Ch 34: Pediatric Emergencies

The infant

0 to 2 Months: Infants younger than 2 months spend most of their time sleeping or eating. They respond mainly to physical stimuli such as light, warmth, hunger, and sound. Infants sleep for up to 16 hours a day between feeding times and parent or caregiver interactions. An infant should be aroused easily from a sleeping state, and it should be considered an emergency if this is not the case. Infants are unable to tell the difference between parents or caregivers and strangers. Other than crying, they have a limited ability to communicate pain or discomfort. Soothing an infant should be relatively easy for the parent or caregiver. Hearing is generally well developed at birth, so calm and reassuring talk is often helpful. If all obvious needs have been addressed and the infant is still inconsolable, this could be a sign of significant illness. Infants at this stage have a sucking reflex for feeding. Head control is limited, but infants can turn their heads and focus on faces. Infants have poor thermoregulation. Their heads have a relatively large surface area. These factors predispose them to hypothermia, so parents or caregivers will often bundle infants in an attempt to keep them warm. It is often necessary to unbundle the infant during your assessment. 2 to 6 Months: Infants between ages 2 and 6 months are more active, which makes them easier to evaluate. They spend more time awake, they begin to smile and make eye contact, and they recognize parents or caregivers. Healthy infants will have a strong sucking reflex, active extremity movement, and a vigorous cry. They may follow a bright light or toy with their eyes or turn their heads toward a loud sound or a familiar voice. During this stage the infant has an increased awareness of what is going on around him or her and will use both hands to examine objects and explore the world. About 70% of infants will sleep through the night by 6 months. At this point in development, infants will begin to roll over. As with younger infants, persistent crying and irritability can be an indicator of serious illness. A lack of eye contact in a sick infant can be a sign of significant illness, depressed mental status, or a delay in development. 6 to 12 Months:Infants begin to babble and by their first year can say their first word. These infants also sit without support, progress to crawling, and finally begin to walk, which predisposes them to increased exposure to physical dangers. At this age, infants are teething and prone to explore their world by picking things up and placing them in their mouths, which increases the risk for choking and poisonings from toxic substances. Infants may show separation anxiety when separated from the parent or caregiver. Let the parent or caregiver hold the infant as you start your physical assessment. As with the younger infants, persistent crying or irritability can be a symptom of serious illness.

The toddler 1-3

12 to 18 Months During this period, toddlers begin to walk and to explore their environment. They are able to open doors, drawers, boxes, and bottles. Because they are explorers by nature and are not afraid, injuries in this age group increase. At 12 to 18 months, toddlers begin to imitate the behaviors of older children and parents and may express a desire to dress like their parents. The toddler knows major body parts when you point to them and may speak 4 to 6 words. Because of a lack of molars, toddlers may not be able to fully chew their food before swallowing, leading to an increased risk of choking. 18 to 24 Months: At the beginning of this stage, the toddler may have a vocabulary of 10 to 15 words. By age 2 years, a toddler should be able to pronounce approximately 100 words. Toddlers begin to understand cause and effect with such activities as playing with pop-up toys (jack-in-the-box) and turning on and off a light switch. The toddler's balance and gait also improve rapidly during this period, leading to increased running and climbing skills. Toddlers tend to cling to their parents or caregivers and often have a special object such as a blanket or teddy bear that comforts them when they are separated. Be sure to use any comforting objects when available to help calm the toddler.

Bag-valve mask

A BVM (with oxygen reservoir) at 15 L/min provides nearly 100% oxygen concentration to the pediatric patient. Assisting ventilations with a BVM is indicated for pediatric patients who: Have respirations that are either too slow or too fast to provide an adequate volume of inhaled oxygen Are unresponsive Do not respond in a purposeful way to painful stimuli Assist ventilation of an infant or child using a BVM in the following way: Ensure that you have the appropriately sized equipment. The proper size mask will extend from the bridge of the nose to the cleft of the chin, avoiding compression of the eyes. The mask is transparent, so you can watch for cyanosis and vomiting. Mask volume should be small to decrease dead space and avoid rebreathing; however, the bag should contain at least 450 mL of air. Use an infant bag, not a neonatal bag, for infants younger than 1 year. Use a pediatric bag for children older than 1 year. Older children and adolescents may need an adult bag. Make sure that there is no pop-off valve on the bag; if the bag has a pop-off valve, make sure that you can hold it shut as necessary to achieve chest rise. Maintain a good seal with the mask on the face. Ventilate at the appropriate rate and volume using a slow, gentle squeeze, not a sharp, quick one. Stop squeezing and begin to release the bag as soon as the chest wall begins to rise, indicating that the lungs are filled to capacity. Remember that one-person BVM ventilation is difficult; the ILCOR guidelines do not recommend this method. Errors in technique, such as providing too much volume with each breath, squeezing the bag too forcefully, or ventilating at a rate that is too fast, can result in gastric distention or overinflation of the lung, resulting in a pneumothorax. An inadequate mask seal or improper head position can lead to hypoventilation or hypoxia.

Asthma

A condition in which the smaller air passages (bronchioles) become inflamed, swell, and produce excessive mucus, which leads to difficulty breathing. Asthma is a true medical emergency if not promptly identified and treated. According to the CDC, 10% of children in the United States have asthma and, in 2007 alone, 185 children died of asthma. Common causes (triggers) include: Upper respiratory infection Exercise Exposure to cold air or smoke Emotional stress Asthma is rare in children younger than 1 year. Children with asthma will wheeze as they attempt to exhale through partially obstructed lower air passages; you may be able to hear loud wheezing without a stethoscope. In other cases, the airways are completely blocked and no air movement is heard. In severe cases, cyanosis and/or respiratory arrest may quickly develop. If possible, allow the pediatric patient to assume a position of comfort in the parent's or caregiver's lap. Avoid overexciting the pediatric patient. Administer supplemental oxygen via a route that is tolerated by the child. Allow the parent or caregiver to assist the team by gathering any medications, calming the pediatric patient, or holding blow-by oxygen or a nonrebreathing mask. A bronchodilator (albuterol, a beta-2 agonist) via a metered-dose inhaler (MDI) with a spacer-mask device may be administered based on local agency protocols. If the parents or caregivers have attempted multiple dosages of albuterol via the MDI or nebulizer, have ALS providers dispatched to meet you en route for additional medication administration and advanced care. If you must assist ventilations in a pediatric patient who is having an asthma attack, use slow, gentle breaths. A prolonged asthma attack that is unrelieved may progress into a condition known as status asthmaticus. The pediatric patient is likely to be frightened, frantically trying to breathe, and using all the accessory muscles. Status asthmaticus is a true emergency. Administer oxygen and provide rapid transport to the emergency department (ED). An exhausted pediatric patient may have stopped feeling anxious or even struggling to breathe. It may look as if this patient is recovering; however, he or she is at a very critical stage and is likely to stop breathing. Aggressive airway management, oxygen administration, and prompt transport are essential in this situation. Consider calling for ALS backup. Follow local protocol.

