Transcript Chapter 31: Pediatric Emergencies

31: Pediatric Emergencies
Cognitive Objectives
(1 of 3)
6-1.1 Identify the developmental considerations
for the following pediatric age groups: infants,
toddlers, preschool, school age, adolescent.
6-1.2 Describe the differences in anatomy and
physiology between the infant, the child, and
the adult patient.
6-1.3 Differentiate the response of the ill or
injured infant or child (age specific) from that
of an adult.
Cognitive Objectives
(2 of 3)
6-1.8 Identify the signs and symptoms of shock
(hypoperfusion) in an infant and child patient.
6-1.11 List common causes of seizures in the
infant and child patient.
6-1.13 Differentiate between the injury patterns
in adults, infants, and children.
Cognitive Objectives (3 of 3)
6-1.15 Summarize the indicators of possible child
abuse and neglect.
6-1.16 Describe the medical/legal responsibilities in
suspected child abuse.
6-1.17 Recognize the need for EMT-B debriefing
following a difficult infant or child transport.
Affective Objectives
6-1.18 Explain the rationale for having knowledge and
skills appropriate for dealing with the infant and
child patient.
6-1.19 Attend to the feelings of the family when
dealing with an ill or injured infant or child.
6-1.20 Understand the provider’s own response
(emotional) to caring for infants or children.
• There are no psychomotor objectives for this
chapter.
Airway Differences
• Larger tongue relative to
the mouth
• Larger epiglottis
• Less well-developed rings
of cartilage in the trachea
• Narrower, lower airway
Breathing Differences
• Infants breathe faster than
children or adults.
• Infants use the diaphragm when
they breathe.
• Sustained, labored breathing
may lead to respiratory failure.
Circulation Differences
• The heart rate increases for illness and injury.
• Vasoconstriction keeps vital organs nourished.
• Constriction of the blood vessels can affect
blood flow to the extremities.
Skeletal Differences
• Bones are weaker and more flexible.
– They are prone to fracture with stress.
• Infants have two small openings in the skull
called fontanels.
– Fontanels close by 18 months.
Growth and Development
• Thoughts and behaviors of children
usually grouped into stages
– Infancy
– Toddler years
– Preschool age
– School age
– Adolescence
Infant
• First year of life
• They respond mainly to
physical stimuli.
• Crying is a way of
expression.
• They may prefer to be with
caregiver.
• If possible, have caregiver
hold the infant as you start
your examination.
Toddler
• 1 to 3 years of age
• They begin to walk and
explore the environment.
• They may resist separation
from caregivers.
• Make any observations you
can before touching a
toddler.
• They are curious and
adventuresome.
Preschool
•
•
•
•
3 to 6 years of age
They can use simple language effectively.
They can understand directions.
They can identify painful areas when
questioned.
• They can understand when you explain
what you are going to do using simple
descriptions.
• They can be distracted by using toys.
School Age
• 6 to 12 years of age
• They begin to think like adults.
• They can be included with the parent when
taking medical history.
• They may be familiar with physical exam.
• They may be able to make choices.
Adolescent
• 12 to 18 years of age
• They are very concerned about body image.
• They may have strong feelings about being
observed.
• Respect an adolescent’s privacy.
• They understand pain.
• Explain any procedure that you are doing.
Family Matters
• When a child is ill or injured, you have several
patients, not just one.
• Caregivers often need support when medical
emergencies develop.
• Children often mimic the behavior of their
caregivers.
• Be calm, professional, and sensitive.
Pediatric Emergencies (1 of 3)
• Dehydration
– Vomiting and diarrhea
– Greater risk than adults
• Fever
– Rarely life threatening
– Caution if occurring with rash
Pediatric Emergencies (2 of 3)
• Meningitis is an inflammation of the tissue that
covers the spinal cord and brain.
• Caused by an infection
• If left untreated can lead to brain damage or death.
Pediatric Emergencies (3 of 3)
• Febrile seizures
– Common between 6 months and 6 years
– Last less than 15 minutes
• Poisoning
– Signs and symptoms vary widely.
– Determine what substances were involved.
Physical Differences
• Children and adults suffer different injuries from
the same type of incident.
• Children’s bones are less developed than an
adult’s.
• A child’s head is larger than an adult’s, which
greatly stresses the neck in deceleration
injuries.
Psychological Differences
• Children are not as psychologically
mature.
• They are often injured due to their
undeveloped judgment and lack of
experience.
