiting

Emergency care for diarrhea and vomiting includes the following: 1. Maintain an open airway, and be prepared to provide oral suctioning. 2. Provide oxygen if respirations are compromised or if signs of shock are present. 3. If signs of shock are present, contact medical direction immediately and transport. 4. If your protocols or medical direction permits, offer the child sips of clear liquids or chipped ice if only diarrhea is present. Many physicians recommend nothing by mouth if there is nausea or vomiting. 5. Some systems recommend that you save a sample of vomitus and rectal discharge (e.g., a soiled diaper). Follow your local protocols.

Patient Care: Sexual Abuse

Emergency care for physical or sexual abuse includes the following steps: 1. Dress and provide other appropriate care for injuries as necessary. 2. Preserve evidence of sexual abuse if it is suspected: - Discourage the child from going to the bathroom (for both defecation and urination). - Give nothing to the patient by mouth. - Do not have the child wash or change clothes. 3. Transport the child.

Patient Care: Epiglottitis

Emergency care for the pediatric patient with epiglottitis is as follows: 1. Contact ALS. (Remember that the hospital may be the closest source of ALS care.) 2. Immediately transport the child, with the child sitting on the parent's lap. 3. Provide high-concentration oxygen from a humidified source. 4. Constantly monitor the child for respiratory distress or arrest, and be ready to resuscitate. 5. Do not place anything into the child's mouth, including a thermometer, tongue blade, or oral airway. To do so may set off spasms along the upper airway that will totally obstruct the airway. NOTE: The child will not want to lie down, and you should not force him to do so. The child must be handled gently since rough handling and stress could lead to a total airway obstruction from spasms of the larynx and swelling tissues. Your primary objective in managing a child with epiglottitis is transporting him to the hospital as rapidly as possible while ensuring that he is not upset. You should also consider taking the child to a hospital with an operating room and pediatric capabilities. Do not prolong your transport to go to the pediatric hospital, but if given the choice, ensure that you transport to the most resourced facility.

Patient Care: Partial Airway Obstruction

Emergency care of a pediatric patient with a mild airway obstruction is as follows: 1. Allow the child to assume a position of comfort, sitting up, not lying down. Assist an infant or younger child into a sitting position. Allow the child to sit on the parent's lap. 2. Offer high-concentration oxygen by pediatric nonrebreather mask or blow-by technique (described later in this chapter). 3. Transport. 4. Do not agitate the child. Limit your examination to avoid upsetting the child. Do not assess blood pressure.

Patient Care: Altered Mental Status

Emergency care of a pediatric patient with altered mental status includes the following steps: 1. Ensure an open airway. Be prepared to suction. 2. Protect the spine while managing the airway if a head injury or other trauma is present. 3. Administer high-concentration oxygen by pediatric nonrebreather mask or blow-by technique. Be prepared to perform artificial ventilations by pediatric pocket mask or bag-valve mask with supplemental oxygen. 4. Treat for shock. 5. Obtain finger-stick blood glucose as appropriate and as allowed by local protocols. 6. Treat hypoglycemia with oral glucose as appropriate and as allowed by local protocols. 7. Transport.

Patient Care: Croup

Emergency care of a pediatric patient with croup is as follows: 1. Place the patient in a position of comfort (usually sitting up). 2. Administer high-concentration oxygen. When possible, this should be from a humidified source. (Do not delay oxygen administration to humidify.) 3. Move slowly to the ambulance. The cool night air may provide relief as the cool air reduces the edema in the airway tissues. 4. Do not delay transport unless ordered to do so by medical direction.

Patient Care: Trauma

Emergency care steps for the pediatric trauma patient should include the following: 1. Ensure an open airway. Use the jaw-thrust maneuver. 2. Suction as necessary, using a rigid suction catheter. 3. Provide high-concentration oxygen. 4. Ventilate with a pediatric pocket mask or bag-valve mask as needed. 5. Provide spinal immobilization (Scan 33-4). 6. Transport immediately. 7. Continue to reassess en route. 8. Assess and treat other injuries en route if time permits.

Other Pediatric Disorders: Seizures

Fever is the most common cause of seizures in infants and children. Epilepsy, infections, poisoning, hypoglycemia, trauma (including head injury), or decreased levels of oxygen can also bring on seizures. Some seizures in children are idiopathic; that is, they have no known cause. They may be brief or prolonged.