Nonrebreathing mask

A nonrebreathing mask delivers up to 95% oxygen to the pediatric patient and allows the patient to exhale all carbon dioxide without rebreathing it. To apply a nonrebreathing mask: Select the appropriately sized pediatric nonrebreathing mask. The mask should extend from the bridge of the nose to the cleft of the chin. Connect the tubing to an oxygen source set at 10 to 15 L/min. Adjust oxygen flow as needed to match the pediatric patient's respiratory rate and depth. The reservoir bag should neither deflate completely nor fill to bulging during the respiratory cycle.

Circulation

A pulse may be difficult to palpate if it is weak, very fast, or very slow. In infants, palpate the brachial pulse or femoral pulse. In children older than 1 year, palpate the carotid pulse. Note the rate and quality of the pulse. Strong central pulses usually indicate that the child is not hypotensive; however, this does not rule out the possibility of compensated shock. Weak or absent peripheral pulses indicate decreased perfusion. The absence of a central pulse indicates the need for CPR. The pulse rate should be interpreted within the context of the overall history, PAT, and the entire primary assessment. A trend of an increasing or decreasing pulse rate may suggest worsening hypoxia or shock or improvement after treatment. When hypoxia or shock becomes critical, bradycardia occurs. Bradycardia is a condition in which the heart rate is less than 80 beats/min in children or less than 100 beats/min in newborns. Bradycardia in a pediatric patient is an ominous sign and often indicates impending cardiopulmonary arrest. Feel the skin for temperature and moisture at the same time you assess the patient's pulse. Estimate the capillary refill time by squeezing the end of a finger or toe for several seconds until the nail bed blanches, and then observing the return of blood to the area. Color should return within 2 seconds after you let go. Assess the pediatric patient's LOC using the AVPU scale or the Pediatric Glasgow Coma Scale. Check the responses of each pupil to a direct beam of light. A normal pupil constricts after a light stimulus. Pupillary response may be abnormal in the presence of drugs, ongoing seizures, hypoxia, or brain injury. Note if the pupils are dilated, constricted, reactive, or fixed. Look for symmetric movement of the extremities and note any neurologic motor deficit such as the inability to move the upper or lower extremities, an inability to communicate, weakness, or difficulty walking (gait). In children ages 3 years and older, pain scales using pictures of facial expressions (Wong-Baker FACES Scale) may be helpful in assessing the level of pain. Keep infants and young children warm (but not overly hot) during transport or when the patient is exposed to assess or reassess an injury. Cover the head in particular, because up to 50% of heat loss can occur with a head that is larger in proportion to the rest of the body. Remember that infants and children are prone to hypothermia because of poor thermoregulation and a larger surface-area-to-mass ratio than adults. Without recognition and treatment of hypothermia, the pediatric patient may become unconscious and lapse into convulsive seizure activity.

length-based resuscitation tape

A tape used to estimate an infant or child's weight on the basis of length; appropriate drug doses and equipment sizes are listed on the tape.

Pneumonia

According to the World Health Organization, pneumonia is the leading cause of death for over 2 million children worldwide annually. Pneumonia is a general term that refers to an infection of the lungs. Pneumonia is often a secondary infection; it occurs during or after treatment for a preexisting infection such as a cold. It can also be caused by direct lung injuries, such as from an accidental ingestion of a chemical or a submersion incident. Children with diseases causing immunodeficiency are at increased risk for pneumonia developing. Often pediatric patients will present with unusually rapid breathing, or will breathe with grunting or wheezing sounds. Additional signs and symptoms include: Nasal flaring Tachypnea Hypothermia or fever Unilateral diminished breath sounds or crackles over the infected lung segments Assess the work of breathing by observing for signs of accessory muscle usage. Pneumonia is particularly serious in infants because they have an increased oxygen demand and less respiratory reserve than older children or adults. For a pediatric patient with suspected pneumonia, your primary treatment will be supportive. Monitor the patient's airway and breathing status, and administer supplemental oxygen if required. If the child is wheezing, administer a bronchodilator if permitted in your EMS system. A diagnosis of pneumonia must be confirmed in the hospital setting with a chest X-ray, followed by the administration of antibiotics as the primary treatment.

Adolescents 12-18

Adolescents are able to discriminate between what is right and wrong. They are able to incorporate their own values and beliefs into their daily decision-making process. Simple injuries or illnesses can be exaggerated or understated due to anxiety about body image or fear of disfigurement. Adolescents struggle with independence, loss of control, body image, sexuality, and peer pressure. They may have mood swings or depression and when ill or injured may act younger than their age. When the adolescent's condition is stable, discuss the situation and allow the adolescent to be involved in his or her care. Provide the adolescent with choices regarding his or her health, while also lending guidance if needed. If the adolescent's condition requires him or her to be exposed or partially exposed to be assessed, take every measure to respect the patient's modesty and privacy. If an EMT of the same gender is available to perform the physical examination, it may lessen the stress of the event. Some adolescents may have a negative or altered body image. An injury that could result in a scar from a laceration or burn will be challenging for you to address. The best practice is to be honest and tactful, and to reassure the adolescent that you are doing everything within your training to help in this situation. Allow the adolescent to speak openly about any thoughts and concerns. Female adolescents may be pregnant, so ask about the possibility. Communicate her answer to the receiving facility and note it on your patient care report.

Airway Obstruction

Airway obstruction in children can be caused by: Trauma A child's teeth may have been dislodged into the airway. Blood, vomitus, or other secretions can also cause mild or severe airway obstruction. Infections, including: Pneumonia Croup Epiglottitis Bacterial tracheitis Consider infection as a possible cause of airway obstruction if a pediatric patient has congestion, fever, drooling, and cold symptoms. Signs and symptoms associated with a partial upper airway obstruction include decreased or absent breath sounds and stridor. Stridor is usually caused by swelling of the area surrounding the vocal cords or upper airway obstruction. Infants or children with a complete airway obstruction will have absent breath sounds and become rapidly cyanotic. Signs and symptoms of a lower airway obstruction include wheezing and/or crackles. The best way to auscultate breath sounds in a pediatric patient is to listen on both sides of the chest at the level of the armpit. If the patient is conscious and coughing forcefully and you know for sure that there is a foreign body in the airway, encourage the child to cough to clear the airway. If the material in the airway does not completely block the flow of air, the pediatric patient may be able to breathe adequately on his or her own without any intervention. Do not intervene except to provide supplemental oxygen. Allow the pediatric patient to remain in whatever position is most comfortable, and monitor his or her condition during transport. The signs of severe airway obstruction include: Ineffective cough (no sound) Inability to speak or cry Increasing respiratory difficulty, with stridor Cyanosis Loss of consciousness If an infant is conscious with a complete airway obstruction, perform up to five back blows followed by five chest thrusts. Position the infant facedown on your forearm. Support the infant's jaw and head with your hand. Use the heel of your other hand to slap the back forcefully five times (between the shoulder blades). If the airway does not clear, flip the infant onto his or her back, using your hand to support the head. Perform up to five chest thrusts in the same manner you would provide chest compressions for CPR. Repeat the process until the obstruction clears or until the infant becomes unconscious. If a child (older than 1 year) is conscious with a complete airway obstruction, perform abdominal thrusts (Heimlich maneuver). Continue until the obstruction clears or until the child becomes unconscious. If there is reason to believe that an unconscious child has a foreign body obstruction and there are no suspected spinal injuries, open the airway using the head tilt-chin lift maneuver and look inside the mouth to see whether the obstructing object is visible. If the object is visible, try to remove it using a finger sweep motion. Never use finger sweeps if you cannot see the object because you may push it further into the airway. Chest compressions increase the pressure in the chest, creating an artificial cough that may force a foreign body from the airway.

