chapter 3 pediatric emergencies

pediatric physical exam

1. Examine the head. Look for bruising or blood or clear fluid draining from the nose or ears. Palpate gently for soft or spongy areas, skull irregularities, or crepitus (feeling of grinding bone fragments). Check the fontanelles in infants.2. Check the eyes. The pupils should be equal in size and reactive to light.3. Examine the neck. Check for the position of the trachea, swollen neck veins, stiffness, tenderness, or crepitus.4. Examine the chest. Check for bruising, equal chest rise and fall, and crepitus. Watch for signs of breathing difficulty.While examining the chest, be aware of the contents of the thorax.5. Auscultate for breath sounds over all lung fields.Auscultation sites. In infants, the lateral lung fields are best evaluated from the mid-axillary position to ensure that sounds appreciated are not referred from the opposite lung. The very small and thin infant thorax can artificially transmit sounds from one side of the chest to the other when auscultated from the front or back.6. Examine the abdomen. Check for bruising, tenderness, or guarding. Look for swelling that may indicate swallowed air.Divide the abdomen into quadrants, and examine each one while remembering which organs are located in each quadrant.7. Examine the pelvis for tenderness, swelling, bruising, or crepitus. If the patient complains of pain, injury, or other problems in the genital area, assess for bruising, swelling, or tenderness in that area.8. Examine the extremities. Evaluate pulses, sensation, and warmth. Look for unequal movement.9. If you have immobilized an extremity, check the patient's capillary refill, peripheral pulses, and sensory status (if age appropriate), and compare them with the other arm or leg.10. Examine the back. Assess for tenderness, bruising, and crepitus. If the child requires immobilization, the back can be checked while the child is being log-rolled onto the spine board.

Inserting an Oropharyngeal Airway in a Child

1. Oropharyngeal airways come in a variety of sizes.2. Size the airway by measuring from the corner of the mouth to the tip of the earlobe.3. Use a tongue depressor to hold the tongue in position. Insert the airway with the tip pointing downward, toward the tongue and throat—the same position it will be in after insertion.4. The oropharyngeal airway in position.

head

A child's head is proportionately larger and heavier than an adult's until about the age of four. Because the head is often the heaviest part of the body, children often fall headfirst. As a result, you should suspect head injury whenever there is a serious mechanism of injury. 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 and, as a result, is typically not assessed by the EMT. The anterior fontanelle is the fontanelle that should always be assessed in an infant. 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. This simply means that the fontanelle is most effectively assessed before the infant is one year old and still relatively available for assessment until about two years of age. The fontanelle is flat and soft while the child is quiet and normally bulges when the infant is crying. A sunken fontanelle may indicate dehydration, whereas a bulging fontanelle may indicate elevated intracranial pressure.

high priority pediatric 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.

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

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 (Figure 33-16). 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.

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.

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 Care Physical or Sexual Abuse

Emergency care for physical or sexual abuse includes the following steps: Dress and provide other appropriate care for injuries as necessary. 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. Transport the child.

High Risk Mechanisms

Falls Over age 15: 20 feet (one story = 10 feet) Under age 15: fall > 10 feet or two to three times child's heigh Auto crash Improperly restrained/unrestrained passenger Child struck by deployed air bag ( Burns to the eyes and face caused by the caustic powder released when air bag deploys.) Pedestrian or bicyclist struck with significant (> 20 mph) impact Child thrown onto hood/windshield or minimal distance on impact Child run over by car

Patient Care Seizures

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

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: Monitor the patient's airway, breathing, circulation, and vital signs. Provide high-concentration oxygen by nonrebreather mask. Ventilate with a pediatric pocket mask or bag-valve mask with supplemental oxygen if necessary. Provide CPR if necessary. Be alert for seizures. Transport immediately. This is a true emergency. Do not delay.

Age classifications

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

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 Emergency care of a pediatric patient with a mild airway obstruction is as follows: 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. Offer high-concentration oxygen by pediatric nonrebreather mask or blow-by technique (described later in this chapter). Transport. Do not agitate the child. Limit your examination to avoid upsetting the child. Do not assess blood pressure.

breathing rates

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.

