CH43 Pediatric Emergencies (started)

Pediatric Anatomy, Physiology, and Pathophysiology: The integumentary system

1. Infants and children have: a. Thinner, more elastic skin b. Larger body surface area (BSA)/weight ratio c. Less subcutaneous (fatty) tissue 2. These factors contribute to: a. Increased risk of injury following exposure to temperature extremes b. Increased risk of hypothermia (can complicate resuscitative efforts) and dehydration c. Increased severity of burns i. Many burns that would be minor or moderate in adults are severe in children. 3. Relatively large surface area predisposes infants and young children to hypothermia.

Pediatric Anatomy, Physiology, and Pathophysiology: The abdomen and pelvis

1. Abdominal injuries are the second leading cause of serious trauma in children (after head injuries). 2. Abdominal organs are situated more anteriorly. a. Less protected by ribs b. Closer together as compared with an adult 3. Organs (eg, liver and spleen) are relatively large. a. Vulnerable to blunt trauma 4. Abdominal distention in a healthy infant is due to two factors: a. Weak abdominal muscles b. Larger solid organs 5. Liver and spleen extend below rib cage in young children. a. Less bony protection b. Rich blood supply, so injuries can result in large blood losses 6. Kidneys are also more vulnerable to injury. a. More mobile b. Less well supported 7. Duodenum and pancreas are likely to be damaged in handlebar injuries 8. Even seemingly insignificant forces can cause serious internal injury. a. Multiple organ injuries are common. 9. Pelvic fractures are relatively rare. a. Generally seen only with high-energy MOIs b. Risk increases in adolescence, when skeleton and MOIs become more like those of adults. H. The musculoskeletal system 1. Reaching adult height requires active bone growth. 2. Growth plates (ossification centers) of a child's bones: a. Made of cartilage b. Relatively weak c. Easily fractured 3. Bones of growing children are weaker than their ligaments and tendons. a. Makes fractures more common than sprains. 4. Joint dislocations without associated fractures are not common. 5. Most growth plates will be closed by late adolescence. 6. Growth plate fractures a. Can be seen with low-energy MOIs b. May be lacking the degree of tenderness, swelling, and bruising usually associated with a broken bone 7. Immobilize all sprains or strains, and suspect fractures. a. Growth plate injuries may result in poor bone growth.

Developmental Stages: Adolescence

1. Ages 13 to 17 years 2. Can be difficult; struggling with independence, as well as social and personal issues 3. With respect to CPR and foreign body airway obstruction procedures, once secondary sexual characteristics have developed (breasts or facial/axillary hair), treat an adolescent as an adult. 4. During assessment, address and reassure the patient. a. Alienating the patient may interfere with assessment and treatment. b. Encourage questions and involvement. c. Address all concerns and fears. d. Provide accurate information—a teen may become alienated and uncooperative if you are suspected of being misleading. e. Respect patient privacy. f. If possible, address the adolescent without a caregiver present. i. Especially about sensitive topics such as sexuality or drug use. ii. Patient may want friends present. 5. Let patient have as much control as appropriate. 6. Maintain scene safety.

Developmental Stages: Preschool-age child

1. Ages 3 to 5 years 2. Rapidly becoming verbal and active a. Can understand directions b. Generally able to tell you what hurts c. Choose words carefully; preschoolers are literal. d. Use plain language, provide lots of reassurance; fears are common. 3. Curious, want to cooperate 4. Respect modesty by keeping them covered. 5. Let child participate or hold equipment that is safe. a. Offer simple choices. i. Avoid yes/no questions. 6. Avoid procedures on the dominant hand or arm. 7. Tantrums may occur when they feel a lack of control. 8. Set limits on behavior if the child acts out.

Developmental Stages: School-age child (middle childhood)

1. Ages 6 to 12 years 2. Capable of abstract thought; understand cause and effect. 3. School is important; focus on popularity and peer pressure. a. Children with chronic illness or disabilities can be self-conscious. 4. Understanding of death may increase anxiety. 5. They may have their own ideas about medical care. 6. By age 8 years, anatomy and physiology are similar to those of adults. a. Breasts develop between ages 8 and 13 years. b. Menstrual period begins between ages 9 and 16 years. c. Testicles increase in the size around age 10 years. d. May be self-conscious about body image. 7. Ask child to describe history leading to 9-1-1 call and symptoms. 8. Explain steps in simple language; answer questions. 9. Offer appropriate choices and control, reassurance, encouragement. 10. Provide simple explanations about causes and treatment of pain. 11. Respect modesty. 12. Asking about school, pets, and so on may provide a distraction. a. Ask caregiver's advice in choosing a topic. 13. Rewarding the child after completing a procedure can help.

