Transcript SECTION 2
Section 7: Special Populations
Chapter 30 Pediatric Outdoor Emergency Care
Chapter 30: Pediatric Outdoor Emergency Care
Objectives
• Differentiate the response of the ill or injured infant or child (age specific) from that of an adult.
• Discuss the field management of the child trauma patient.
• Demonstrate an assessment of an infant, toddler, and school-aged child.
• Demonstrate oxygen delivery for the infant and child.
• Demonstrate the techniques of foreign body airway obstruction removal in a child.
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Airway Differences
• Larger tongue relative to the mouth • Less well-developed rings of cartilage in the trachea • Head tilt-chin lift may occlude the airway.
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Breathing Differences
• Infants breathe faster than children or adults.
• Infants depend on diaphragm use when they breathe.
• Sustained, labored breathing may lead to respiratory failure.
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Circulation Differences
• The heart rate increases during illness and injury.
• Vasoconstriction keeps vital organs nourished, ie, pale skin may mean decreased perfusion.
• Constriction of the blood vessels can affect blood flow to the extremities.
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Skeletal Differences
• Growth plates exist at the ends of long bones.
• Bones are weaker and more flexible.
• Bones are prone to fracture with stress.
• Infants have two small openings in the skull called fontanels.
• Fontanels close by age 18 months.
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Growth and Development
• Thoughts and behaviors of children are usually grouped into stages: – Infancy – Toddler years – Preschool age – School age – Adolescence 8
Chapter 30: Pediatric Outdoor Emergency Care
Infant
• Infancy is the first year of life.
• Infants respond mainly to physical stimuli.
• Crying is the infant’s main avenue of expression.
• Infants may prefer to be with their caregiver.
• If possible, have the caregiver hold the infant as you start your examination.
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Toddler
• 1 to 3 years of age • Begin to walk and explore the environment • May resist separation from caregivers • Make any observations you can before touching a toddler.
• They are curious and adventuresome.
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Preschool-Age Child
• 3 to 6 years of age • Use simple language effectively • Understand directions • Identify painful areas when questioned • Understand what you are going to do from simple descriptions • Can be distracted with toys 11
Chapter 30: Pediatric Outdoor Emergency Care
School-Age Child
• 6 to 12 years of age • Begin to think like adults • Can be included with the parent when taking medical history • May be familiar with physical exam • May be able to make choices 12
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The Adolescent
• 12 to 18 years of age • Very concerned about body image • May have strong feelings about being observed • Need respect for privacy • Understand pain • Explain any procedure that you are doing.
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Approach to Assessment
• Approach at eye level. • Note appearance and activity level. • Note “work-of-breathing” (WOB).
• Determine responsiveness with AVPU. • Grade behavior at the stage of development level, ie, toddler, infant.
• Maintain normal body temperature. 14
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Helpful Hints
• Remain calm and appear confident. • You are caring for a whole family. • Honesty is important.
• Inform caregiver and child often. • Keep the family together. • Provide hope and reassurance to all. 15
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Care of the Pediatric Airway
(1 of 2) • Position the airway in a neutral sniffing position.
• If spinal injury suspected, use jaw thrust maneuver to open the airway.
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Care of the Pediatric Airway
(2 of 2) • Positioning the airway: – Place the patient on a firm surface.
– Fold a small towel under the patient’s shoulders and back.
– Place tape across patient’s forehead to limit head rolling.
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Oropharyngeal Airways
• Determine the appropriately sized airway.
• Place the airway next to the face to confirm correct size.
• Position the airway.
• Open the mouth.
• Insert the airway until flange rests against lips.
• Reassess airway.
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Nasopharyngeal Airways
(1 of 2) • Determine the appropriately sized airway.
• Place the airway next to the face to make certain length is correct.
• Position the airway.
• Lubricate the airway.
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Nasopharyngeal Airways
(2 of 2) • Insert the tip into the right naris.
• Carefully move the tip forward until the flange rests against the outside of the nostril.
• Reassess the airway.
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BVM Devices
• Equipment must be the right size.
• Ventilate at the proper rate and volume.
• A BVM device may be used by one or two rescuers.
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Assessing Ventilation
• Observe chest rise in older children.
• Observe abdominal rise and fall in younger children or infants.
• Skin color indicates amount of oxygen getting to organs.
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Airway Obstruction
• Croup – An infection of the airway below the level of the vocal cords, caused by a virus • Epiglottitis – Infection of the soft tissue in the area above the vocal cords 23
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Signs and Symptoms
• Decreased or absent breath sounds • Stridor • Wheezing • Rales 24
Chapter 30: Pediatric Outdoor Emergency Care
Signs of Complete Airway Obstruction
• Ineffective cough (no sound) • Inability to cry or speak • Increasing respiratory difficulty, with stridor • Cyanosis • Loss of responsiveness 25
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Removing a Foreign Body Airway Obstruction
(1 of 5) • In an unconscious child: – Place the child on a firm, flat surface.