Other Pediatric Disorders: Fever

Fever usually accompanies infections (ear infections are common) as well as such childhood diseases as chicken pox, mononucleosis, pneumonia, epiglottitis, and meningitis. The fever also may be due to heat exposure, any infection, or some other noninfectious disease.

Patient Care: Severe Airway Obstruction

Follow these steps for emergency care of a severe airway obstruction: 1. Perform airway clearance techniques. For infants less than one year old, alternate 5 back blows and 5 chest thrusts. If the patient becomes unconscious, begin CPR. After 30 compressions, visualize the airway. If an object is visible, remove it. Do not use blind finger sweeps to clear the airway. Attempt to ventilate and continue chest compressions if necessary. For children older than one year, provide subdiaphragmatic abdominal thrusts (the Heimlich maneuver) until they lose consciousness. If they lose consciousness, begin CPR and airway visualization as just explained. 2. Attempt artificial ventilations with a pocket mask or bag-valve-mask unit in the appropriate pediatric size and supplemental oxygen.

Patient Care: Shock

Follow these steps for emergency care: 1. Ensure an open airway. 2. Manage severe external hemorrhage if present. 3. Provide high-concentration oxygen. Be prepared to artificially ventilate. 4. Lay the patient flat. 5. Keep the patient warm. 6. Transport immediately. Perform any additional assessment and treatments en route.

Patient Assessment: Vomiting and Diarrhea

For any pediatric patient with diarrhea or vomiting: 1. Monitor the airway. 2. Monitor respiration. 3. Be alert for signs of shock.

Patient Care: Drowning

For the drowning patient, provide the following care: 1. Provide artificial ventilation or CPR as necessary. This is your first treatment priority. 2. Protect the airway. Suction if necessary. 3. Consider spinal immobilization. 4. Protect against possible hypothermia, especially if the patient has been in cool or cold water. As soon as practical, remove wet clothing, dry the skin, and cover with a blanket. 5. Treat any trauma. 6. Transport all drowning patients to the hospital, even if they seem to have recovered.

Gastrostomy Tubes and Gastric Feeding

Gastrostomy tubes, tubes placed through the abdominal wall directly into the stomach, are used when a patient is not able to be orally fed. The most dangerous potential problem associated with their use involves respiratory distress. The emergency care will include the following steps: - Being alert for altered mental status in diabetic patients. They may become hypoglycemic quickly when unable to eat. - Ensuring an open airway. - Suctioning the airway as needed. - Providing oxygen if needed. - Transporting the patient in either a sitting position or lying on the right side with the head elevated to reduce the risk of aspiration.

During motor-vehicle collisions

Unrestrained child passengers (those without seat belts or restraint in a child safety seat) tend to have head and neck injuries. Restrained passengers may have abdominal and lower spine injuries. Children who are struck by autos while bicycle riding often have head, spinal, and abdominal injuries. The child who has been struck by a vehicle may present with the following triad of injuries: - Head injury - Abdominal injury with possible internal bleeding - Lower extremity injury (possibly a fractured femur)

Transport to a trauma center with pediatric care capabilities if identified: Falls

Head and upper neck injuries and fractures to upper and lower extremities from moderate falls, 5-15 feet Head, neck, spine, abdominal, and chest injuries and fractures of upper and lower extremities from high falls over 15 feet

Providing Supplemental Oxygen and Ventilations

High-concentration oxygen should be administered to children in respiratory distress, those with inadequate respirations, or those in possible shock. Infants and young children are often afraid of an oxygen mask. For these patients who will not tolerate a mask, try a "blow-by" technique. In this technique you hold, or have a parent hold, the oxygen tubing or the pediatric nonrebreather mask 2 inches from the patient's face so the oxygen will pass over the face and be inhaled. Remember that a nonrebreather mask will always provide more efficient oxygen delivery, and many children tolerate it well. Use blow-by only if more efficient administration methods fail.

Patient Care: Seizures

If the patient has a seizure in your presence, possibly during transport, provide the following care: 1. Maintain an open airway. Do not insert an oropharyngeal airway or bite stick. 2. Position the patient on his side if there is no possibility of spinal injury. 3. Be alert for vomiting. Suction as needed. 4. Provide oxygen. If the patient is in respiratory arrest, provide artificial ventilations with supplemental oxygen. 5. Transport. 6. Monitor for inadequate breathing and/or altered mental status, which may occur following a seizure.