Injury Patterns:
Automobile Collisions
• The exact area of
impact will depend on
the child’s height.
• A car bumper dips
down when stopping
suddenly, causing a
lower point of impact.
• Children often sustain
high-energy injuries.
Injury Patterns:
Sports Activities
• Head and neck injuries can occur from highspeed collisions during contact sports.
• Immobilize the cervical spine.
• Follow local protocols for helmet removal.
Head Injuries
• Common injury among children
• The head is larger in proportion to an
adult.
• Nausea and vomiting are signs of pediatric
head injury.
Chest Injuries
• Most chest injuries in
children result from blunt
trauma.
• Children have soft, flexible
ribs.
• The absence of obvious
external trauma does not
exclude the likelihood of
serious internal injuries.
Abdominal Injuries
• Abdominal injuries are very common in children.
• Children compensate for blood loss better than
adults but go into shock more quickly.
• Watch for:
– Weak, rapid pulse
– Cold, clammy skin
– Poor capillary refill
Injuries to the Extremities
• Children’s bones bend more easily than
adults’ bones.
• Incomplete fractures can occur.
• Do not use adult immobilization devices
on children unless the child is large
enough.
Pneumatic Antishock
Garments (PASG)
• Rarely used for treating children
• When to use a PASG:
– Obvious lower extremity trauma
– Pelvic instability
– Clear signs and symptoms of decompensated shock
• Should only be used if it fits properly
• Should never inflate the abdominal compartment
Burns
• Most common burns involve exposure to hot
substances.
• 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.
Submersion Injury
• Drowning or near drowning
• Second most common cause of
unintentional death of children in the United
States
• Assessment and reassessment of ABCs
are critical.
• Consider the need for C-spine protection.
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
suspicions to authorities.
Signs of Child Abuse
Questions 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?
Questions 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?
Questions 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 involving a glove distribution?
• Is there an unexplained decreased level
of consciousness?
Questions 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?
Emergency Medical Care
• EMT-Bs must report all suspected
cases of child abuse.
• Most states have special forms for
reporting.
• You do not have to prove that abuse
occurred.
Sexual Abuse
• Children of any age or either sex can be
victims.
• Limit examination.
• Do not allow child to wash, urinate, or
defecate.
• Maintain professional composure.
• Transport.
Sudden Infant Death
Syndrome (SIDS)
• Several known risk factors:
– Mother younger than 20 years old
– Mother smoked during pregnancy
– Low birth weight
Tasks at Scene
• Assess and manage the patient.
• Communicate with and support the
family.
• Assess the scene.
Assessment and Management
• Assess ABCs and provide interventions as
necessary.
• If child shows signs of postmortem changes,
call medical control.
• If there is no evidence of postmortem changes,
begin CPR immediately.
Communication and Support
• The death of a child is very stressful for the
family.
• Provide support in whatever ways you can.
• Use the infant’s name.
• If possible, allow the family time with the
infant.
Scene Assessment
• Carefully inspect the environment, following local
protocols.
• Concentrate on:
– Signs of illness
– General condition of the house
– Family interaction
– Site where infant was discovered
Apparent Life-Threatening Event
• Infant found not breathing, cyanotic, and
unresponsive but resumes breathing with
stimulation
• Complete careful assessment.
• Transport immediately.
• Pay strict attention to airway management.
Death of a Child (1 of 2)
• Be prepared to support the family.
• Family may insist on resuscitation efforts.
• Introduce yourself to the child’s caregivers.
• Do not speculate on the cause of death.
Death of a Child (2 of 2)
• Allow the family to see the child and say good-bye.
• Be prepared to answer questions posed by
caregivers.
• Seek professional help for yourself if you notice
signs of posttraumatic stress.
Children With Special Needs
• Children born prematurely who have associated
lung problems
• Small children or infants with congenital heart
disease
• Children with neurologic diseases
• Children with chronic diseases or with functions
that have been altered since birth
Tracheostomy Tube
Artificial Ventilators
• Provide respirations for children unable to
breathe on their own.
• If ventilator malfunctions, remove child from
the ventilator and begin ventilations with a
BVM device.
• Ventilate during transport.
Central IV Lines
Gastrostomy Tubes
• Food can back up the esophagus into the lungs.
• Have suction readily available.
• Give supplemental oxygen if the patient has
difficulty breathing.
Shunts
• Tubes that drain excess fluid from around
brain
• If shunt becomes clogged, changes in
mental status may occur.