– Inspect the upper airway and remove any visible object.
– Attempt rescue breathing.
– If ventilation is unsuccessful after two attempts, position your hands on the abdomen.
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Removing a Foreign Body Airway Obstruction
(2 of 5) • Give five abdominal thrusts.
• Open airway again to try and see object.
• Only try to remove object if you see it.
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Removing a Foreign Body Airway Obstruction
(3 of 5) • Attempt rescue breathing.
• If unsuccessful, reposition head and try again.
• Repeat abdominal thrusts if obstruction persists.
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Removing a Foreign Body Airway Obstruction
(4 of 5) • In a conscious child: – Kneel behind the child.
– Give the child five abdominal thrusts.
– Repeat the technique until object comes out.
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Removing a Foreign Body Airway Obstruction
(5 of 5) • If the child becomes unconscious, inspect the airway.
• Attempt rescue breathing.
• If airway remains obstructed, repeat thrusts.
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Management of Airway Obstruction in Infants
• Hold the infant face-down.
• Deliver five back blows.
• Bring infant upright on the thigh.
• Give five quick chest thrusts.
• Check airway.
• Repeat cycle as often as necessary.
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Vital Signs by Age
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Vital Signs: Respirations
• Abnormal respirations are a common sign of illness or injury.
• Count respirations for 30 seconds.
• In children younger than 3 years, count the rise and fall of the abdomen.
• Note work of breathing.
• Listen for noises.
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Vital Signs: Pulse
• In infants, feel over the brachial or femoral area.
• In older children, use the carotid artery.
• Count for at least 1 minute.
• Note strength of the pulse.
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Vital Signs: Blood Pressure
• Use a cuff that covers two thirds of the arm.
• If scene conditions make it difficult to measure blood pressure accurately, do not waste time trying.
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Vital Signs: Skin
• Feel for temperature and moisture.
• Estimate capillary refill.
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Signs and Symptoms of Respiratory Emergencies
• Nasal flaring • Grunting respirations • Wheezing, stridor, or abnormal sounds • Use of accessory muscles • Retractions of rib cage • Tripod position in older children 37
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Respiratory Emergencies
• Croup: viral infection that responds well to hydration • Epiglottitis: bacterial infection on the decline due to HIB vaccine • Asthma: common, and treated with inhalers, rarely epinephrine • Bronchiolitis, bronchitis, and pneumonia: infections of lung and lung passages 38
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Airway
• Be alert for airway problems in all children with trauma.
• Unconscious children breathing on their own are at risk for airway obstruction.
• Use jaw-thrust maneuver when necessary.
• Keep suction available.
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Emergency Care
• Provide supplemental oxygen in the most comfortable manner.
• Place child in position of comfort; this may be in caregiver’s lap.
• If patient is in respiratory failure, begin assisted ventilations immediately.
• Continue to provide supplemental oxygen.
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Breathing
• Give supplemental oxygen to all children with possible: – Head injuries – Chest injuries – Abdominal injuries – Shock • Use properly sized equipment.
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Seizures
• Result of disorganized electrical activity in the brain • Types of seizures – Generalized (grand mal) seizures – Partial seizures – Absence (petit mal) seizures • Usually followed by a postical period • Status epilepticus—a continuous seizure or multiple seizures without a return to consciousness for 30 minutes or more.
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Febrile Seizures
• Febrile seizures are most common in children from 6 months to 6 years.
• Febrile seizures are caused by fever.
• They last less than 15 minutes, with tonic-clonic activity.
• Postictal period may or may not follow.
• Assess ABCs and begin cooling measures.
• Arrange for prompt transport.
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Emergency Medical Care of Seizures
(1 of 2) • Perform initial assessment, focusing on the ABCs.
• Securing and protecting the airway is the priority.
• Place patient in the recovery position.
• Be ready to suction.
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Emergency Medical Care of Seizures
(2 of 2) • Deliver oxygen by mask, blow-by, or nasal cannula.
• Begin BVM ventilations if there are no signs of improvement.
• Call ALS for transport if appropriate.
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Altered Level of Responsiveness
• The first step in treatment is to assess the ABCs and provide proper care.
• Use the AVPU scale.
• Obtain a brief history from caregivers.
• After initial assessment, secure airway.
• Support patient’s vital functions.
• Arrange for prompt transport.
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Common Causes
A E I O U T I P S • • • •
A
lcohol
E
pilepsy, endocrine, or electrolyte imbalance
I
nsulin or hypoglycemia
O
piates or other drugs • • • • •
U
remia
T
rauma or temperature
I
nfection
P
sychogenic or poison
S
hock, stroke, or shunt obstruction 47
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Poisoning
• Poisoning is common in children.
• Care will be based on how awake and alert the child appears.