Primary Assessment: Assessing Breathing

If the patient is not breathing or is breathing inadequately, provide artificial ventilations with supplemental oxygen. If the patient is experiencing respiratory distress, provide high-concentration oxygen via a device that is appropriate for the patient's age and clinical condition. To assess breathing, observe the following: 1. CHEST EXPANSION. There should be equal movement on both sides of the chest. 2. WORK OF BREATHING. Watch for nasal flaring when the patient inhales and retractions, or pulling in of the sternum and ribs, with inhalation. 3. SOUNDS OF BREATHING. Listen for stridor, crowing, or other noisy respirations. Breath sounds should be present and equal on both sides of the chest. Note the presence of grunting at the end of expiration, which is a worrisome sign. 4. BREATHING RATE. Normal respiratory rates for infants and children are as follows: 12 to 20 per minute in an adolescent, 15 to 30 per minute in a child, 25 to 50 per minute in an infant. Breathing that is either faster or slower than normal is inadequate and requires artificial ventilation as well as oxygen. 5. COLOR. Cyanosis (blue or gray color) indicates that the patient is not getting enough oxygen.

Patient Assessment: Drowning

If the patient is unresponsive and you suspect he may be in cardiac arrest: 1. Establish unresponsiveness, breathlessness, and pulselessness. 2. If the patient is unresponsive, breathless, and pulseless, perform 5 cycles of compressions and ventilations (30:2 ratio) at a rate of 100 compressions per minute before activating the emergency response system if this has not already been done. 3. If trauma may have been a cause or result of the submersion incident (such as injury from a dive), maintain spinal stabilization and follow trauma assessment procedures. Remember, however, that resuscitation is your first priority. 4. Consider possible ingestion of alcohol as a cause of the drowning, especially in adolescents. 5. Consider the possibility of "secondary drowning syndrome"—deterioration after normal breathing resumes, minutes to hours after the event.

Reassessment: Pediatrics

In some cases in which the patient is seriously ill or traumatized, maintaining the airway and supporting ventilations will keep the EMT from performing a complete physical exam and history: 1. Reassess mental status. 2. Maintain an open airway. 3. Monitor breathing. 4. Reassess the pulse. 5. Monitor skin color, temperature, and moisture. 6. Reassess vital signs: - Every 5 minutes in unstable patients. If the child is unstable and has respiratory compromise, put your hand on the child's chest and feel for changes in the respirations. You might decide to keep your hand on the child's thorax throughout the transport to ensure that you do not miss a rapid and significant change in respiratory status. - Every 15 minutes in stable patients Ensure that all appropriate care and treatment are being given. 7. Ensue that all appropriate care and treatment are being given.

Physical Exam: Pelvis

In the event of trauma, check for stability of the pelvic girdle.

Special concerns in pediatric care

Infants and children may be subject to either medical problems or trauma. Concerns that frequently apply to both medical emergencies and trauma are airway maintenance, providing supplemental oxygen when appropriate, supporting ventilations, caring for shock, and protecting the infant or child from hypothermia

Chest and Abdomen

Infants and young children are abdominal breathers, using their diaphragms for breathing more than adults. Watch the abdomen as well as the chest to evaluate their breathing. Younger patients also have less-developed chest muscles and more flexible bones. Because of this, abdominal organs are more susceptible to injury, and the force of trauma is often transferred throughout the entire abdomen.

Trauma: Abdomen

Infants and young children rely on their diaphragms for breathing more than adults do The abdomen can be a site of hidden injuries. You must suspect an internal abdominal injury when the patient deteriorates even without evidence of external injury. In addition, air in the stomach can distend the abdomen and interfere with artificial ventilation. This may also lead to vomiting. Be prepared to suction the patient.

Head

Infants have several "soft spots," or fontanelles, across the top of the head. The two primary fontanelles we consider are the anterior (located just anterior to the center of the skull) and the posterior (located in the midline of the upper back of the skull). The posterior fontanelle usually is completely closed by two months of age. The anterior fontanelle is closed in 1 percent of infants by three months; in 38 percent by twelve months; and in 96 percent by twenty-four months. A sunken fontanelle may indicate dehydration, whereas a bulging fontanelle may indicate elevated intracranial pressure.

Physical Exam: Abdomen

Note any rigid or tender areas and distention. Because a child's abdominal organs are large in relation to the size of the abdominal cavity and because there is little protection offered by the still-undeveloped abdominal muscles, these organs are more susceptible to trauma than an adult's. Because most children eight years of age or younger are abdominal breathers, any injury that impedes the diaphragm can compromise a young child's breathing.

