32: Pediatric Assessment and Management Cognitive Objectives (1 of 3) 6-1.4 Indicate various causes of respiratory emergencies. 6-1.5 Differentiate between respiratory distress and respiratory failure. 6-1.6 List steps in the management of foreign body airway obstruction. Cognitive Objectives (2 of 3) 6-1.7 Summarize EMS care strategies for respiratory distress and respiratory failure. 6-1.8 Identify the signs and symptoms of shock (hypoperfusion) in the infant and child patient. 6-1.9 Describe the methods of determining end organ perfusion in the infant and child patient. 6-1.10 State the usual cause of cardiac arrest in infants and children versus adults. Cognitive Objectives (3 of 3) 6-1.12 Describe the management of seizures in the infant and child patient. 6-1.14 Discuss the field management of the infant and child trauma patient. • There are no affective objectives for this chapter. Psychomotor Objectives (1 of 2) 6-1.21 Demonstrate the techniques of foreign body airway obstruction removal in the infant. 6-1.22 Demonstrate the techniques of foreign body airway obstruction removal in the child. 6-1.23 Demonstrate the assessment of the infant and child. Psychomotor Objectives (2 of 2) 6-1.24 Demonstrate bag-valve-mask artificial ventilations for the infant. 6-1.25 Demonstrate bag-valve-mask artificial ventilations for the child. 6-1.26 Demonstrate oxygen delivery for the infant and child. Additional Objectives* Cognitive 1. Describe the steps in positioning an infant and/or child to maintain an open airway. 2. Summarize neonatal resuscitation procedures. Affective None Psychomotor 3. Demonstrate the techniques necessary in neonatal resuscitation. *These are noncurriculum objectives. Pediatric Assessment and Management • Caring for sick and injured children presents special challenges. • EMT-Bs may find themselves anxious when dealing with critically ill or injured children. • Treatment is the same as that for adults in most emergency situations. Scene Size-up • Take note of your surroundings. • Scene assessment will supplement additional findings. • Observe: – Position of the patient – Condition of the home – Clues to child abuse Initial Assessment • Begins before you touch the patient • Form a general impression. • Determine a chief complaint. • The Pediatric Assessment Triangle can help. Pediatric Assessment Triangle • Appearance – Awake – Aware – Upright • Work of breathing – Retractions – Noises • Skin circulation Assessing the ABCs • Ensure airway is open and position patient. • Breathing assessment – Effort – Obstructions – Rate • Circulation assessment – Rate – Skin color, temperature, and capillary refill Transport Decision • Children under 40 lb should be transported in a child safety seat, if the situation allows. • Seat should be secured to the cot or captain’s chair. • Cannot be secured to bench seat • Child may have to be transported without a seat, depending on condition. Focused History and Physical Exam • Should be completed on scene unless severity requires rapid transport • Young children should be examined toe to head. • Focused exam on noncritical patients • Rapid exam on potentially critical patients Vital Signs by Age Age Respirations (breaths/min) Pulse (beats/min) Systolic Blood Pressure (mm Hg) Newborn: 0 to 1 mo 30 to 60 90 to 180 50 to 70 Infant: 1 mo to 1 yr 25 to 50 100 to 160 70 to 95 Toddler: 1 to 3 yr 20 to 30 90 to 150 80 to 100 Preschool age: 3 to 6 yr 20 to 25 80 to 140 80 to 100 School age: 6 to 12 yr 15 to 20 70 to 120 80 to 110 Adolescent: 12 to 18 yr 12 to 16 60 to 100 90 to 110 Older than 18 yr 12 to 20 60 to 100 90 to 140 Respirations • Abnormal respirations are a common sign of illness or injury. • Count respirations for 30 seconds. • In children less than 3 years, count the rise and fall of the abdomen. • Note effort of breathing. • Listen for noises. 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. Blood Pressure • Use a cuff that covers two thirds of the upper arm. • If scene conditions make it difficult to measure blood pressure accurately, do not waste time trying. Skin Signs • Feel for temperature and moisture. • Estimate capillary refill. Detailed Physical Exam and Ongoing Assessment • • • • Status changes frequently in children. The PAT can help with reassessment. Repeat vital signs frequently. If child deteriorates, repeat the initial assessment. Care of the Pediatric Airway (1 of 2) • Position the airway. • Position the airway in a neutral sniffing position. • If spinal injury is suspected, use jaw-thrust maneuver to open the airway. 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. 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. 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. 