• If a shunt malfunctions, the patient may
go into respiratory arrest.
Review
1. How does a child’s anatomy differ from an adult’s
anatomy?
A. The child’s trachea is more rigid
B. The tongue is proportionately smaller
C. The epiglottis is less floppy in a child
D. The child’s head is proportionately larger
Review
Answer: D
Rationale: There are several important anatomic
differences between children and adults. A child’s
head—specifically the occiput—is proportionately
larger. Their tongue and epiglottis are also
proportionately larger, and the epiglottis is floppier
and more omega-shaped. The child’s airway is
narrower at all levels, and the trachea is less rigid
and easily collapsible.
Review
1. How does a child’s anatomy differ from an adult’s anatomy?
A. The child’s trachea is more rigid
Rationale: A child’s trachea is less rigid, narrower, and more
anterior than an adult’s.
B. The tongue is proportionately smaller
Rationale: A child’s tongue is proportionally larger than an
adult’s.
C. The epiglottis is less floppy in a child
Rationale: A child’s epiglottis is floppier and shaped differently
than an adult’s.
D. The child’s head is proportionately larger
Rationale: Correct answer
Review
2. When assessing a conscious and alert 9-year-old
child, you should:
A. isolate the child from his or her parent.
B. allow the child to answer your questions.
C. obtain all of your information from the parent.
D. avoid placing yourself below the child’s eye level.
Review
Answer: B
Rationale: A 9-year-old child is capable of answering
questions. By allowing a child to answer your
questions, you can gain his or her trust and build a
good rapport, which facilitates further assessment and
treatment. Do not isolate the child from his or her
parent, yet do not allow the parent to do all the talking,
unless the child is unable to communicate. When
assessing any patient, you should place yourself at or
slightly below the patient’s eye level. This position is
less intimidating and helps to minimize patient anxiety.
Review
2. When assessing a conscious and alert 9-year-old child, you
should:
A. isolate the child from his or her parent.
Rationale: Do not isolate a child from his or her parents.
B. allow the child to answer your questions.
Rationale: Correct answer
C. obtain all of your information from the parent.
Rationale: Some information from parents is useful, but allow
the child to speak.
D. avoid placing yourself below the child’s eye level.
Rationale: Never tower over a child, instead maintain yourself
at/or below eye level.
Review
3. You are called to a residence for a child in respiratory
distress. The child, a 3-year-old boy, is ventilatordependent and has a tracheostomy tube. He is
tachypneic and you hear gurgling sounds in the tube.
You should:
A. remove the ventilator from the tracheostomy tube and
suction the tube.
B. reposition the child’s airway and reassess his
respiratory rate and effort.
C. turn off the mechanical ventilator and apply oxygen
via nonrebreathing mask.
D. remove the tracheostomy tube and ventilate the child
with a bag-mask device.
Review
Answer: A
Rationale: Secretions often accumulate in or around a
tracheostomy tube, resulting in partial or complete
obstruction. A gurgling sound from the tube indicates
this and can lead to hypoxia if not corrected. Proper
treatment involves detaching the ventilator, suctioning
the tracheostomy tube, reattaching the ventilator, and
reassessing the patient. If the child’s condition has not
improved, ventilate him with a bag-mask device
attached to the tube, resuction the tube if needed, and
transport at once.
Review (1 of 2)
3. You are called to a residence for a child in respiratory distress.
The child, a 3-year-old boy, is ventilator-dependent and has a
tracheostomy tube. He is tachypneic and you hear gurgling
sounds in the tube. You should:
A. remove the ventilator from the tracheostomy tube and suction
the tube.
Rationale: Correct answer
B. reposition the child’s airway and reassess his respiratory rate and
effort.
Rationale: The child’s airway is maintained by a rigid tube,
repositioning it will not facilitate a better airway.
Review (2 of 2)
3. You are called to a residence for a child in respiratory distress.
The child, a 3-year-old boy, is ventilator-dependent and has a
tracheostomy tube. He is tachypneic and you hear gurgling
sounds in the tube. You should:
C. turn off the mechanical ventilator and apply oxygen via
nonrebreathing mask.
Rationale: If suctioning is not helpful, the mechanical ventilator can
be disconnected. However, ventilations must be continued by
using a bag-mask connected to 100% oxygen.
D. remove the tracheostomy tube and ventilate the child with a bagmask device.
Rationale: Never remove a tracheotomy tube, doing so may
eliminate the only route for the patient to receive oxygen and
may induce trauma or create additional obstructions.