Pediatric Anatomy, Physiology, and Pathophysiology: The chest and lungs

1. Chest trauma: Third leading cause of serious injury in pediatric trauma 2. Child's chest wall is quite thin. a. Less musculature and subcutaneous fat to protect ribs and organs 3. Ribs are more pliable and flexible than an adult's. a. Can lead to significant intrathoracic injury with minimal external findings 4. Children have fewer rib fractures and flail chest events. 5. Injuries to thoracic organs may be more severe. a. Pliable rib cage and fragile lung tissue are more easily compressed during blunt trauma. b. Children are more vulnerable to: i. Pulmonary contusions ii. Cardiac tamponade iii. Diaphragmatic rupture 6. Lungs are prone to pneumothorax from excessive pressures during bag-mask ventilation. 7. Thin chest wall makes it easy to hear heart and lung sounds. a. However, pneumothoraces and esophageal intubations are often missed due to sounds readily transmitted throughout the chest. 8. Rib cage is more compliant, making retractions easy to see. 9. Look for signs of chest injuries with suspected chest trauma. a. Note that signs of pneumothorax or hemothorax in children are often subtle. b. May not see signs such as jugular vein distention c. May be difficult to determine tracheal deviation

Pediatric Anatomy, Physiology, and Pathophysiology: The neck and airway

1. Children have short, stubby necks. a. Can be difficult to feel carotid pulse or see jugular veins 2. Airway is much smaller than an adult airway. a. More prone to obstruction by: i. Foreign body inhalation ii. Inflammation with infection iii. Disproportionately large tongue 3. During the first few months of life, infants are obligate nose breathers. a. Nasal obstruction with mucus can result in significant respiratory distress. 4. Epiglottis: a. Long and floppy b. U-shaped c. Narrow d. Extends at a 45° angle into the airway e. Difficult to visualize the vocal cords during intubation 5. Narrowest part of a young child's airway occurs at the level of the cricoid cartilage. a. Below the vocal cords, rather than at the vocal cords as in adults b. Influences your choice of endotracheal (ET) tubes 6. Remember the following: a. Keep nares clear with suctioning in infants younger than 6 months. b. Tracheal cartilage is softer and more collapsible; avoid hyperextension of neck. i. May result in reverse hyperflexion, kinking of the trachea ii. May displace the tongue posteriorly, obstructing the airway c. Keep the airway clear of all secretions. i. Even a small amount of particulate matter may cause obstruction. d. Use care when managing the airway (eg, inserting airway adjuncts). i. Jaw is smaller. ii. Soft tissues are delicate and prone to swelling. e. Correct positioning can often maintain airway and negate the use of adjuncts.

Children differ from adults in their anatomy, physiology, and emotions and experience a range of illnesses and injuries that varies across the pediatric age span.

1. Children perceive their illness or injury differently than adults. 2. Young children may not be able to report what is bothering them. 3. Fear or pain may hamper assessment. 4. Stressed or frightened parents and caregivers may also pose challenges. 5. Your approach to pediatric patients must be based on their age and accommodate their unique developmental and social issues.

Pediatric Anatomy, Physiology, and Pathophysiology: The nervous system

1. Continually develops throughout childhood 2. Until it is fully developed, neural tissue and vasculature are fragile, easily damaged, prone to bleeding from injury. 3. Brain and spinal cord are not as well protected in children. a. Takes less force to cause brain and spinal cord injuries b. Brain injuries are frequently more devastating. 4. Subarachnoid space is relatively smaller than adult's a. Less cushioning effect for the brain b. Head momentum may cause bruising and damage. i. Eg, "shaken baby syndrome" 5. Pediatric brain requires nearly twice the cerebral blood flow as an adult's. a. Makes even minor injuries significant b. Increases risk of hypoxia i. Hypoxia and hypotension exacerbate head injuries, causing ongoing damage. 6. Brain continues to develop rapidly after birth. a. Responses become more organized and purposeful. 7. The spinal column a. Develops along with the child b. In young children, the cervical spine fulcrum is higher because head is heavier. i. Closer to C1-C2 c. As child grows, fulcrum descends to "adult level." i. Around C5 through C7 d. Infant who sustains blunt head trauma involving acceleration-deceleration forces is at high risk for a fatal, high cervical spinal injury. e. School-age child will likely sustain a lower cervical spinal injury, may be paralyzed. 8. Vertebral fractures and spinal cord injuries in young children are uncommon. a. Spinal ligaments and joint capsules are more lax. i. Increased mobility and cord injury in the absence of identifiable vertebral bony fracture or dislocation b. Vertebral bodies are aligned anteriorly and can slide forward. i. Potential for cord damage with significant forward flexion. 9. Thoracic and lumbar spinal injuries are relatively uncommon. a. Seen in children in association with specific mechanisms: i. Seat belt-associated lumbar spine injuries (often associated with abdominal injury) ii. Compression fracture due to axial loading in a fall b. With a significant mechanism of injury (MOI): i. Assume cervical spine injury. ii. Transport with spinal immobilization.

