1. Infants and Children

2. Developmental Concerns Infants Newborns and infants (Birth to 1 yr) Minimal stranger anxiety Do not like to be separated from parents Do not tolerate NRBs Poor thermoregulators = Need to be kept warm Breathing rate best obtained at a distance Note -Chest rise Color Level of activity Examine heart and lungs 1st Head last Builds confidence Allows optimal assessment before child becomes agitated

3. Developmental Concerns Toddlers Toddlers- (1 yr-3 yrs) Do not like to be touched Do not like being separated from parents Do not like having clothing removed Do not tolerate NRBs Children interpret illness as punishment Remove Examine - Replace Assure the pt they have not been bad Afraid of needles Fear of pain Trunk to head assessment Builds confidence Done before child becomes agitated

4. Developmental Concerns Preschool Preschool- (3 yrs-6yrs) Do not like to be touched Do not like being separated from parents Do not like to have clothing removed -Remove Assess Replace Do not tolerate NRBs Assure child they were not bad Afraid of blood Fear of pain Fear of permanent injury Modest

5. Developmental Concerns Adolescents School age- (6 yrs- 12 yrs) Afraid of blood Fear of pain Fear of permanent injury Modest Fear if disfigurement Adolescent- (12 yrs-18 yrs) Fear of permanent injury Modest Fear of disfigurement Treat as adults May desire to be assessed privately Away from parents/administrators/friends

6. Anatomical/Physiological Concerns: Airway Small airways throughout the resp system Tongue is large in relations to small mandible DO NOT hyperextend Infants are obligate nose breathers Can be significant airway complication in unresponsive child Positioning airway is different Easily blocked by secretions and swelling Suctioning the nasopharynx can improve respirations Children can compensate well for short periods of time Increased breathing rate and effort of breathing Compensation rapidly followed by decompensation Rapid respiratory muscle fatigue General fatigue of the infant

7. Airway Techniques Airway opening Head tilt chin lift = no trauma Modified jaw thrust = trauma Do not hyperextend Infants below 1 y/o sniffing position Small children 1-8 yrs Extend but do not hyperextend

8. Another type of sniffing position

9. Suctioning Suctioning Blood, vomit, small particulate matter from airway Nasopharynx Rigid suction catheter Insert only as far back as you can see Pressure less than 300 mmHg Should not exceed 100 mmHg in newborns Suction for 15 seconds or less Soft suction catheter Suction for 15 seconds or less If appropriate, hyperventilate the pt before and after suctioning If airway is full of secretions that cannot be easily cleared Log roll pt onto side

10. Airway Adjuncts Adjuncts Oral airways Not for initial artificial ventilation Should not have a gag reflex Size as normal Use tongue depressor Insert tongue blade to base of tongue Push down against tongue while lifting upwards Insert OPA directly in without rotation Nasal airways Not for initial artificial ventilation Size as normal Insert as normal Contraindicated in trauma

11. Oxygen Deliver Oxygen Delivery Nonrebreathers Blow By Hold O2 tubing 2 from face Insert tubing into a paper cup or stuffed animal Artificial Ventilation Mask/bag size determined by age/size of pt Consider trauma -Neonatal Pediatric - Child Modified jaw thrust Manual in line stabilization Mouth to mask ventilation Use of BVM Squeeze bag slowly and evenly allowing chest rise Rate at 20 breaths per minute Provide O2 at 100% using an O2 reservoir

12. Infants and Children Assessment Pediatric Assessment Triangle General impression can be obtained from overall appearance (Well v. sick) Mental Status Effort of breathing Color Quality of cry/speech Interaction to parents/environment Normal behavior based on age Playing Moving around Attentive v non attentive Eye contact Recognized parents Responds to parents calling Emotional state Response to the EMT Tone/body position

13. Approach to Evaluation Begin from across the room MOI Scene size up General impression Respiratory assessment Note chest expansion/symmetry Effort of breathing Nasal flaring Stridor, crowing, noisy Retractions Grunting Respiratory rate Perfusion assessment Skin color

14. Approach to Evaluation Hands on Hands on Approach Assess breath sounds Assess circulation Present Absent Stridor or wheezing Assess brachial or femoral pulse Assess peripheral pulse Assess capillary refill Assess BP in children 3 y/o and older Assess skin color, temperature, moisture Detailed physical exam Trunk to head approach Situation and age dependant Should help reduce infant/child anxiety