• Focus on the ABCs.
• Do not administer syrup of ipecac unless directed by medical control.
• Collect poison containers and vomitus.
• Arrange for prompt transport.
• Child’s condition could change at any time.
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Shock
• Circulatory system is unable to deliver sufficient blood to organs.
• Shock has many different causes.
• Patients may have increased heart rate and respirations, and pale or blue skin.
• Children do not show decreased blood pressure until shock is severe.
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Assessing Circulation
• Pulse: greater than 160 beats/min suggests shock • Skin signs: assess temperature and moisture • Capillary refill: is it delayed or are the fingers just cold?
• Color: is skin pink, pale, ashen, or blue?
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Emergency Medical Care for Shock
• Ensure airway.
• Support ventilations with supplemental oxygen.
• Control bleeding.
• Elevate feet and maintain body temperature.
• Arrange for immediate transport.
• Monitor vital signs.
• Arrange for ALS backup as needed.
• Ensure that caregiver accompanies patient. 51
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Dehydration
• Determine if child is vomiting and/or has diarrhea and for how long.
• Watch for clues: – Dry lips and gums – Fewer wet diapers – Shrunken eyes – Irritable or sleepy – Poor skin turgor – Cool, clammy skin 52
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Other Emergencies
• Hyperthermia: watch for overdressing and infants left in vehicles • Hypothermia: newborns are especially susceptible • Sepsis: usually follows a history of upper respiratory infection • Sports-related injuries: seen in activities with high speed or contact 53
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Head Injuries
• Nausea and vomiting are common signs and symptoms.
• The most important step is to ensure the airway is open.
• Respiratory arrest can occur; be prepared.
• Avoid hyperventilating the patient until normal ventilations with a BVM device have been established for a few minutes.
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Immobilization
• Any child with a head or back injury should be immobilized.
• Young children may need padding beneath their torso.
• Children may need padding along the sides of the backboard.
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Chest Injuries
• Most chest injuries in children result from blunt trauma.
• Children have soft, flexible ribs.
• The absence of obvious trauma does not exclude the likelihood of serious internal injuries.
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Abdominal Injuries
• Abdominal injuries are very common in children.
• Children compensate for blood loss better than adults but go into shock more quickly.
• Children involved in trauma tend to swallow air, creating stomach distention.
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Injuries to the Extremities
• A child’s bones bend more easily than an adult’s.
• Incomplete fractures can occur.
• Growth plates are susceptible to fracture.
• Treat fractures in the same manner as in adults, but
do not use
adult splints unless the child is large enough to fit the device. 58
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Burns
• Most common burns involve exposure to hot substances, items, or caustic materials.
• Suspect internal injuries from chemical ingestion when burns are present around lips and mouth.
• Infection is a common problem with burns.
• Consider the possibility of child abuse.
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Submersion Injury
• Drowning or near drowning • Second most common cause of unintentional death of children in the U.S.
• Assessment and reassessment of ABCs are critical.
• Patient may be in respiratory or cardiac arrest.
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Family Matters
• When children are injured, rescuers will have to deal with caregivers as well. • Calm parents = calm children • Keep caregiver with child. • Support and inform family often. • Act calm, confident, and professional.
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Child Abuse
• Child abuse refers to any improper or excessive action that injures or harms a child or infant.
• This includes physical abuse, sexual abuse, neglect, and emotional abuse.
• More than 2 million cases are reported annually.
• Be aware of signs of child abuse and report it to authorities.
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Considerations Regarding Signs of Abuse
(1 of 4) • Is the injury typical for the child’s developmental stage?
• Is reported method of injury consistent with injuries?
• Is the caregiver behaving appropriately?
• Is there evidence of drinking or drug abuse?
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Considerations Regarding Signs of Abuse
(2 of 4) • Was there a delay in seeking care for the child?
• Is there a good relationship between child and caregiver?
• Does the child have multiple injuries at various stages of healing?
• Does the child have any unusual marks or bruises?
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Considerations Regarding Signs of Abuse
(3 of 4) • Does the child have several types of injuries?
• Does the child have burns on the hands or feet that look like gloves or socks?
• Is there an unexplained decreased level of consciousness?
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Considerations Regarding Signs of Abuse
(4 of 4) • Is the child clean and an appropriate weight?
• Is there any rectal or vaginal bleeding?
• What does the home look like? Clean or dirty? Warm or cold? Is there food?
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Emergency Medical Care
• Take care of ABCs.
• Treat all injuries.
• Arrange for transport if you suspect abuse.
• Do not make accusations.
• Law enforcement and child protective services must investigate all reports of abuse.
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Response to Pediatric Emergencies
• Providers may experience a wide range of emotions after dealing with a child or infant.
• You may feel anxious if you have limited experience with children; therefore, practice is necessary. • After difficult incidents, a debriefing may be helpful.
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