Infants and 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 Emergency care of children with special challenges has often been complicated by the lack of information that EMTs and emergency department staff are able to quickly obtain about the children's medication, condition, history, precautions needed, and special management plans. In 1999 the American College of Emergency Physicians (ACEP) and the American Academy of Pediatrics (AAP) developed the Emergency Information Form for Children with Special Needs that should be kept up to date and on hand by the patient's caregivers. If a copy of this form is available at the patient's home, it should be brought along if the child is transported to the hospital.

regression

Some children, when stressed, will act like a younger child. This is called regression.

Patient Assessment Physical Abus

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. ]Be on the alert for: Repeated responses to provide care for the same child or children in a family. Remember that in areas with many hospitals, you may see the child more frequently than any one hospital. 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. (True, some do—this is only an indication, not proof.) 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 child may seem to expect no comfort from the parents and may have little or no apparent reaction to pain. 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. These should arouse your suspicions and cause you to more carefully assess the situation.

pediatric scene size up

Standard Precautions should be taken as appropriate. In addition, be aware that ordinary childhood diseases can be devastating when contracted by an adult. 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. look for signs of abuse

shock

The most important thing to understand about shock in infants and children is that their bodies are able to compensate for it for a long time. When the compensating mechanisms fail, at approximately 30 percent blood loss, hypovolemic shock develops very rapidly. This means that a child may appear to be fine then "go sour" in a hurry. This is in contrast to the adult patient in whom hypovolemic shock develops earlier and more gradually, making it easier to assess and treat than in a child. The definitive care for shock takes place at the hospital (usually in the operating room). Since infants and children are prone to go into hypotensive shock—shock in which the blood pressure has dropped severely—so suddenly, it is important not to wait for signs of hypotensive shock to develop. Instead, in any situation in which shock is a possibility, provide oxygen (which boosts the supply of oxygen to poorly perfused tissues and helps keep up heart function) and transport as quickly as possible.

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

Airway and Respiratory System

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. 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 (Figure 33-3). "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.

Tracheostomy Tubes

Tracheostomy tubes are tubes that have been placed into the child's trachea to create an open airway (Figure 33-22). They are often used when a child has been on a ventilator for a prolonged time. Although there are various types of tubes, the potential complications are identical. 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

Patient Care Shock

Ensure an open airway. Manage severe external hemorrhage if present. Provide high-concentration oxygen. Be prepared to artificially ventilate. Lay the patient flat. Keep the patient warm. Transport immediately. Perform any additional assessment and treatments en route.

Immobilizing a Child Using a KED

Although many pediatric immobilization devices are available, an adult Kendrick Extrication Device (KED) can also be used successfully to immobilize a child if adjusted to suit the child's size and anatomy. Manually stabilize the child's neck and spine throughout, and apply a cervical spine immobilization collar before securing the child to the KED. 1. Open the KED and place padding on it to properly position and align the child's head and body. Log-roll the child onto the KED. 2. Fold the side pieces inward to provide side padding and support and to allow visualization of the chest and abdomen. Since the torso straps will be rolled to the inside, secure the torso with tape. Fold the head flaps securely against the child's head, and tape across the head and chin.

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

Reassessment—Pediatric

As time permits, you should do the following steps. 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: Reassess mental status. Maintain an open airway. Monitor breathing. Reassess the pulse. Monitor skin color, temperature, and moisture. 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.

suctioning

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. Do not suction for more than a few seconds at a time, as cutting off the body's oxygen supply is especially dangerous to infants and children, causing cardiac arrest more quickly than in adults. You may give a few extra breaths after suctioning.

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

pediatric blood loss

Children have very little circulating blood volume, and as a result, it does not require much blood loss to raise concern for a child. Consider a one-year old boy: the average weight for this child is about 24.5 pounds (11 kg), and his total circulating blood volume would be roughly 1199 ml (11 kg × 109 ml/kg). A significant or concerning blood loss would be roughly 20 percent of his total blood volume (shock occurs at roughly 30 percent blood loss), or 240 ml, the equivalent of roughly two-thirds of a twelve-ounce can of soda (360 ml).