15. Common Problems Partial Airway Obstruction Partial Airway Obstruction S/S Infants who are alert and sitting Stridor, crowing, noisy Retractions on inspiration Pink Good peripheral perfusion Still alert, not unconscious Emergency care Allow position of comfort Assist younger child to sit up Do not lay down May sit on parents lap Offer O2 Transport Do not agitate child Limited exam

16. Common Problems Complete Airway Obstruction Complete Airway Obstruction S/S No crying/speaking and cyanosis Childs cough becomes ineffective Increased resp difficulty with stridor Loss of consciousness AMS Emergent clearing of airway -Total blockage of airway -ORPartial obstruction with -AMS Cyanosis Infant procedures Child procedures Attempt artificial ventilation with BVM and good seal

17. Airway Obstructions Complete obstructions Infants less than 1 y/o Back blows/chest thrusts Visual foreign body removal Children 1 y/o+ Abdominal thrusts Visual foreign body removal

18. Upper v Lower Respiratory Presentations Upper Airway Obstruction Lower Airway Disease Stridor on inspiration Wheezing and breathing effort on exhalation Rapid breathing without stridor Complete Airway Obstruction No crying No speaking Cyanosis No coughing

19. S/S of Resp Compromise S/S of Early Respiratory Distress Nasal flaring Retractions Intercostal, Supraclavicular, Subcostal Adnominal, Neck Stridor Audible wheezing Grunting S/S of Progressive Respiratory Distress Rate above 60 breaths per minute Cyanosis Decreased muscle tone Severe use of accessory muscles Poor peripheral perfusion AMS Grunting S/S of Respiratory Arrest Rate less than 10 breaths per minute Limp/flaccid muscle tone Unconscious Slow, absent heart rate Weak, absent distal pulses

20. Treatment of Resp Compromise Emergency Care of Respiratory Compromise O2 O2 and Assist ventilation is severe distress Resp distress and AMS Cyanosis with O2 Resp distress with poor muscle tone Resp failure Provide O2 and ventilate with Resp arrest

21. Common Problems Seizures General comments: Assessment Assess for injuries incurred by seizure activity Caused by Rarely life threatening in children with a Hx However, consider any seizure to be life threatening May be brief or prolonged Although they can be brief there could be a more serious underlying problem Fevers Infections Trauma Hypoglycemia Poisoning Hypoxia Idiopathic Hx of seizures Has the child has prior seizures? If yes, is this the normal seizure pattern? Has the child taken any anti seizure medications?

22. Treatment of Seizures Assure airway position and patency If no C-spine trauma place pt on side Have suction ready Provide O2 Treat S/S of respiratory compromise if found Inadequate breathing and AMS may follow a seizure Transport

23. Common Problems Altered Mental Status Caused by Hypoglycemia Poisoning Seizure Infection Head trauma Hypoxia Hypoperfusion Emergency Care Assure patency of airways Be prepared to artificially ventilate/suction Transport

24. Common Problems Poisoning Poisoning Common reason for EMS activation Identify suspected container through Hx Bring container to hospital if possible Emergency Care Responsive Pt Contact med control Consider activated charcoal O2 Transport Monitor pt for AMS/unresponsiveness Unresponsive Pt Assure patency of airway Be prepared to artificially ventilate O2 Call med control Transport Rule out trauma as cause of AMS

25. Common Problems Fever Fever General comments: Many causes, rarely life threatening Severe case is meningitis Fever with a rash is a significant finding May precipitate a febrile seizure Emergency Care Transport Be prepared for a seizure

26. Common Problems Shock Shock General comments: Common Causes: Diarrhea and dehydration Trauma Vomiting Blood loss Infection Abd injuries Less common causes: Rarely a primary cardiac event Allergic reactions Poisoning Cardiac S/S Rapid resp rate Pale, cool, clammy skin Weak/absent peripheral pulses Delayed capillary refill Decreased urine output ALOC/AMS Absence of tears even when crying

27. Treatment of Shock Assure airway/O2 Be prepared to artificially ventilate Manage bleeding if present Place pt in shock position Keep warm IMMEDIATE transport Detailed exam en route if time permits