Respiratory Distress VS. Respiratory Failure

Inside the child with an airway or breathing problem, the body will take steps to compensate for the problem. The body will have increased respiratory rate and volume, increased heart rate, and constricted blood vessels. When these compensatory mechanisms are working, we typically refer to the patient's condition as respiratory distress. On the outside, this patient will present with difficulty breathing. You will observe the compensation by recognizing an increased respiratory rate and an increased pulse. You may note pale skin and/or delayed capillary refill. Most important, respiratory distress can be recognized by the signs of adequate oxygenation and ventilation. Mental status is a key finding since mental status changes with oxygen. The compensatory mechanisms just described will eventually fail, and the respiratory distress will become respiratory failure. Continued hypoxia tires the muscles of respiration, and they begin to fail. As a result, increased carbon dioxide and low oxygen levels begin to interfere with brain function. Outside, respiratory failure can be identified by all the signs of respiratory distress plus cyanosis of the skin, slowing or irregular respirations, and altered mental status. Do not assume the absence of cyanosis means that the child is still compensating. If the other clinical signs of failure are present, treat the child as having respiratory failure, not distress.

Transport to a trauma center with pediatric care capabilities if identified: Child run over by car

Internal chest injuries, often without obvious external damage. Internal abdominal injuries, often without obvious external damage. Fractures of upper and lower extremities and pelvis.

Patient Assessment: Seizures

Interview the patient as well as family members and bystanders who saw the convulsion. Ask: - Has the child had prior seizures? - If yes, is this the child's normal seizure pattern? (How long did the seizure last? What part of the body was seizing?) - Has the child had a fever? - Has the child taken any antiseizure medication? Other medication? Assess the child for signs and symptoms of illness or injury, taking care to note any injuries sustained during the convulsion. All infants and children who have undergone a seizure require medical evaluation. The seizure itself may not be serious, but it may be a sign of an underlying condition. Be aware that seizures may also be caused by a head injury.

Patient Care: Meningitis

It is most important to carefully take appropriate Standard Precautions. Wear appropriate respiratory protection since meningitis is an airborne disease. When meningitis is suspected, provide the following care: 1. Monitor the patient's airway, breathing, circulation, and vital signs. 2. Provide high-concentration oxygen by nonrebreather mask. 3. Ventilate with a pediatric pocket mask or bag-valve mask with supplemental oxygen if necessary. 4. Provide CPR if necessary. 5. Be alert for seizures. 6. Transport immediately. This is a true emergency. Do not delay.

Physical Exam: Airway

Keep the infant's head in the neutral position and the child's head in the neutral-plus or sniffing position. If there is no suspicion of spinal injury, place a flat, folded towel under the patient's shoulders to get the appropriate airway alignment. Hyperextension or hyperflexion may close off the airway.

Physical Exam: Chest

Listen closely for even air entry and the sounds of breathing on both sides of the chest. Be alert for wheezes and other noises. Check for symmetry, bruising, paradoxical movement, and retraction of the sternum or the muscles between the ribs. Remember that a child's soft ribs may not break, but there may be underlying injuries to the organs within the chest.

Physical Exam: Nose and Ears

Look for blood and clear fluids coming from the nose and ears. Suspect skull fractures if either fluid is present. Children are nose breathers, so mucus or blood clot obstructions will make it hard for them to breathe.

Other Pediatric Disorders: Meningitis

Meningitis is a potentially life-threatening infection of the lining of the brain and spinal cord (the meninges). It is usually caused by a bacterial or a viral infection and most commonly occurs between the ages of one month and five years. However, it is not uncommon to see meningitis in adolescents.