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

Patient Care Poisoning

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

Patient Care Altered Mental Status

Emergency care of a pediatric patient with altered mental status includes the following steps: Ensure an open airway. Be prepared to suction. Protect the spine while managing the airway if a head injury or other trauma is present. 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. Treat for shock. Obtain finger-stick blood glucose as appropriate and as allowed by local protocols. Treat hypoglycemia with oral glucose as appropriate and as allowed by local protocols. Transport.

Patient Care Trauma

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

Patient assessment is an extremely important skill for EMTs to learn, and with pediatric patients, it may be even more significant for three reasons:

First, the condition of sick and traumatized children can change rapidly. Second, sometimes signs and symptoms in children are subtle and will be missed without close observation. Finally, the child's inability to fully understand what you are doing and why may make them less compliant and less capable of articulating what they are feeling.

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. They are rarely life-threatening conditions in the children who frequently have them. However, the EMT should consider seizures, including those caused by fever, to be life threatening. Usually you will arrive after the convulsion has passed.

child abuse

Psychological (emotional) abuse Neglect Physical abuse Sexual abuse What constitutes neglect is a serious legal question. If a child goes without proper food, shelter, clothing, supervision, treatment of injuries and illnesses, a safe environment, and love, the effects surely will be seen but will seldom directly trigger an emergency call. Physical and sexual abuse are the problems likely to be seen by EMTs. If signs of neglect are observed in the course of a call, they should also be reported to the receiving physician and proper authorities in the event that the child is not transported.

Patient Care Diarrhea and Vomiting

For any pediatric patient with diarrhea or vomiting: Monitor the airway. Monitor respiration. Be alert for signs of shock. Emergency care for diarrhea and vomiting includes the following: Maintain an open airway, and be prepared to provide oral suctioning. Provide oxygen if respirations are compromised or if signs of shock are present. If signs of shock are present, contact medical direction immediately and transport. 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. Some systems recommend that you save a sample of vomitus and rectal discharge (e.g., a soiled diaper). Follow your local protocols.

Assessing Circulation

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 (Figure 33-7). In infants and children five years old or younger, also check capillary refill. When you press on the nail bed or press the top of a hand or foot, the area will turn white (Figure 33-8). If the patient's circulation is adequate, the normal pink color will return in less than 2 seconds, or in less time than it takes to say "capillary refill." Check for and control any blood loss.

Patient Care Drowning

For the drowning patient, provide the following care: Provide artificial ventilation or CPR as necessary. This is your first treatment priority. Protect the airway. Suction if necessary. Consider spinal immobilization. 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. Treat any trauma. 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.

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.

If the patient is conscious but cannot maintain an open airway, a nasopharyngeal airway can be inserted (Scan 33-3). 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.

If the patient is conscious but cannot maintain an open airway, a nasopharyngeal airway can be inserted (Scan 33-3). 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. 1. Nasopharyngeal airways come in a variety of sizes.2. The airway should be about the thickness of the patient's little finger and should measure from the nostril to the tragus (cartilage at the front) of the ear.3. The nasopharyngeal airway in position.

Patient Assessment Drowning

If the patient is unresponsive and you suspect he may be in cardiac arrest: Establish unresponsiveness, breathlessness, and pulselessness. 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. 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. Consider possible ingestion of alcohol as a cause of the drowning, especially in adolescents. Consider the possibility of "secondary drowning syndrome"—deterioration after normal breathing resumes, minutes to hours after the event

Sudden Infant Death Syndrome

In the United States, sudden infant death syndrome (SIDS)—the sudden, unexplained death during sleep of an apparently healthy baby in its first year of life—occurs in 2,000 to 2,500 babies each year When asleep, the typical SIDS patient will show periods of cardiac slowdown and temporary cessation of breathing known as sleep apnea. Eventually the infant will stop breathing and will not start again on its own. Unless reached in time, the episode will be fatal. The baby's condition is most commonly discovered in the early morning when the parents go to wake the baby. 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.