Respiratory Emergencies: Respiratory arrest, distress, and failure

1. First determine severity. a. Distress, failure, or arrest b. Keep anatomic and physiologic respiratory differences in mind. 2. Respiratory distress entails increased work of breathing to maintain oxygenation and/or ventilation. a. A compensated state in which increased work of breathing results in adequate pulmonary gas exchange b. Classified as mild, moderate, or severe. c. Hallmarks i. Retractions (suprasternal, intercostal, subcostal) ii. Abdominal breathing iii. Nasal flaring iv. Grunting

Pediatric Anatomy, Physiology, and Pathophysiology: The head

1. Infants and young children's heads are large relative to the rest of their bodies. a. An infant's head is two thirds its adult size. b. Large surface area means more mass relative to the rest of the body. c. Important factor in the incidence of head injuries i. Tend to lead with their head in a fall d. Traumatic brain injury is the leading cause of death and significant disability in pediatric trauma patients. 2. Take care when positioning the airway because of proportionally larger occiput. a. Seriously injured, younger than 3 years: Place a thin layer of padding under the back to obtain neutral position. b. Seriously ill, younger than 3 years: Place a folded sheet under occiput to obtain sniffing position 3. Large head means more surface area for heat loss. a. Keep covered for warmth. 4. During infancy, the anterior and posterior fontanelles are open. a. Areas where the infant's skull bones have not fused together b. Allow compression of the head during birth and rapid growth of the brain c. Posterior fontanelles close by age 4 months. d. Anterior fontanelles close by age 1 year. e. Important anatomic landmark when assessing a sick or injured infant i. Bulging suggests increased intracranial pressure. ii. Sunken fontanelles suggest dehydration.

Pediatric Anatomy, Physiology, and Pathophysiology: Metabolic differences

1. Limited stores of glycogen and glucose are rapidly depleted as a result of injury or illness. a. Be suspicious of hypoglycemia. b. Check blood glucose levels with lethargy, seizures, or decreased activity. 2. Children are highly susceptible to hypothermia due to lowered glucose. a. Large BSA/weight ratio further increases risk. 3. Newborns lack the ability to shiver (way of producing heat). a. Hypothermia is a serious risk. i. May predispose the newborn to spontaneous bleeding in the head 4. Significant hypovolemia and electrolyte derangements are more common as a result of severe vomiting and diarrhea. 5. Keep the child warm during transport; prevent the loss of body heat. a. Cover the head (source of significant heat loss). 6. Newborns requiring aggressive resuscitation after delivery should not be overly warmed because this can worsen their neurologic outcome.

Developmental Stages: Neonate and infant

1. Neonatal period: First month of life 2. Infancy: First 12 months of life 3. Respect caregiver's perception that "something is wrong." a. Watch for persistent crying, irritability, and lack of eye contact. b. May be a symptom of a serious problem, such as: i. Bacterial infection ii. Cardiac problem iii. Depressed mental status iv. Electrolyte disturbance 4. Nonspecific concerns about behavior, feeding, sleep pattern, or arousability can indicate a serious underlying illness or injury. 5. Increased mobility can lead to injury. 6. Consider possible abuse with behaviors that don't match developmental stage. 7. Considerations for patient assessment include the following: a. Choose the best location. b. Keep child warm. c. Support a young infant's head and neck. d. Older infants in stable condition will be calmest in a parent's arms. e. Warm hands, stethoscope. f. Be opportunistic with exam, use a soft voice, smile. g. If child is quiet, listen to heart and lungs first. h. A pacifier or gloved finger to suck on may quiet a crying child. i. Jingling keys or shining a penlight may distract an older infant. j. No small objects i. Risk of aspiration

Pediatric Anatomy, Physiology, and Pathophysiology: The respiratory system

1. Tidal volume is slightly smaller than in adults, but metabolic oxygen demand is doubled. 2. Functional residual capacity is smaller. a. Result is proportionally smaller oxygen reserves 3. Functional residual capacity: Volume of air in the lungs following exhalation a. Also referred to as oxygen reserve 4. Infants breath faster than older children. a. Lungs can better handle oxygen exchange as child ages. b. 30 to 60 breaths/min is normal for newborns. c. Rate for teens is closer to adult range. 5. Higher respiratory rate and oxygen demand raise risk for effects from inhaled toxins. a. Proportionately larger amount of toxic fumes typically inhaled b. Causes symptoms sooner 6. Infants use the diaphragm, not chest muscles, during inspiration. a. Any pressure on the abdomen of an infant or young child can block diaphragm movement, cause respiratory compromise. 7. Young children experience muscle fatigue much more quickly than older children. a. Can lead to respiratory failure if a child has had to breathe hard for long periods. 8. Infants and children, especially during respiratory distress, are highly susceptible to hypoxia because of: a. Decreased functional residual capacity b. Increased oxygen demand c. Easily fatigued respiratory muscles 9. Infants and children will develop hypoxia rapidly with apnea and ineffective bagging. a. Can spiral into cardiovascular collapse b. Use a larger bag if needed. c. Use only enough pressure to achieve visible chest rise in order to avoid pneumothorax. d. Bag's volume should have no less than 450-500 mL.