NORMAL PULSE RATE (BEATS PER MINUTE, AT REST)

Newborn: 120 to 160 Infant (0-5 months): 90 to 140 Infant (6-12 months): 80 to 140 Toddler (1-3 years): 80 to 130 Preschooler (3-5 years): 80 to 120 School age (6-12 years): 70 to 110 Adolescent (13-18 years): 60 to 105

NORMAL RESPIRATION RATE (BREATHS PER MINUTE, AT REST)

Newborn: 30 to 50 Infant (0-5 months): 25 to 40 Infant (6-12 months): 20 to 30 Toddler (1-3 years): 20 to 30 Preschooler (3-5 years): 20 to 30 School age (6-12 years): 15 to 30 Adolescent (13-18 years): 12 to 20

In general emergency care, the following age categories are more useful to keep in mind:

Newborns and infants: birth to 1 year Toddlers: 1 to 3 years Preschool: 3 to 5 years School age: 6 to 12 years Adolescent: 13 to 18 years

Supporting the Parents or Other Care Providers

Parents may react in one of several ways when their child suffers a sudden life-threatening injury or illness. Their first reaction may be one of denial or shock. Some parents will react by crying, screaming, or becoming angry. Another common reaction is self-blame and guilt. In all of these instances, be calm, reassuring, and supportive. Use simple language to explain what has happened and what is being done to and for their child. In some cases an upset parent may interfere with your care of the child. This is a natural reaction to protect the child from further harm. Usually you can persuade the parent to assist you by asking him to hold the child's hand, give you a medical history, or comfort the child. A key component of successfully engaging the child is garnering the trust of the parent or caregiver.

Positive Pressure Ventilations

Positive pressure ventilations should be provided at the rate of 12 to 20 per minute (one every 3 to 5 seconds) for an infant or child up to puberty, and at 10 to 12 per minute (one every 5 to 6 seconds) if the child has reached puberty. Note that the rate is higher when performing a neonatal resuscitation. In that case use a rate of 40-60 breaths per minute. Use a pocket face mask or a bag-valve-mask unit in the correct infant or child size

Patient Care: Difficultly Breathing

Provide oxygen to all children with respiratory emergencies. For children in early respiratory distress: - Provide oxygen by pediatric nonrebreather mask or blow-by technique if the patient will not tolerate a mask. For children in respiratory failure (those with respiratory distress and altered mental status, cyanosis even when oxygen is administered, poor muscle tone, or inadequate breathing) or respiratory arrest: - Provide assisted ventilations with pediatric pocket mask or bag-valve mask and supplemental oxygen.

Patient Assessment: Sexual Abuse

Rearrange or remove clothing only as necessary to determine and treat injuries. This will help preserve evidence where possible. Examine the genitalia only if there is obvious injury or the child tells you of a recent injury. The child may be hysterical, frightened, or withdrawn and unable to give you a history of the incident. Be calm and as reassuring as possible. The following are common signs of sexual abuse: - Obvious signs of sexual assault, including burns or wounds to the genitalia. - Any unexplained genital injury such as bruising, lacerations, or bloody discharge from genital orifices (openings). - Seminal fluid on the body or clothes or other discharges associated with sexually transmitted diseases. - In rare cases the child may tell you he was sexually assaulted.

Patient Assessment: Difficultly Breathing

Recognize the following signs of early respiratory distress: - Nasal flaring - Retraction of the muscles above, below, and between the sternum and ribs - Use of abdominal muscles - Stridor (high-pitched, harsh sound) - Audible wheezing - Grunting - Breathing rate greater than 60 In addition to these signs of early respiratory distress, watch for these signs of respiratory failure: - Altered mental status - Slowing or irregular respiratory rate - Cyanosis (especially after the addition of supplemental oxygen) - Decreased muscle tone - Poor peripheral perfusion (capillary refill greater than 2 seconds) - Decreased heart rate (a late sign)

role of the EMT in cases of suspected abuse or neglect

Remember that you are charged with providing emergency care for an injured child. You are not a police officer, court investigator, social worker, or judge. Gather information from the parents or caregiver away from the child without expression of disbelief or judgment. Talk with the child separately about how an injury occurred. As you assess the patient and provide appropriate care, control your emotions and hold back accusations. Do not indicate to the parents or other adults at the scene that you suspect child abuse or neglect. Do not ask the child if he has been abused. If you are suspicious about the mechanism of injury, transport the child even though the severity of injury may not warrant such action. However, even when talking to your partner, the hospital staff, the police, and your superiors, use the terms suspected and possible. Always be objective and report only the facts.

Trauma: Burns

Review the pediatric differences in the "rule of nines" in the chapter "Soft-Tissue Trauma" as it applies to estimating the extent of burns in children and infants. Follow these guidelines when managing patients with burns: - Identify candidates for transportation to burn centers. Local protocols should guide your determination. - Cover the burn with sterile dressings. Nonadherent dressings are the best, but sterile sheets may be used. Moist dressings should be used with caution in the pediatric patient. Remember that children's body surface area is larger proportionately to their body mass, making them more prone to heat loss. Burned patients who become hypothermic have a higher death rate. You must keep the infant or child covered to prevent a drop in body temperature.