Review
4. Which of the following indicators of perfusion is
more reliable in small children than in adults?
A. Skin color
B. Heart rate
C. Capillary refill
D. Respiratory rate
Review
Answer: C
Rationale: Capillary refill time (CRT) is an excellent
indicator of perfusion in children younger than 6
years of age. It is less reliable in older children and
adults. There are certain factors, however, that can
affect CRT, such as cold temperatures and
peripheral vasoconstriction.
Review
4. Which of the following indicators of perfusion is more reliable in
small children than in adults?
A. Skin color
Rationale: Skin color may indicate hypoxia, hyperthermia,
hypothermia, jaundice, and possibly shock.
B. Heart rate
Rationale: Heart rate changes are a compensatory mechanism and
can be due to hypoxia, shock, etc.
C. Capillary refill
Rationale: Correct answer
D. Respiratory rate
Rationale: Respiratory rates are driven by hypoxia and the need to
increase the concentration of oxygen in the blood.
Review
5. The purpose of a shunt is to:
A. minimize pressure within the skull.
B. reroute blood away from the lungs.
C. instill food directly into the stomach.
D. drain excess fluid from the peritoneum.
Review
Answer: A
Rationale: A ventriculoperitoneal (VP) shunt—simply
called a “shunt”—is a tube that extends from the
ventricles (cavities) of the brain to the peritoneal
cavity. VP shunts are used to drain excess fluid
from the brain, thus preventing increased pressure
within the skull.
Review
5. The purpose of a shunt is to:
A. minimize pressure within the skull.
Rationale: Correct answer
B. reroute blood away from the lungs.
Rationale: The shunt is connected from the brain to the abdomen.
C. instill food directly into the stomach.
Rationale: The shunt drains excess cerebrospinal fluid from the
brain.
D. drain excess fluid from the peritoneum.
Rationale: The shunt drains excess cerebrospinal fluid from the
brain.
Review
6. A frantic mother calls EMS because the ventilator that
her child is dependent upon is malfunctioning and she
fears that it will stop working altogether. The EMT-B
should:
A. call for an ALS unit to perform endotracheal intubation
on the child.
B. detach the ventilator from the tube and ventilate the
child with a bag-mask device.
C. attempt to repair the ventilator and monitor the child
for signs of increased hypoxia.
D. remove the tracheostomy tube and provide assisted
breathing with a pocket mask.
Review
Answer: B
Rationale: If a mechanical ventilator malfunctions, simply
detach the ventilator from the tracheostomy tube,
attach a bag-mask device to the tube, and resume
ventilations. Do not attempt to “repair” the ventilator;
there are many types of mechanical ventilators and
most EMTs are not familiar with them. If the
tracheostomy tube is severely obstructed despite
suctioning, it may be necessary to remove the tube
and ventilate over the stoma with a pocket mask.
However, the issue here is with the ventilator, not the
tracheostomy tube.
Review (1 of 2)
6. A frantic mother calls EMS because the ventilator that her child is
dependent upon is malfunctioning and she fears that it will stop
working altogether. The EMT-B should:
A. call for an ALS unit to perform endotracheal intubation on the
child.
Rationale: This option may be necessary if assisted ventilations
using a bag-mask are ineffective, which is not the case here.
B. detach the ventilator from the tube and ventilate the child with a
bag-mask device.
Rationale: Correct answer
Review (2 of 2)
6. A frantic mother calls EMS because the ventilator that her child is
dependent upon is malfunctioning and she fears that it will stop
working altogether. The EMT-B should:
C. attempt to repair the ventilator and monitor the child for signs of
increased hypoxia.
Rationale: Do not attempt to “repair” the ventilator. There are many
types of mechanical ventilators and most EMTs are not familiar
with all of them.
D. remove the tracheostomy tube and provide assisted breathing
with a pocket mask.
Rationale: The problem is a ventilator malfunction — not a
tracheostomy tube issue or obstruction.
Review
7. When assessing and monitoring an infant’s heart
rate, it is important to remember that:
A. as hypoxia worsens, the infant’s heart rate
significantly increases.
B. the heart rate is the primary compensatory
mechanism against hypoxia.
C. the infant’s heart rate can only reach a maximum
of 170 beats/min.
D. the primary site to assess the infant’s pulse is at
the radial artery.