Toddler Assesment

Allow the toddler to hold any special object that brings him or her comfort. When possible, demonstrate the assessment on a doll or stuffed animal first, which may limit the toddler's anxiety and make it easier to perform the assessment. Toddlers have trouble describing or localizing pain because they do not have the verbal ability to be precise. The use of visual clues and the Wong-Baker FACES pain scale can be helpful with this age group. Restrain the toddler for as short a time as possible, and allow him or her to be comforted by the parent or caregiver immediately after a painful procedure. Whenever possible, begin your assessment at the feet or far from the location of any pain to keep from upsetting the toddler. Involve the parent or caregiver in any procedures. This not only provides you with an extra set of hands, but the presence of the parent or caregiver will comfort the toddler. If a parent or caregiver is unavailable, reassure the toddler using simple words and a calm, soothing voice.

Respiratory Emergencies

Asthma Pneumonia Croup (laryngotracheobronchitis) Epiglottitis (supraglottitis) Bronchiolitis Pertussis (whooping cough)

Which of the following is the LEAST reliable assessment parameter to evaluate when determining the presence of shock in infants and children? Pulse rate Blood pressure Skin condition Capillary refill

Blood pressure

Oxygen Delivery Devices

Blow-by oxygen Nasal cannula Nonrebreathing mask Bag-valve mask

Blow-by oxygen

Blow-by oxygen is not as effective as a face mask or nasal cannula for delivering oxygen. In the blow-by technique, an oxygen tube is held near the infant or child's nose and mouth. It is often used after childbirth to deliver a small amount of oxygen to the neonate. On rare occasions when other adjuncts cannot be used or the pediatric patient will not tolerate any other adjunct, this technique may be necessary. The blow-by technique at 6 L/min provides more than 21% oxygen concentration. It does not provide a high oxygen concentration, but it is better than no oxygen. To administer blow-by oxygen: Place oxygen tubing through a small hole in the bottom of an 8-oz (237-mL) cup. A cup is a familiar object that is less likely to frighten young children than an oxygen mask. Connect tubing to an oxygen source set at 6 L/min. Hold the cup approximately 1 to 2 inches (2 to 5 cm) away from the child's nose and mouth.

Fever Emergencies and Management

Body temperatures of 100.4°F (38°C) or higher are considered to be abnormal. Common causes of a fever in pediatric patients include: Infection, such as pneumonia, meningitis, or urinary tract infection Status epilepticus Cancer Drug ingestion (aspirin) Arthritis and systemic lupus erythematosus (rash across nose) High environmental temperature Hyperthermia differs from fever in that it is an increase in body temperature caused by an inability of the body to cool itself. Hyperthermia is typically seen in warm environments, such as a closed vehicle on a hot day. An accurate body temperature is an important vital sign for pediatric patients. A rectal temperature is the most accurate for infants to toddlers. Older children will be able to follow directions if placing a thermometer under the tongue or under the arm. A fever can have several causes, such as a viral or a bacterial infection. Depending on the source of infection, the pediatric patient may have additional signs of respiratory distress, shock, a stiff neck, a rash, skin that is hot to the touch, flushed cheeks, seizures, and bulging fontanelles in an infant. Assess the patient for other signs and symptoms such as nausea, vomiting, diarrhea, decreased feedings, and headache. A fever that is accompanied by a stiff neck, sensitivity to light, and a rash may be an indication that the patient has either bacterial or viral meningitis. A pediatric patient with a fever may require only minimal interventions in the field. Provide rapid transport and manage the patient's ABCs. Follow standard precautions if you suspect that the patient may have a communicable disease such as meningitis.

Bronchiolitis

Bronchiolitis is a specific viral illness of newborns and toddlers, often caused by respiratory syncytial virus (RSV), that causes inflammation of the bronchioles. RSV is highly contagious and spread through droplets when the pediatric patient coughs or sneezes. RSV is more common in premature infants and results in copious secretions that may require suctioning. The virus can survive on surfaces, including hands and clothing, so the infection tends to spread rapidly through schools and in child care centers. Bronchiolitis occurs during the first 2 years of life and is more common in boys. Bronchioles become inflamed, swell, and fill with mucus. The airways of infants and young children can become easily blocked. When assessing a pediatric patient, look for signs of dehydration—infants with RSV often refuse liquids. If the RSV has progressed to bronchiolitis, shortness of breath and fever may be present. Approach the pediatric patient with a calm demeanor and allow for a position of comfort. Treat airway and breathing problems as appropriate. Humidified oxygen is helpful if available. Consider calling for ALS backup and transport to the appropriate hospital.

Signs of abuse

Bruises: Observe the color and location of any bruises. New bruises are pink or red. Over time, bruises turn blue, then green, then yellow-brown and faded. Note the location. Bruises to the back, buttocks, ears, or face are suspicious and are usually inflicted by a person. Burns: Burns to the penis, testicles, vagina, or buttocks are usually inflicted by someone else, as are burns that encircle a hand or foot to look like a glove. You should suspect abuse if the child has cigarette burns or grid pattern burns. Fractures:Fractures of the humerus or femur do not normally occur without major trauma, such as a fall from a high place or a motor vehicle crash. Falls from a bed are not usually associated with fractures. Maintain some index of suspicion if an infant or young child sustains a femur fracture or a complete fracture of any bone. Children are more likely to experience greenstick (incomplete) fractures, as opposed to complete fractures, due to their soft and pliable bones. A complete fracture in a pediatric patient indicates that the child was exposed to significant traumatic force. Shaken baby syndrome: Infants who are victims of shaken baby syndrome may sustain life-threatening head trauma by being shaken or struck on the head. There is bleeding within the head and damage to the cervical spine as a result of intentional, forceful shaking. The infant will be found unconscious, often without evidence of external trauma. The call for help may be for an infant who has stopped breathing or is unresponsive. The infant may appear to be in cardiopulmonary arrest, but what has likely occurred is that the shaking tore blood vessels in the brain, resulting in bleeding around the brain. The pressure from the blood results in an increased cranial pressure, leading to coma and/or death. NeglectNeglect is refusal or failure on the part of the parent or caregiver to provide life necessities, such as food, water, clothing, shelter, personal hygiene, medicine, comfort, and personal safety. Children who are neglected are often dirty or too thin or appear developmentally delayed because of a lack of stimulation. You may observe such children when you are making calls for unrelated problems. Report all cases of suspected neglect.

with trauma or Cardiac arrest it is not ABC but is

CAB

Croup (laryngotracheobronchitis)

Croup is an infection of the airway below the level of the vocal cords, usually caused by a virus. This disease is typically seen in children between ages 6 months and 3 years. It is easily passed between children. The disease starts with a cold, cough, and a low-grade fever that develops over 2 days. The hallmark signs of croup are stridor and a seal-bark cough, which is a signal of significant narrowing of the air passage of the trachea that may progress to significant obstruction. Croup often responds well to the administration of humidified oxygen. Bronchodilators are not indicated for croup and can make the child worse.