28. Common Problems Water Related Accidents Near Drowning Ventilation is TOP priority Consider possible trauma hypothermia possible ingestion (alcohol, etc) Protect airway Suction if necessary Secondary Drowning Syndrome Minutes to hours after the event Deteriorate after breathing normally Therefore, transport ALL near drowning pts

29. Common Problems SIDS Sudden Infant Death Syndrome (SIDS) S/S Sudden death of infant within 1st year Causes are many and not well understood Most commonly found during early morning Emergency Care Try to resuscitate unless rigor mortis Parents will be in distress Avoid comments that may place blame

30. Infants and Children Trauma Injuries are the #1 COD in infants/children Blunt injury is mot common Pattern of injury if different from adults Motor Vehicle Passengers Struck with riding bicycle Injuries to head/neck Burns Sport injuries Head, Spine, Abd injury Falls from heights Unrestrained = Head/Neck injuries Restrained= Abdomen and spinal injuries Head/neck Child abuse

31. Infants and Children Trauma: Specific Body Regions Head Chest Soft very pliable ribs May have injuries without external signs Abdomen Maintain airway via modified jaw thrust More likely to sustain head injuries S/S of shock with head injury suggest other injuries Respiratory arrest is common secondary to head injury Common S/S = Nausea/Vomiting Major airway complication = Tongue More common in children than adults Often a source of hidden injuries ALWAYS consider this in multi-system trauma pt who is deteriorating without external S/S Be aware of complications of gastric distention Extremities Manage in the same manner as adults

32. Other Considerations PASG, Burns Pneumatic Anti Shock Garments Use ONLY if child fits Do not inflate abd compartment Indication S/S hypoperfusion S/S of pelvic instability Criticality of burns Cover with sterile dressing Possible transport to a burn center per protocol

33. Care of the traumatically injured pediatric Assure airway position and patency Use modified jaw thrust O2 Assist ventilation in resp distress Ventilate with BVM in resp arrest Immobilization IMMEDIATE transport

34. Abuse and Neglect Abuse Neglect Multiple bruises in different stages of healing Injury inconsistent with MOI Repeated calls to the same location Fresh burns Parents seem inappropriately unconcerned Conflicting stories Fear on the part of the child to discus how they were hurt S/S of Neglect Giving insufficient attention/respect to an individual who has a right to that attention S/S of Abuse Improper or excessive action so as to injure or cause harm Lack of adult supervision Malnourished appearing child Unsafe living environment Untreated chronic illness CNS injuries are the most lethal in the field (Shaken Baby Syndrome) Do NOT accuse in the field Required reporting by state law What you SEE and what you HEAR NOT what you THINK

35. Virginia Child Abuse Hotline In State (800) 552-7096 Out of State (804) 786-8536

36. Special Needs Children Examples: Premature babies with lung disease Babies and children with heart disease Infants/children with neurological disease Children with chronic diseases Often these pt are at home technologically dependant

37. Infants and Children Special Needs Children Tracheostomy Tube Complications: Obstruction, Bleeding, Air leak, Dislodged, Infection Care: Maintain open airway Suction Maintain position of comfort Transport Home Ventilators Care: Assure patency of airway Artificially ventilate with O2 Transport The parents will be familiar with the equipment Shunts Device running from brain to abd to drain excess CSF Will find reservoir on side of skull Be prepared for AMS Prone to resp arrest Manage airway Assure adequate ventilation Transport

38. Infants and Children Special Needs Children Central Lines Complications Care Cracked line Infection Clotting off Bleeding If bleeding, apply pressure Transport Gastronomy Tube and Gastric Feeding Tube inserted directly into stomach for feeding Be alert for breathing problems: Assure adequate airway Have suction ready If diabetic Hx, anticipate AMS O2 Transport Sitting Lying on Right side, head elevated

39. Family Response Multiple patients Calm, supportive interaction with family Improves ability to deal with child Calm parents = Calm child Agitate parents = Agitate child Parents may respond with anger/hysteria Allow parents to remain part of the care unless condition does not allow Parents should instructed to calm child Child cannot be cared for in isolation from family Transport in position of comfort Hold O2, etc Parents are EXPERTS on what is normal and abnormal for their child

40. Provider Response Anxiety from lack of experience Fear of failure Stress of identifying pt with own child Much of adult learning applies to children REMEMBER the differences PRACTICE

41. That does it