Developmental Stages: Toddler

1. Toddler period includes ages 1 to 3 years. a. Includes the "terrible twos" b. Not capable of reasoning c. Poorly developed sense of cause and effect d. Language development is occurring rapidly e. Growing ability to crawl, walk, run, and climb f. Painful procedures may make lasting impressions. 2. Use the Pediatric Assessment Triangle (PAT) to measure the child's interactions with the caregiver, vocalizations, and mobility. 3. Strategies for examining a toddler include the following: a. Examine a toddler in stable condition on parent's lap. i. Avoids separation anxiety b. Get down to the child's level. c. Talk to the child. d. Have a parent assist when possible to deal with stranger anxiety. e. Use play and distraction when possible. i. For example, listen to a doll's chest first. f. Offering choices helps child feel in control. i. Answer to yes/no questions is likely to be "No!" g. Consider saving upsetting or painful steps for last. h. Be flexible—full head-to-toe exam may not be possible.

Pediatric Anatomy, Physiology, and Pathophysiology: The cardiovascular system

1. You must know normal pulse rate ranges for children. a. Children rely mainly on pulse rate to maintain adequate cardiac output and compensate for decreased oxygenation. b. Infant's pulse rate can be 200 beats/min or more when compensating for injury or illness. 2. Children have limited but vigorous cardiac reserves. a. Proportionally larger circulating blood volume compared with adults b. Absolute blood volume is less, approximately 70 mL/kg. c. Ability to constrict blood vessels (vasoconstriction) keeps vital organs perfused. 3. Injured children can maintain blood pressure for longer periods than adults, even though they are in shock (hypoperfusion). a. Proportionally larger volume of blood loss must occur in children before hypotension develops. 4. Suspect shock when an infant or child presents with tachycardia. 5. Bradycardia usually indicates severe hypoxia. a. Manage aggressively. 6. Hypotension in a child is an ominous sign. a. Often indicates impending cardiopulmonary arrest. 7. Constriction of the blood vessels can be so profound that blood flow to the periphery of the body diminishes. a. Signs of vasoconstriction can include: i. Weak peripheral (for example, radial) pulses ii. Delayed capillary refill (in children younger than 6 years) iii. Pale, cool extremities 8. The heart a. Circulation in the fetus is very different than in the newborn i. Large right-sided forces on the electrocardiogram (ECG) are normal in young infants. b. During the first year of life, the ECG axis and voltages shift to reflect left ventricular dominance. c. Cardiac output is rate dependent in infants and young children. i. Relatively poor ability to increase stroke volume is reflected in their normal pulse rates and in rate response to physiologic stress and hypovolemia. d. Pediatric mediastinum is more mobile than adults. i. High risk of injury to mediastinal organs ii. May not be immediately evident on exam e. Cardiac tamponade can present with muffled heart tones. f. Cardiac contusions can cause dysrhythmias.

Parents of Ill or Injured Children:

A. Most children will have at least one caregiver present, meaning you will be dealing with more than one patient—even if only the child is ill or injured. 1. Serious illness or injury to a child is one of the most stressful situations for caregivers. a. They may react with anger or fear. 2. Establishing a rapport with caregivers is vital. a. They are a source of important information and assistance. b. Children look to their parents when they are frightened and often mimic their response. i. Calming a parent may help the patient. 3. Approach caregivers in a calm, quiet, professional manner. a. Enlist their help in caring for the child. b. Explain what you are doing. c. Provide honest reassurance and support. d. Do not blame the parent. e. Transport at least one caregiver with the child. 4. Comfort an emotional parent, but remember that your first priority is the child. a. Do not let a distraught or aggressive parent interfere with your care. b. Enlist the help of other family members or law enforcement if needed.

Respiratory Emergencies:

A. You will frequently encounter respiratory problems in children who range from mildly ill to near death. 1. In pediatrics, respiratory failure and arrest precede the majority of cardiopulmonary arrests; by contrast, a primary cardiac event is the usual cause of sudden death in adults. 2. Early identification and intervention can stop the progression from respiratory distress to cardiopulmonary failure and help to avert much pediatric morbidity and mortality.