Disaster Management

Decision points in the JumpSTART triage system include: Ability to walk (except in infants) Presence of spontaneous breathing Respirations of less than 15 or of greater than 45 breaths/min Palpable peripheral pulse Appropriate response to painful stimuli on the AVPU scale Pediatric patients who are able to walk are designated as the third or minor priority (green tag), meaning they are not in immediate need of treatment. Patients who breathe spontaneously, have a peripheral pulse, and are appropriately responsive to painful stimuli are designated as the second priority (yellow tag). Their treatment and transport can be delayed. Pediatric patients who are breathing but pulseless, who are apneic and responsive to positioning or rescue breathing, or who are inappropriately responsive to painful stimuli are designated as the highest priority (red tag). These patients need immediate care and transport. Pediatric patients who are both apneic and pulseless, or who are apneic and unresponsive to rescue breathing, are considered deceased or expectant deceased (black tag). for kids less than 8

Epiglottitis (supraglottitis)

Epiglottitis is an infection of the soft tissue in the area above the vocal cords. Bacterial infection is the most common cause. Infants and children are the most common age groups diagnosed with epiglottitis, but it occurs in patients of all ages. In preschool- and school-aged children especially, the epiglottis can swell to two to three times its normal size, putting the airway at risk of complete obstruction. The condition usually develops in otherwise healthy children, and symptoms are relatively sudden in onset. Children with this infection look ill, report a very sore throat, and have a high fever. They will often be found in the tripod position and drooling.

Febrile Seizures

Febrile seizures: Typically occur on the first day of a febrile illness Are characterized by generalized tonic-clonic seizure activity Last less than 15 minutes with a short postictal phase, or none at all These seizures may be a sign of a more serious problem, such as meningitis. Obtain a history from the parent or caregiver because these pediatric patients may have had a febrile seizure in the past. Carefully assess the ABCs. Begin cooling measures with tepid (not cold) water. Provide prompt transport. All pediatric patients with febrile seizures need to be seen in the hospital setting.

The most common cause of dehydration in pediatric patients is vomiting and diarrhea.

Fever and altered LOC are common symptoms of meningitis in patients of all ages.

Injuries to Specific Body Systems

Head injuries: Head injuries are common in children because the size of a child's head, in relation to the body, is larger than that of an adult. An infant also has a softer, thinner skull, which may result in injury to the underlying brain tissues. The scalp and facial vessels can bleed easily and may cause significant blood loss if the bleeding is not controlled. Nausea and vomiting are common signs and symptoms of head injury in children; however, it is easy to mistake these for an abdominal injury or illness. You should suspect a serious head injury in any child who experiences nausea and vomiting after a traumatic event. Pediatric patients are managed in the same manner as adults. Chest injuries: Chest injuries in children are usually the result of blunt trauma rather than penetrating objects. Children have soft, flexible ribs that can be significantly compressed without breaking. This chest wall flexibility can produce a flail chest. Even though there may be no external sign of injury, such as broken ribs, contusions, or bleeding, there may be significant injuries within the chest. Pediatric patients are managed in the same manner as adults. Abdominal injuries:Abdominal injuries are common in children. Children can compensate for significant blood loss better than adults without signs or symptoms of shock developing. They can also have a serious injury without early external evidence of a problem. All children with abdominal injuries should be monitored for signs and symptoms of shock, including: A weak, rapid pulse Cold, clammy skin Decreased capillary refill (an early sign) Confusion Decreased systolic blood pressure (a late sign) Even in the absence of signs and symptoms of shock, or with only very few signs and symptoms, remain cautious about the possibility of internal injuries. Pediatric patients are managed in the same manner as adults. Burns:Burns to children are generally considered more serious than burns to adults because infants and children have more surface area relative to total body mass, which means greater fluid and heat loss. Children do not tolerate burns as well as adults do. Children are more likely to go into shock, develop hypothermia, and experience airway problems because of the unique differences of their ages and anatomy. The most common burns involve exposure to hot substances such as scalding water in a bathtub, hot items on a stove, or exposure to caustic substances such as cleaning solvents or paint thinners. Older children are more likely to be burned by flames from fire. Suspect possible internal injuries from chemical ingestion when you see a child who has burns, particularly around the face and mouth. Burned skin cannot resist infection as effectively as normal skin can, so use sterile techniques when handling the skin of children with burn wounds if possible. The table provides some general guidelines to follow, which may help you determine which pediatric patients should be treated primarily at specialized burn centers. Consider the possibility of child abuse in any burn situation, and report any information about your suspicions to the appropriate authorities. Pediatric patients are managed in the same manner as adults. Injuries of the extremities:Children have immature bones with active growth centers. Growth of long bones occurs from the ends at specialized growth plates. These growth plates are potential weak spots in the bone and are often injured as a result of trauma. In general, children's bones bend more easily than adults' bones, so greenstick (incomplete) fractures can occur. Extremity injuries in pediatric patients are generally managed in the same manner as those in adults. Painful, deformed limbs with evidence of broken bones should be splinted. Specialized splinting equipment, such as a traction splint for fractures of the femur, should be used only if it fits the pediatric patient. Do not attempt to use adult immobilization devices on a pediatric patient unless the pediatric patient is large enough to properly fit in the device.

A pediatric patient in anaphylactic shock will have:

Hypoperfusion Stridor and/or wheezing Increased work of breathing An altered appearance with restlessness, agitation, and sometimes a sense of impending doom Hives

TICLS

Increased work of breathing often manifests as: Abnormal airway noise: Grunting or wheezing Accessory muscle use: Contractions of the muscles above the clavicles (supraclavicular) Retractions: Drawing in of the muscles between the ribs (intercostal retractions) or of the sternum (substernal retractions) during inspiration Head bobbing: The head lifts and tilts back during inspiration, then moves forward during expiration. Nasal flaring: The nares (the external openings of the nose) widen, usually seen during inspiration. Tachypnea: Increased respiratory rate Tripod position: In older children, this position will maximize the effectiveness of the airway. TICLS includes: Tone Interactiveness Consolability Look or gaze Speech or cry

The five stages of human growth include:

Infancy The toddler years Preschool years School-age years Adolescence

Gastrointestinal Emergencies and Management

Liver and splenic injuries are common among children and may result in life-threatening emergencies. The patient needs to be monitored for signs and symptoms of shock, which include an altered mental status; pale, cool skin; tachypnea; tachycardia; and bradycardia (late sign). A common source of gastrointestinal upset is the ingestion of certain foods or unknown substances, such as milk or ice cream (lactose intolerance). In most cases, you will be faced with a pediatric patient who is experiencing abdominal discomfort with nausea, vomiting, and/or diarrhea. Both vomiting and diarrhea can cause dehydration in children. Appendicitis is common in pediatric patients and, if untreated, can lead to peritonitis or shock. Appendicitis will typically present with a fever and pain on palpation of the right lower abdominal quadrant. Rebound tenderness is a common sign. If you suspect appendicitis, promptly transport the pediatric patient to the hospital for further evaluation. Because children are sensitive to fluid loss, obtain a thorough history from the parent or primary caregiver. In particular, ask questions such as: How many wet diapers has your child had today? Is your child tolerating liquids and is he or she able to keep them down? How many times has your child had diarrhea and for how long? Are tears present when your child cries? These questions can help to determine how dehydrated the pediatric patient may be. If the pediatric patient is dehydrated, transport to the hospital for further care.