Other Pediatric Disorders: Sudden Infant Death Syndrome (SIDS)

SIDS is the sudden, unexplained death during sleep of an apparently healthy baby in its first year of life. Many possible causes for this syndrome have been investigated but are not well understood. It is not up to you, as an EMT, to diagnose SIDS. All you or the parents will know is that the baby is in respiratory or cardiac arrest. You will treat the baby as you would any patient in this condition: - Unless there is rigor mortis (stiffening of the body after death), provide resuscitation. - Be certain that the parents receive emotional support and that they understand that everything possible is being done for the child at the scene and during transport.

Transport to a trauma center with pediatric care capabilities if identified: Auto Crash (Improper restrained/unrestrained passenger)

Serious head and neck injuries, facial abrasions, and lacerations. Soft-tissue injuries of the neck from shoulder belt used without lap belt or shoulder belt used on a too-small child. Internal abdominal injuries from lap belt used without shoulder belt or lap belt improperly positioned over abdomen. Fracture of lower vertebrae and spinal cord damage from violent flexion at waist when lap belt is used without shoulder belt.

Transport to a trauma center with pediatric care capabilities if identified: Child struck by deployed air bag

Severe head and neck injuries. Burns to the eyes and face caused by the caustic powder released when air bag deploys.

Transport to a trauma center with pediatric care capabilities if identified: Pedestrian or bicyclist struck with significant (> 20 mph) impact OR Child thrown onto hood/windshield or minimal distance on impact

Severe head injuries, especially if thrown any distance, by force of high speed at impact. Multiple head, chest, abdominal, and leg injuries. Fractures of long bones, especially the femurs. Internal injuries and bleeding of the liver and/or spleen. (Kidney, liver—blows to right upper quadrant; spleen—blows to flank and torso.)

Caring for Shock

Shock is another term for hypoperfusion, which is the inadequate circulation of blood and oxygen throughout the body. The following are some common causes of shock in infants and children: - Diarrhea and/or vomiting with resulting dehydration - Infection - Trauma (especially abdominal injuries) - Blood loss The following are some less common causes of shock in infants and children: - Allergic reactions - Poisoning - Cardiac events (rare)

Patient Assessment: Poisoning

Some types of poisonings are not often associated with adult patients but are common to children. These special cases are: 1. ASPIRIN POISONING. Look for hyperventilation or hypoventilation, vomiting, and sweating. The skin may feel hot. Severe cases cause seizures, coma, or shock. 2. ACETAMINOPHEN POISONING. Many medications have this compound, including Tylenol, Comtrex, Bancap, Excedrin PM, and Datril. Initially the child may have no abnormal signs or symptoms. The child may be restless (early) or drowsy. Nausea, vomiting, and heavy perspiration may occur. Loss of consciousness is possible. 3. LEAD POISONING. This usually comes from ingesting chips of lead-based paint. It is often a chronic condition (building up over a long time). Look for nausea with abdominal pain and vomiting. Muscle cramps, headache, muscle weakness, and irritability are often present. 4. IRON POISONING. Iron compounds such as ferrous sulfate are found in some vitamin tablets and liquids. As little as 1 gram of ferrous sulfate can be lethal to a child. Within 30 minutes to several hours, the child will show nausea and bloody vomiting, often accompanied by diarrhea. Typically the child will develop shock, but this may be delayed for up to 24 hours as the child appears to be getting better. 5. PETROLEUM PRODUCT POISONING. The patient will usually be vomiting with coughing or choking. In most cases you will smell the distinctive odor of a petroleum distillate (e.g., gasoline, kerosene, heating fuel).

Physical Exam: Pediatric

The EMT normally performs the physical examination or body assessment in head-to-toe order; however, on alert infants and small children, this is reversed. Starting with the toes or trunk and working your way toward the head will let the child get used to you and your touch before you attempt to touch him around the head and face. Unless there are possible injuries that indicate the child should not be moved, a young child should be held on the parent's lap during the physical exam.

Blood volume

The blood volume of a pediatric patient is less than the blood volume of an adult. A newborn does not have enough blood to fill a twelve-ounce soda can, and an eight-year-old has only about two liters of blood. Blood loss that might be considered moderate in an adult can be a life-threatening situation for a child.