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. 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. Oxygen Delivery Devices • Nonrebreathing mask at 10 to 15 L/min provides 90% oxygen concentration. • Blow-by technique at 6 L/min provides more than 21% oxygen concentration. • Nasal cannula at 1 to 6 L/min provides 24% to 44% oxygen concentration. BVM Devices • Equipment must be the right size. • BVM device at 10 to 15 L/min provides 90% oxygen concentration. • Ventilate at the proper rate and volume. • May be used by one or two rescuers One-rescuer BVM Ventilation A B C D Airway Obstruction • Croup – A viral infection of the airway below the level of the vocal cords • Epiglottitis – Infection of the soft tissue in the area above the vocal cords • Foreign body airway obstructions Signs and Symptoms • Decreased or absent breath sounds • Stridor • Retractions • Difficulty speaking Signs of Severe Airway Obstruction • Signs and symptoms – Ineffective cough (no sound) – Inability to cry – Increasing respiratory difficulty, with stridor – Cyanosis – Loss of consciousness Removing a Foreign Body Airway Obstruction (1 of 5) • In an unconscious child: – Place the child on a firm, flat surface. • Open airway using head tilt-chin lift maneuver. – Inspect the upper airway and remove any visible object. – Attempt rescue breathing. • If unsuccessful, reposition head and try again. – If ventilation is still unsuccessful begin CPR. Removing a Foreign Body Airway Obstruction (2 of 5) • Place heel of one hand on lower half of sternum between the nipples. • Administer 30 chest compressions at a depth of 1/3 to 1/2 the depth of the chest. Removing a Foreign Body Airway Obstruction (3 of 5) • Open airway using head tilt-chin lift maneuver. If you see the object, remove it. • Repeat process. 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. Removing a Foreign Body Airway Obstruction (5 of 5) • If the child becomes unconscious, inspect the airway. • Attempt rescue breathing. • If airway remains obstructed, begin CPR. Management of Airway Obstruction in Infants • • • • • • Hold the infant facedown. Deliver five back slaps. Bring infant upright on the thigh. Give five quick chest thrusts. Check airway. Repeat cycle as often as necessary. Neonatal Resuscitation • Resuscitation measures include: – Positioning airway – Drying – Warming – Suctioning – Tactile stimulation Neonatal Equipment Additional Efforts • Deliver chest compressions at 120 per minute. • Coordinate chest compressions with ventilations at a ratio of 3:1. • If meconium is present, suction infant vigorously. BLS Review • Cardiac arrest in children is commonly due to respiratory arrest. • Many causes of respiratory arrest • For purposes of pediatric BLS: – Infancy ends at 1 year of age. – Childhood extends from 1 year of age to onset of puberty (12 to 14 years of age). Determine Responsiveness • Gently tap on shoulder and speak loudly. • If responsive, place in position of comfort. • If you find an unresponsive child when you are not on duty: – Provide BLS for about 2 minutes. – Then call EMS system. Airway • Airway may be obstructed by tongue. • Use head tilt-chin lift technique or jaw-thrust maneuver to open the airway. • Jaw-thrust maneuver is safer if possibility of neck injury exists. Breathing • Look, listen, and feel. • Provide rescue breathing if needed. • Perform Sellick maneuver to prevent gastric distention. Circulation • Assess circulation after airway is open and two rescue breaths have been given. • Check for pulses. • Evaluate for other signs of circulation. • Take at least 5 seconds but not more than 10 seconds trying to find a pulse. • If infant or child is not breathing, the pulse is often too slow or absent. CPR will be required. Infant CPR (1 of 2) • Place infant on firm surface and maintain airway. • Place two fingers in the middle of the sternum. • Use two fingers to compress the chest 1/3 to 1/2 the depth of the chest at a rate of 100/min. Infant CPR (2 of 2) • Allow sternum to return briefly to its normal position between compressions. • Coordinate rapid compressions and ventilations in a 30:2 ratio. • Reassess the infant for return of breathing and pulse after every 2 minutes of CPR. Child CPR (1 of 2) • Place child on firm surface and maintain airway with one hand. • Place heel of other hand over lower half of the sternum. – Avoid the xiphoid process. • Compress chest 1/3 to 1/2 the depth of the chest at a rate of 100/min. Child CPR (2 of 2) • Coordinate compressions with ventilations in a 30:2 ratio for one rescuer, 15:2 for two rescuers, pausing for ventilations. • Reassess for breathing and pulse after every 2 minutes of CPR. • If the child resumes effective breathing, place child in recovery position.