Meningitis

Meningitis can occur in both children and adults, but some pediatric patients are at greater risk than others, including: Males Newborn infants Children with compromised immune systems (such as HIV/AIDS or cancer) Children who have any history of brain, spinal cord, or back surgery Children who have had head trauma Children with shunts, pins, or other foreign bodies within their brain or spinal cord At especially high risk are children with a ventriculoperitoneal (VP) shunt. VP shunts drain excess fluids from around the brain into the abdomen. These children have tubing that can usually be seen and felt just under the scalp. Fever and altered LOC are common symptoms of meningitis in patients of all ages. Changes in the LOC can range from a mild or severe headache to confusion, lethargy, and/or an inability to understand commands or interact appropriately. The child may also experience a seizure, which may be the first sign of meningitis. Infants younger than 2 to 3 months can have apnea, cyanosis, fever, a distinct high-pitched cry, or hypothermia. Bending the neck forward or back increases the tension within the spinal canal and stretches the meninges, causing a great deal of pain. This results in the characteristic stiff neck, and children will often refuse to move their neck, lift their legs, or curl into a C position, even if coached to do so. One sign of meningitis in an infant is increasing irritability, especially when being handled. Another sign is a bulging fontanelle without crying.

Nasal cannula

Nasal cannula at 1 to 6 L/min provides 24% to 44% oxygen concentration. Some pediatric patients prefer the nasal cannula, whereas others find it uncomfortable. To apply a nasal cannula: Choose the appropriately sized pediatric nasal cannula. The prongs should not fill the nares entirely. If the nares blanch, select a smaller cannula. Connect the tubing to an oxygen source set at 1 to 6 L/min.

Signs and symptoms of increased work of breathing include:

Nasal flaring Abnormal breath sounds Accessory muscle use Tripod position As the pediatric patient progresses to possible respiratory failure: Efforts to breathe decrease. The chest rises less with inspiration. Cyanosis may develop (a late sign). Not all pediatric patients develop cyanosis. You should be just as concerned about a pediatric patient with pale skin as one with blue skin.

Meningitis

Neisseria meningitidis The bacterium that causes a form of bacterial meningitis characterized by rapid onset of symptoms, often leading to shock and death.

Airway adjuncts are devices that help to maintain the airway or assist in providing artificial ventilation, including:

Oropharyngeal airways Nasopharyngeal airways Bite blocks BVMs

Pediatric patients weighing less than 40 pounds (18 kg) who do not require spinal immobilization should be transported in a car seat if the situation allows. Car seats are designed to be either forward-facing or rear-facing; they cannot be mounted sideways on a bench seat. Car seats should not be mounted in the front of an ambulance, especially if the ambulance is equipped with air bags.

Pediatric patients younger than 2 years must be transported in a rear-facing position because of the lack of mature neck muscles.

Pertussis (whooping cough)

Pertussis is a communicable disease caused by a bacterium that is spread through respiratory droplets. As the result of vaccinations, this potentially deadly disease is less common in the United States. The typical signs and symptoms are similar to a common cold: coughing, sneezing, and a runny nose. As the disease progresses, the coughing becomes more severe and is characterized by the distinctive "whoop" sound heard during inspiration. Infants infected with pertussis may develop pneumonia or respiratory failure. To treat pediatric patients, keep the airway patent (open) and transport. Because pertussis is contagious, follow standard precautions, including wearing a mask and eye protection.

You must have a thorough understanding of how trauma affects children in terms of:

Physical differences: As discussed, children are smaller than adults; therefore, when they are hurt in the same type of crash as an adult, the location of their injuries may differ from those in an adult. Children's bones and soft tissues are less well developed than those of adults; therefore, the force of an injury affects these structures somewhat differently than it does in an adult. Because a child's head is proportionately larger than an adult's, it exerts greater stress on the neck structures during a deceleration injury. Because of these anatomic differences, always carefully assess children for head and neck injuries. Psychologic differences:Children are less mature psychologically than adults; therefore, they are often injured because of their undeveloped judgment and their lack of experience. Children and adolescents are also more likely to sustain injuries from diving into shallow water because they forget to check the depth of the water before they dive. In such situations, always assume that the child has serious head and neck injuries. Injury patterns:Although you are not responsible for diagnosing injuries in children, your ability to recognize and report serious injuries will provide critical information to hospital staff. It is important for you to understand the special physical and psychologic characteristics of children and what makes them more likely to have certain kinds of injuries. Vehicle Collisions Children playing or riding a bicycle can dart out in front of motor vehicles without looking. The driver may have very little time to slow down or stop to prevent hitting the child. The area of greatest injury varies, depending on the size of the child and the height of the bumper at the time of impact. When vehicles slow down at the moment of impact, the bumper dips slightly, causing the point of impact with the child to be lowered. The exact area that is struck depends on the child's height and the final position of the bumper at the time of impact. Children who are injured in these situations often sustain high-energy injuries to the head, spine, abdomen, pelvis, or legs. In addition to differences in size and anatomy, children will often turn toward an oncoming vehicle when they see it approaching and, therefore, sustain different injuries than an adult who turns away. Sports Activities Children, especially those who are older or adolescents, are often injured in organized sports activities. Head and neck injuries can occur after high-speed collisions in contact sports. Remember to immobilize the cervical spine when caring for children with sports-related injuries when indicated. Familiarize yourself with local protocols related to helmet removal.

central pulses

Pulses that are closest to the core (central) part of the body where the vital organs are located; include the carotid, femoral, and apical pulses.

School age 6-12

School-age children can think in concrete terms, respond sensibly to direct questions, and help take care of themselves. Concerns about popularity and peer pressure occupy a great deal of time and energy. Children with chronic illness or disabilities can become self-conscious because of concerns about fitting in with their peers. At this stage, the child is usually familiar with the process of physical examination. This may make your job easier or more difficult, depending on whether the child's prior health care experiences have been positive or negative. Begin your assessment at the head and move toward the feet, similar to assessing an adult. Whenever possible, give the child simple, appropriate choices. Only ask the type of questions that let you control the answer and do not bargain or debate with the patient. Encourage cooperation by allowing the child to listen to his or her own heartbeat through the stethoscope. Ensure the patient's modesty during the examination. School-age children can understand the difference between emotional and physical pain and have concerns about what pain means. Give them simple explanations about what is causing their pain and what will be done about it. Games and conversation may distract them. Ask them to describe their favorite place, pets, school activities, or toys. Ask the parent's or caregiver's advice in choosing the right distraction. Rewarding the child after a procedure can be very helpful in his or her future cooperation and recovery.