Maintaining an Open Airway

The child's head should be positioned in a more neutral position than an adult's because of the danger of closing the airway when the neck is flexed or hyperextended. Placing a folded towel under the shoulders of a young infant or child will help to keep the airway aligned. To achieve the proper position, perform a head-tilt, chin-lift maneuver if there is no trauma or a jaw-thrust maneuver with spinal immobilization if trauma is suspected. Be prepared to suction the airway as needed. Use suction catheters that are sized for infant and child patients. Do not touch the back of the patient's throat, as this may activate the gag reflex, causing vomiting. It is also possible to stimulate the vagus nerve in the back of the throat, which can slow the heart rate. The tongues of infants and children are likely to slide back into the pharynx and obstruct the airway. If the patient is unconscious and does not have a gag reflex, you may insert an oropharyngeal airway to prevent the tongue from blocking the airway. If the patient is conscious but cannot maintain an open airway, a nasopharyngeal airway can be inserted. Note, however, that a nasopharyngeal airway should not be used if the child has facial trauma or head injuries because the airway could penetrate a breach in the cranium.

Patient Assessment: Partial Airway Obstruction

The following are common signs of a partial airway obstruction in a pediatric patient: - Noisy breathing (stridor, crowing) - Retractions of the muscles around the ribs and sternum when inhaling - Normal skin color - Peripheral perfusion is satisfactory (capillary refill under 2 seconds in a child five years old or less) - Still alert, not unconscious

Patient Assessment: Epiglottitis

The following are common signs of epiglottitis: - A sudden onset of high fever - Painful swallowing (the child often will drool to avoid swallowing) - Patient will assume a tripod position, sitting upright and leaning forward with the chin thrust outward (sniffing position) and the mouth wide open in an effort to maintain a wide airway opening. This child will also present with excessive drooling. - Patient will sit very still, but the muscles will work hard to breathe, and the child can tire quickly from the effort. - Child appears significantly more ill than with croup.

Patient Assessment: Shock

The following are common signs of shock in pediatric patients: - Rapid heart rate - Mental status changes - Rapid respiratory rate - Pale, cool, and clammy skin - Weak or absent peripheral pulses - Delayed capillary refill, more than 2 seconds (in a child five years or younger) - Decreased urine output (Ask parents about diaper wetting; look at diaper.) - Absence of tears, even when crying

Patient Assessment: Meningitis

The following are signs and symptoms of meningitis: - High fever - Stiff neck - Lethargy - Irritability - Headache - Sensitivity to light - In infants, bulging fontanelles unless the child is dehydrated - Painful movement during which the child does not want to be touched or held - Seizures - A rash if the infection is bacterial

Trauma: Head

The head is proportionately larger and heavier in the small child. This leads to head injury when the head is propelled forward in a collision. Suspect internal injuries whenever a child with a head injury presents with shock since head injury itself is seldom a cause of shock. Respiratory arrest is a common secondary effect of head injury, so be alert to this possibility.

Trauma: Chest

The less developed respiratory muscles of the chest and the more elastic ribs make the pediatric chest more easily deformed

Respiratory Disorders

The likeliest cause of cardiac arrest in a child, other than trauma, is respiratory failure. For the pediatric patient, it is important to distinguish whether the probable cause of the breathing difficulty is an upper airway problem or a lower airway problem. The care that you would give for an upper airway obstruction is not indicated for a lower airway disorder. Also, because respiratory problems can have such serious consequences in infants and children, it is critical to be alert for early signs of respiratory failure.

Lower Airway Problems

The lower airway begins at the opening of the trachea and ends at the alveoli. Lower airway disorders affect the large and small bronchiole tubes and the alveoli themselves. Common lower airway disorders include asthma, pneumonia, and other respiratory infections. Lower airway disorders commonly cause difficulty breathing, but the distinguishing sign is wheezing lung sounds. It is important to remember, however, that not all lower airway problems will be accompanied by wheezing.