Secondary Assessment—Pediatric

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 (Figure 33-9). Review Table 33-2 for normal ranges of pediatric vital signs. It may be helpful to carry a pocket guide or reference card with pediatric vital signs when responding to pediatric calls. As noted earlier, it is not recommended that you try to memorize these normal values because the likelihood of being able to effectively recall this infrequently used data when under stress is low. Instead, have reference cards or tables immediately available.

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. Some departments use blow-by oxygen devices that resemble stuffed animals. These commercially made products may be less threatening to a child than traditional oxygen devices. Follow the manufacturer's recommendations regarding liter flow per minute when using these devices. Some children respond well when oxygen tubing is pushed through the bottom of a paper cup, especially if the cup is colorful or has a picture drawn inside it (Figure 33-13). Hand the cup to the child or ask a parent to hold it. Infants and young children instinctively explore new things by bringing them up to their mouths. As the patient handles and explores the cup, he will breathe in the oxygen. Do not use a Styrofoam cup. Styrofoam may flake and the child can inhale the particles.

Patient Care Severe Airway Obstruction

Perform airway clearance techniques. For infants less than one year old, alternate 5 back blows and 5 chest thrusts (Figure 33-12). 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. (Airway clearance sequences are summarized in Table 33-4.) Attempt artificial ventilations with a pocket mask or bag-valve-mask unit in the appropriate pediatric size and supplemental oxygen (Tabl puberty and older: 10-12 breaths/min birth to puberty: 12-20 breaths/minute 40-60 breaths/min for neonatal resuscitation.

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. Remain professional and control your emotions. Protect the child from embarrassment. Say nothing that may make the child believe that he is to blame for the sexual assault. (Many believe that they are.) It is also important that you remain calm and composed to ensure that you do not tip off the potential abuser to your suspicions because they may refuse to allow you to continue to care for the child, thus creating a volatile situation that may further endanger the child.

Patient Care Difficulty Breathing

Recognize the following signs of early respiratory distress (Figure 33-18): 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 n 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) 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.

respiratory disorders

Respiratory disorders are a great concern in infants and children. For example, it is important to remember that, although cardiac arrest in the adult is likely to be caused by a heart problem, the likeliest cause of cardiac arrest in a child, other than trauma, is respiratory failure

Patient Assessment Poisoning

Some types of poisonings are not often associated with adult patients but are common to children. These special cases are: ASPIRIN POISONING. Look for hyperventilation or hypoventilation, vomiting, and sweating. The skin may feel hot. Severe cases cause seizures, coma, or shock. 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. 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. 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. 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).

Patient Care 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. Emergency care for the pediatric patient with epiglottitis is as follows: Contact ALS. (Remember that the hospital may be the closest source of ALS care.) Immediately transport the child, with the child sitting on the parent's lap. Provide high-concentration oxygen from a humidified source. Do not increase the child's anxiety. If he or she resists the mask, let the parent hold it in front of the child's face. (Do not delay oxygen administration to humidify.) Constantly monitor the child for respiratory distress or arrest, and be ready to resuscitate. 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.

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

upper airway vs lower airway

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. 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. Although you may not be able to identify the root cause of the problem, distinguishing an upper airway problem from a lower airway problem will help you properly target your immediate treatments.

Anatomic and Physiologic Characteristics of Infants and Children

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

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)

Patient Care 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. 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. Cooling the child without bringing on hypothermia is an important care objective. If you find an infant or child has a high fever, take the following steps: 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. 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. Monitor for shivering and avoid hypothermia. This may develop quickly in children. If shivering develops, stop the cooling activities and cover the child with a light blanket. 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. 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. 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.)

menigitis

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. 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

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." 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: Appearance Work of breathing Circulation to skin from the doorway impression : For the first side of the triangle, look at the patient's appearance. 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? For the second side of the triangle, 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? For the base of the triangle, look at those signs that might indicate a circulation problem, such as pallor, mottling, or cyanosis (a gray-blue coloration). repeat triangle but with closer 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.

When auscultating the lateral lung fields of an​ infant, what is the preferred​ position?

mid axillary