Seizures

Seizures in infants can be subtle, consisting only of an abnormal gaze, sucking motions, or "bicycling" motions. In older children, seizures are more obvious and typically consist of repetitive muscle contractions and unresponsiveness. The postictal state begins once a seizure has stopped; the patient's muscles relax, becoming almost flaccid, and the breathing becomes labored. The longer and more intense a seizure is, the longer it will take for the imbalance to correct itself. Longer and more severe seizures will result in longer postictal unresponsiveness and confusion. Once the pediatric patient regains a normal level of consciousness, the postictal state is over. Seizures that continue every few minutes without regaining consciousness or last longer than 30 minutes are referred to as status epilepticus. Recurring or prolonged seizures should be considered potentially life-threatening situations in which pediatric patients need emergency medical care. If the pediatric patient does not regain consciousness or continues to seize, protect the pediatric patient from harming himself or herself and call for ALS backup. These pediatric patients need advanced airway management and medication to stop the seizure. Position the head to open the airway. Clear the mouth with suction. Consider placing the pediatric patient in the recovery position if he/she is actively vomiting and suction is inadequate to control the airway. Provide 100% oxygen by nonrebreathing mask or blow-by method. If there are no signs of improvement, begin BVM ventilation with appropriately sized equipment with supplemental oxygen. Transport the pediatric patient to the appropriate facility.

Neglect is refusal or failure on the part of the parent or caregiver to provide life necessities, such as food, water, clothing, shelter, personal hygiene, medicine, comfort, and personal safety. Children who are neglected are often dirty or too thin or appear developmentally delayed because of a lack of stimulation. You may observe such children when you are making calls for unrelated problems. Report all cases of suspected neglect.

Sexual Abuse Your assessment of a child who has been sexually abused should be limited to determining the type of dressing any injuries require. Sometimes, a sexually abused child is also beaten, so treat any bruises or fractures as well. Do not examine the genitalia of a young child unless there is evidence of bleeding or there is an injury that must be treated. If you suspect that a child is a victim of sexual abuse, do not allow the child to wash, urinate, or defecate before a physician completes a physical examination. Although this step can be difficult for the victim, it is important to preserve evidence. If possible, ensure that an EMT or police officer of the same gender remains with the child, unless locating one will delay transport. Maintain professional composure the entire time you are assessing and caring for a sexually abused child. Assume a concerned, caring approach, and shield the child from onlookers and curious bystanders. Obtain as much information as possible from the child and any witnesses. Record any information carefully and completely on the patient care report. Transport all children who are victims of sexual assault. Sexual abuse of a child is a crime. Cooperate fully with law enforcement officials in their investigations.

Pediatric patients respond differently than adults to fluid loss. They may respond by increasing their heart rate, increasing respirations, and showing signs of pale skin (pallor) or blue skin (cyanosis). Signs of shock in infants and children are as follows:

Tachycardia Poor capillary refill (>2 seconds) Mental status changes

Anatomy and Physiology of Other Systems

The circulatory system It is important to know the normal pulse ranges when evaluating children. An infant's heart can beat as many as 160 times or more per minute if the body needs to compensate for injury or illness. This is the primary method the body uses to compensate for decreased perfusion. Children are able to compensate for decreased perfusion by constricting the vessels in the skin. Constriction of the blood vessels can be so profound that blood flow to the extremities can be diminished. Signs of vasoconstriction include: Pallor (early sign) Weak distal (eg, radial or pedal) pulses in the extremities Delayed capillary refill Cool hands or feet The nervous system The pediatric nervous system is immature, underdeveloped, and not well protected. The head-to-body ratio of an infant and young child is disproportionately larger, making this population more prone to head injuries from falls or motor vehicle crashes. The occipital region is larger, which increases the momentum of the head during a fall. The subarachnoid space is relatively smaller, leaving less cushioning for the brain. The brain tissue and the cerebral vasculature are fragile and prone to bleeding from shearing forces, such as during an incidence of shaken baby syndrome. The pediatric brain requires a higher amount of cerebral blood flow, oxygen, and glucose. Glucose stores are limited in the pediatric patient. These special needs mean that the pediatric brain is at risk for secondary brain damage from hypotension and hypoxic events. Spinal cord injuries are less common in pediatric patients. Approximately 12,000 new spinal cord injuries are reported yearly in the United States. Roughly 10% of those spinal injuries occur in children younger than age 16 years. If a child's cervical spine is injured, it is most likely to be an injury to the ligaments as the result of a fall. If you suspect a neck injury, perform manual in-line stabilization or follow local protocols. The gastrointestinal system The abdominal muscle structures are less developed in the pediatric patient, which results in less protection from blunt or penetrating trauma. The internal organs, such as the liver and the spleen, are proportionally larger and situated more anteriorly, so they are prone to bleeding and injury. Because the internal organs are positioned in a closer proximity to each other, there is a higher risk for multiple organ injury caused by minimal direct impact to this region, such as from a lap belt in a motor vehicle. The liver, spleen, and kidneys are more frequently injured in children than in adults. The musculoskeletal system A child's bones are softer than an adult's. As a result of the active growth plates, children's bones are weaker and more flexible, making them prone to fracture with stress. The open growth plates are also weaker than ligaments and tendons, leading to length discrepancies if there is an injury to the growth plate. Because of these factors, immobilize extremities with suspected sprains or strains because they may actually be stress fractures. The bones of the infant's head are flexible and soft, which allows the head to be delivered through the birth canal and for the growth of the brain during development. Located on the front (anterior) and back (posterior) portions of the head are soft spots known as fontanelles. Each will close at particular stages of development: 18 months for the anterior suture and 6 months for the posterior suture. Some bulging is a normal assessment finding when the infant is either crying, coughing, or lying on the back or stomach. The fontanelles of an infant can be a useful assessment tool for such issues as increased cranial pressure (bulging with a noncrying infant) or dehydration (a sunken appearance). The thoracic cage in children is highly elastic and flexible because it is primarily composed of cartilaginous connective tissue. The ribs and vital organs are less protected by muscle and fat. The highly flexible ribs mean that fractures in pediatric patients are rare, unless a high-energy impact to the chest wall is encountered, such as during a motor vehicle crash. Underlying damage may still exist within the thoracic cavity without any exterior markings. The integumentary system The child's skin is thinner with less subcutaneous fat. It tends to burn more deeply and easily than an adult's, as in the case of a sunburn. Infants and children also have a larger body-surface-area-to-body-mass ratio, which can lead to significant fluid and heat losses.