Patient Assessment: Severe Airway Obstruction

The obstruction may be complete, or a partial obstruction may be severe enough to prevent adequate intake of oxygen. Signs of a severe obstruction are: - Cyanosis - Child's cough becomes ineffective; child cannot cry or speak - Increased respiratory difficulty accompanied by stridor or respiratory arrest - Altered mental status or loss of consciousness

Pediatric Assessment Triangle (PAT)

The pediatric assessment triangle (PAT) is a method of pediatric assessment from two viewpoints: - The first is the general impression formed as you approach the child, often referred to as an assessment "from the doorway." These first few seconds will provide you with a great deal of information that can be important in determining the seriousness of the patient's condition. - The second is the impression based on the remainder of the primary assessment that is done next to the patient. Each of the three sides of the triangle represents a different patient presentation that should be evaluated: 1. Appearance: 2. Work of breathing 3. Circulation to skin

Upper Airway Problems

The upper airway starts at the mouth and nose and ends at the opening of the trachea. Upper airway disorders affect structures such as the mouth, the throat (the pharynx and hypopharynx), and the area around the opening of the trachea (the larynx). Common upper airway disorders include foreign body obstructions, trauma, and swelling from burns and infections. In addition to difficulty breathing, upper airway disorders can commonly be identified by the presence of stridor or difficulty speaking.

Difficultly Breathing

There are a number of respiratory diseases or disorders an infant or child may have that will cause difficulty breathing, ranging from the serious, such as epiglottitis, to the less serious, such as a cold. The role of the EMT is to recognize signs of early respiratory distress and treat it before it advances to a life-threatening stage.

Inserting OPA in children

To insert an oropharyngeal airway, insert a tongue depressor to the base of the tongue. Push down against the tongue while lifting the jaw upward. Then insert the oropharyngeal airway. An important difference to note is that when an oropharyngeal airway is inserted in an adult, it is inserted with the tip pointing toward the roof of the mouth, then rotated 180 degrees into position. For an infant or child, the oropharyngeal airway is inserted with the tip of the airway pointing downward, toward the tongue and throat, in the same position it will be in after insertion

Tracheostomy Tubes

Tracheostomy tubes are tubes that have been placed into the child's trachea to create an open airway. They are often used when a child has been on a ventilator for a prolonged time. You may be called to help when there is: - Obstruction - Bleeding from the tube or around the tube - Air leaking around the tube - Infection - Dislodged tube Your emergency care will consist of: - Maintaining an open airway - Suctioning the tube as needed - Allowing the patient to remain in a position of comfort, perhaps on the parent's lap - Transporting the patient to the hospital

Pediatric Trauma Emergencies

Trauma is the number one cause of death in infants and children. Blunt trauma far exceeds penetrating trauma in this age group. Much of this trauma occurs because children are curious and learning about their environment. Exploring often leads to injury from accidental falls (or things falling on them), burns, entrapment, crushing, and other mechanisms of injury.

Respiratory Disease Causing Upper Airway Problems

Two illnesses that sometimes cause upper airway problems in children are croup and epiglottitis. Croup is caused by a group of viral illnesses that result in inflammation of the larynx, trachea, and bronchi. It is typically an illness of children six months to about four years of age that often occurs at night. This problem sometimes follows a cold or other respiratory infection. Tissues in the airway (particularly the upper airway) become swollen and restrict the passage of air. Epiglottitis is most commonly caused by a bacterial infection that produces swelling of the epiglottis and partial airway obstruction. Although routine childhood vaccinations have made this disease in children rare, it should be suspected when treating any child with stridor (a high-pitched sound caused by air moving through narrowed passageways), especially in children who are unvaccinated.

Patient Assessment: Fever

Use relative skin temperature as a sign if you do not have a reliable means to obtain an accurate temperature. Applying the ungloved back of your hand to the patient's forehead or to the abdomen beneath the clothing is another way to determine relative skin temperature. A high relative skin temperature is always enough reason to transport and seek medical opinion. Other signs are: - Fever with a rash is a sign of a potentially serious condition. - A seizure or seizures may accompany a high fever.

Primary Assessment: Assessing Mental Status

Use the AVPU method of assessing mental status, taking the child's age and developmental characteristics into account. You may need to shout to elicit a response to verbal stimulus. If necessary, tap or pinch the patient to test for response to painful stimulus. Never shake an infant or child.

Scene Size-Up and Safety

When entering an area where there is a pediatric patient, enter slowly and make some important observations. The first is to determine if the scene is safe. Even though it is a rare occurrence, sometimes there may be a risk from violence or abusive behavior, possibly directed towards the child. Standard Precautions should be taken as appropriate. Because 90 percent of child poisonings occur in the home and overall and accidental poisoning remains among the top ten causes of pediatric unintentional injury and death in the United States, careful evaluation of the scene for clues of accidental poisoning is of paramount importance.