Review
Answer: B
Rationale: Infant’s and small children rely heavily on
their heart rates to maintain adequate oxygenation
and perfusion. As they are compensating, heart
rates of 200 beats/min or higher are not
uncommon. As hypoxia worsens, however, their
heart rate will begin to fall; this is an ominous signs
and indicates impending cardiopulmonary arrest.
An infant’s heart rate should be assessed at the
brachial artery.
Review
7. When assessing and monitoring an infant’s heart rate, it is
important to remember that:
A. as hypoxia worsens, the infant’s heart rate significantly
increases.
Rationale: Continued hypoxia will cause bradycardia.
B. the heart rate is the primary compensatory mechanism against
hypoxia.
Rationale: Correct answer
C. the infant’s heart rate can only reach a maximum of 170
beats/min.
Rationale: Infant heart rates can exceed 200 beats/min.
D. the primary site to assess the infant’s pulse is at the radial artery.
Rationale: The primary site for palpating an infant’s pulse is the
brachial artery (in the upper arm).
Review
8. Which of the following statements regarding febrile
seizures is correct?
A. Febrile seizures usually indicate a serious
underlying condition, such as meningitis.
B. Most febrile seizures occur in children between the
ages of 2 months and 2 years of age
C. Febrile seizures are rarely associated with tonicclonic activity, but last for more than 15 minutes
D. Febrile seizures usually last less than 15 minutes
and often do not have a postictal phase
Review
Answer: D
Rationale: Febrile seizures are the most common
seizures in children; they are common in children
between the ages of 6 months and 6 years of age.
Most pediatric seizures are due to fever alone—
hence the name “febrile” seizure. However,
seizures and fever may indicate a more serious
underlying condition, such as meningitis. Febrile
seizures are characterized by generalized tonicclonic activity and last less than 15 minutes; if a
postictal phase occurs, it is generally very short.
Review (1 of 2)
8. Which of the following statements regarding febrile seizures is
correct?
A. Febrile seizures usually indicate a serious underlying condition,
such as meningitis.
Rationale: Most febrile seizures are caused by fever, but a fever and
seizures may be an indication of a serious underlying condition.
B. Most febrile seizures occur in children between the ages of 2
months and 2 years of age
Rationale: Most febrile seizures occur in children between the ages
of 6 months and 6 years.
Review (2 of 2)
8. Which of the following statements regarding febrile seizures is
correct?
C. Febrile seizures are rarely associated with tonic-clonic activity,
but last for more than 15 minutes
Rationale: Febrile seizures last less than 15 minutes.
D. Febrile seizures usually last less than 15 minutes and often do
not have a postictal phase
Rationale: Correct answer
Review
9. When a small child falls from a significant height,
his or her ______ MOST often strikes the ground
first.
A. head
B. back
C. feet
D. side
Review
Answer: A
Rationale: Compared to adults, children have
proportionately larger heads. When they fall from a
significant height, gravity usually takes them head
first. This is why head trauma is the most common
cause of traumatic death in children.
Review
9. When a small child falls from a significant height, his or her ______
MOST often strikes the ground first.
A. Head
Rationale: Correct answer
B. Back
Rationale: The head is heavier and gravity tends to tilt the head in a
downward direction.
C. Feet
Rationale: Adults will attempt to land feet first.
D. Side
Rationale: The head is heavier and gravity tends to tilt the head in a
downward direction.
Review
10. When using the mnemonic CHILD ABUSE to
assess a child for signs of abuse, you should recall
that the “D” stand for:
A. delay in care.
B. divorced parents.
C. dirty appearance.
D. disorganized speech.
Review
Answer: A
Rationale: The mnemonic CHILD ABUSE stands for
Consistency of the injury with the child’s
developmental age, History inconsistent with the
injury, Inappropriate parental concerns, Lack of
supervision, Delay in seeking care, Affect, Bruises
of varying stages, Unusual injury patterns,
Suspicious circumstances, and Environmental
clues. A delay in care may happen when the parent
or caregiver does not want the abuse noted by
other people.
Review
10. When using the mnemonic CHILD ABUSE to assess a child for
signs of abuse, you should recall that the “D” stand for:
A. delay in care.
Rationale: Correct answer
B. divorced parents.
Rationale: Divorce may put the child at greater risk, but does not
indicate the child is being abused.
C. dirty appearance.
Rationale: This is something providers should be aware of. A
potential for abuse exists, but this does not indicate that the child
is being abused.
D. disorganized speech.
Rationale: This may indicate a learning disability or handicap.