Dehydration Emergencies and Management

The most common cause of dehydration in pediatric patients is vomiting and diarrhea. If left untreated, dehydration can lead to shock and eventually death. Infants and children are at greater risk than adults for dehydration because their fluid reserves are smaller than those in adults. Life-threatening dehydration can overcome an infant in a matter of hours. An infant with mild dehydration may have dry lips and gums, decreased saliva, and fewer wet diapers throughout the day. As the dehydration grows more severe, the lips and gums may become very dry, the eyes may look sunken, and the infant may be sleepy and/or irritable, refusing bottles. The skin may be loose and have no elasticity; this is called poor skin turgor. Infants may have sunken fontanelles. Children who are moderately to severely dehydrated may have mottled, cool, clammy skin and delayed capillary response time. Respirations will usually be increased. Blood pressure may remain within a normal range while the pediatric patient is in shock because the compensatory mechanisms are still in place. Emergency medical care should include assessing the ABCs and obtaining baseline vital signs. If the dehydration is severe, ALS backup may be necessary so that IV access can be obtained and rehydration can begin. All pediatric patients with signs and symptoms of moderate to severe dehydration should be transported to the ED for further evaluation and treatment.

The Preschool-Age Child

The most rapid increase in language occurs during the preschool-age stage of development. Preschool-age children have a rich imagination, which can make them particularly fearful about pain and change involving their bodies. They often believe that their thoughts or wishes can cause injury or harm to themselves or to others. They may believe that an injury is the result of a bad deed they did earlier in the day. They are also learning which behaviors are appropriate and which behaviors will lead to a "time out." Tantrums may occur when preschool-age children feel they cannot control a situation or its outcomes. The risk of foreign body airway obstruction continues to be high at this age. Communicate simply and directly. Tell the child what you are going to do immediately before you do it; this way, the child has no time to develop frightening fantasies. At this age, preschool-age children are easily distracted with counting games, small toys, or conversation. Never lie to the patient. Begin your assessment with the feet and move toward the head, similar to assessing a toddler. Use adhesive bandages to cover the site of an injection or other small wound, because the preschool-age child might be worried about keeping his or her body together in one piece. Keep in mind that modesty is developing at this age, so keep the child covered when possible.

The Preschool-Age Child 3-6

The most rapid increase in language occurs during the preschool-age stage of development. Preschool-age children have a rich imagination, which can make them particularly fearful about pain and change involving their bodies. They often believe that their thoughts or wishes can cause injury or harm to themselves or to others. They may believe that an injury is the result of a bad deed they did earlier in the day. They are also learning which behaviors are appropriate and which behaviors will lead to a "time out." Tantrums may occur when preschool-age children feel they cannot control a situation or its outcomes. The risk of foreign body airway obstruction continues to be high at this age. Communicate simply and directly. Tell the child what you are going to do immediately before you do it; this way, the child has no time to develop frightening fantasies. At this age, preschool-age children are easily distracted with counting games, small toys, or conversation. Never lie to the patient. Begin your assessment with the feet and move toward the head, similar to assessing a toddler. Use adhesive bandages to cover the site of an injection or other small wound, because the preschool-age child might be worried about keeping his or her body together in one piece. Keep in mind that modesty is developing at this age, so keep the child covered when possible.

Differences in Adult/ Child Respiratory System

The pediatric airway is smaller in diameter and shorter in length. The lungs are smaller. The heart is higher in a child's chest. The glottic opening (vocal cords) is higher and positioned more anteriorly, and the neck appears to be nonexistent. The anatomy of a pediatric airway and other important structures differs from that of an adult's in the following ways: A larger, rounder occiput, or back of the head, which requires more careful positioning of the airway A proportionately larger tongue relative to the size of the mouth and a more anterior location in the mouth The child's tongue is larger relative to the small mandible and can easily block the airway. A long, floppy, U-shaped epiglottis in infants and toddlers that is larger than an adult's relative to the size of the airway and extends at a 45-degree angle into the airway Less-developed rings of cartilage in the trachea that may easily collapse if the neck is flexed or hyperextended A narrowing, funnel-shaped upper airway compared to that of a cylinder-shaped lower airway Because of the smaller diameter of the trachea in infants, their airway is easily obstructed by secretions, blood, or swelling. Infants are obligate nose breathers, which may require diligent suctioning or reassessment and management to maintain a clear airway. These differences influence the treatment decisions that you make about pediatric patients, including whether or not intervention is needed and, if so, what procedure to use. An infant needs to breathe faster than an older child. A respiratory rate of 30 to 60 breaths/min is normal for the newborn. The adolescent is expected to have rates closer to the adult range (12 to 20 breaths/min). Children not only have a higher metabolic rate, but also a higher oxygen demand that is twice that of an adult. This, in part, is related to the actual size of the lung tissues and the volume that can be exchanged. This higher oxygen demand combined with a smaller oxygen reserve increases the risk of hypoxia because of apnea or ineffective ventilation efforts. Young children experience muscle fatigue much more quickly than older children. This can lead to respiratory failure if a child has to physically fight harder to breathe for long periods of time. Anything that places pressure on the abdomen of a young child can block the movement of the diaphragm and cause respiratory compromise. Gastric distention can also interfere with movement of the diaphragm and lead to hypoventilation. Use caution when applying straps to a spinal immobilization device because this may hinder full symmetrical chest wall expansion and thus limit tidal volume. Breath sounds in children are easier to hear because of their thinner chest walls, but because less air is exchanged with each breath, detection of poor air movement or complete absence of breath sounds may be more difficult.

Poisoning Emergencies and Management

The pediatric patient may appear normal at first, even in serious cases, or he or she may be confused, sleepy, or unconscious. Infants may be poisoned as a result of being fed a harmful substance by a sibling, parent, or caregiver, or as a result of child abuse. Infants can be exposed to drugs and poisons left on floors and carpeting or in a setting in which harmful drugs are being smoked. Toddlers are curious and often ingest poisons when they find them in the home or garage. Adolescents are more likely to have ingested alcohol and street drugs while partying or during a suicide attempt. After you have completed your primary assessment, ask the parent or caregiver the following questions: What is the substance(s) involved? Approximately how much of the substance was ingested or involved in the exposure (eg, number of pills, amount of liquid)? At what time did the incident occur? Are there any changes in behavior or level of consciousness? Was there any choking or coughing after the exposure? (These can be signs of airway involvement.) Contact the national Poison Control hotline for assistance in identifying poisons at 1-800-222-1222. This free service is available 24 hours a day, 7 days a week. Perform an external decontamination. Remove tablets or fragments from the patient's mouth, and wash or brush poison from the skin. Treatment is supportive: Assess and maintain the pediatric patient's ABCs and monitor breathing. Provide oxygen and perform ventilations if necessary. If the patient demonstrates signs and symptoms of shock, position the child supine, keep the child warm, and transport promptly to the nearest appropriate hospital. In some cases, you will give activated charcoal, if approved by medical control or local protocol. Activated charcoal is not indicated for pediatric patients who: Have ingested an acid, an alkali, or a petroleum product Have a decreased LOC and cannot protect their airway Are unable to swallow If local protocol permits, you will likely carry plastic bottles of premixed suspension, each containing up to 50 g of activated charcoal. Some common trade names for the suspension form are InstaChar, Actidose, and LiquiChar. The usual dose for a child is 1 g of activated charcoal per kilogram of body weight. The usual pediatric dose is 12.5 to 25 g.

Drowning Emergencies and Management

The principal condition that results from drowning is lack of oxygen. Even a few minutes (or less) without oxygen affects the heart, lungs, and brain, causing life-threatening problems such as cardiac arrest, respiratory failure, and coma. Submersion in icy water can lead to hypothermia. Although it is possible for victims of submersion hypothermia to survive long periods in cardiac arrest, most people in this situation die. Diving into the water increases the risk of neck and spinal cord injuries. Signs and symptoms of a drowning patient will vary based on the type and length of submersion. A pediatric patient involved in a drowning emergency may have: Coughing Choking Airway obstruction Difficulty breathing Altered mental status Seizure activity Unresponsiveness Fast, slow, or no pulse noted Pale, cyanotic skin Abdominal distention from ingestion of fluids Once the pediatric patient is successfully removed from the water, assess and manage the ABCs, and call for ALS backup to intervene if needed. Administer oxygen at 100% via a nonrebreathing mask, or via BVM if assisted ventilations are required. Be prepared to suction as these patients often vomit. If trauma is suspected, apply a cervical collar and place the pediatric patient on a backboard. Pad all open spaces under the pediatric patient before securing the patient onto the backboard. If the pediatric patient is unresponsive and in cardiopulmonary arrest, perform CPR. Before using an AED on a pulseless drowning patient, ensure that the patient is dried off.

Child Abuse and Neglect

The term child abuse means any improper or excessive action that injures or otherwise harms a child or infant; it includes physical abuse, sexual abuse, neglect, and emotional abuse. EMTs are commonly called to testify in abuse cases, so it is essential to record all findings, including any statements made by parents or caregivers or others on the scene. If you suspect that physical or sexual abuse is involved, ask yourself the following questions: Is the injury typical for the developmental level of the child? Is the method of injury reported by the parent or caregiver consistent with the pediatric patient's injury? Is the parent or caregiver behaving appropriately (concerned about the child's well-being)? Is there evidence of drinking or drug use at the scene? Was there a delay in seeking care for the child? Is there a good relationship between the child and the parent or caregiver? Does the child have multiple injuries at different stages of healing? Does the child have any unusual marks or bruises that may have been caused by cigarettes, heating grates, or branding injuries? Does the child have several types of injuries, such as burns, fractures, and bruises? Does the child have any burns on the hands or feet that involve a glove distribution (marks that encircle a hand or foot in a pattern that looks like a glove)? Is there an unexplained decreased level of consciousness? Is the child clean and an appropriate weight for his or her age? Is there any rectal or vaginal bleeding? What does the home look like? Clean or dirty? Is it warm or cold? Is there adequate food?

Sudden Infant Death Syndrome

To reduce the risk of sudden infant death syndrome (SIDS), the American Academy of Pediatrics recommends that an infant be placed on his or her back on a firm mattress, in a crib that is free of bumpers, blankets, and toys. The CDC recommends having the baby sleep in the same room, but not in the same bed, chair, or sofa, as an adult. Although it is impossible to predict SIDS, there are several known risk factors, including: Mother younger than 20 years Mother smoked during pregnancy Low birth weight Deaths as the result of SIDS can occur at any time of the day; however, these children are often discovered in the morning when the parents or caregivers go in to check on the infant. If you are the first provider at the scene of suspected SIDS, you will face three tasks: Assessment of the scene Assessment and management of the patient Communication and support of the family

In pediatric patients, the most common causes of shock include:

Traumatic injury with blood loss (especially abdominal) Dehydration from diarrhea and vomiting Severe infection Neurologic injury, such as severe head trauma A severe allergic reaction to an allergen (anaphylaxis), such as an insect bite or food allergy Diseases of the heart A collapsed lung (tension pneumothorax) Blood or fluid around the heart (cardiac tamponade or pericarditis)

Pain Management

When dealing with pediatric pain management issues, you are limited to the following interventions: Positioning Ice packs Extremity elevation

Shock

When you assess circulation, pay particular attention to: Pulse Assess both the rate and the quality of the pulse. A weak, "thready" pulse is a sign that there is a problem. The appropriate rate depends on age; generally, except in the case of a newborn, anything over 160 beats/min suggests shock. Skin signs Assess the temperature and moisture of the hands and feet. How does this compare with the temperature of the skin on the trunk of the body? Is the skin dry and warm, or cold and clammy? Capillary refill time Squeeze a finger or toe for several seconds until the skin blanches, and then release it. Does the fingertip return to its normal color within 2 seconds, or is it delayed? Color Assess the patient's skin color. Is it pink, pale, ashen, or blue? Changes Changes in pulse rate, color, skin signs, and capillary refill time are all important clues suggesting shock. Blood pressure is the most difficult vital sign to measure in pediatric patients. The cuff must be the proper size—two-thirds the length of the upper arm. The value for normal blood pressure is also age-specific. Remember that blood pressure may be normal with compensated shock. Low blood pressure is a sign of decompensated shock, requiring care from an ALS team and rapid transport. Part of your assessment should also include talking with the parents or caregivers to determine when the signs and symptoms first appeared and whether any of the following has occurred: Decrease in urine output (with infants, are there fewer than 6 to 10 wet diapers?) Absence of tears, even when the child is crying A sunken or depressed fontanelle (infant patient) Changes in LOC and behavior Limit your management to these simple interventions: Do not waste time performing field procedures. Ensure that the airway is open; prepare for artificial ventilation. Control bleeding. Give supplemental oxygen by mask or blow-by method as tolerated. Continue to monitor airway and breathing. Place the pediatric patient in a position of comfort. Keep the pediatric patient warm with blankets and by turning up the heat in the patient compartment. Provide rapid transport to the nearest appropriate facility and continue monitoring vital signs en route. Call for ALS backup as needed. Allow a parent or caregiver to accompany the pediatric patient whenever possible.

Pediatric Assessment Triangle

pediatric assessment triangle (PAT) A structured assessment tool used to rapidly form a general impression of the infant or child without touching him or her; consists of assessing appearance, work of breathing, and circulation to the skin. As you evaluate the pediatric patient's appearance, note: Level of consciousness (LOC) or interactiveness Muscle tone These signs will provide you with information about the adequacy of the pediatric patient's cerebral perfusion and overall function of the central nervous system. An infant or child with a normal LOC will act appropriately for his or her age, exhibiting good muscle tone and maintaining good eye contact. An abnormal LOC is characterized by: Age-inappropriate behavior or interactiveness Poor muscle tone Poor eye contact with the parent or caregiver or with you

Always position the airway in a neutral sniffing position. This accomplishes two goals at once: Keeps the trachea from kinking Maintains the proper alignment if you have to immobilize the spine Previous

sniffing position An upright position in which the patient's head and chin are thrust slightly forward to keep the airway open; the optimum position for the uninjured child who requires airway management.