29)infants and children

Infants and Children

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

Developmental ConcernsToddlers

• Toddlers- (1 yr-3 yrs)• Do not like to be touched• Do not like being separated from

parents• Do not like having clothing removed

• Remove – Examine - Replace• Do not tolerate NRB’s• Children interpret illness as

punishment• 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

Developmental ConcernsPreschool

• 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 NRB’s• Assure child they were not

“bad”• Afraid of blood• Fear of pain• Fear of permanent injury• Modest

Developmental ConcernsAdolescents

• 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

Anatomical/Physiological Concerns: Airway

• Small airways throughout the resp system• Easily blocked by secretions and swelling

• Tongue is large in relations to small mandible• Can be significant airway complication in unresponsive child

• Positioning airway is different• DO NOT hyperextend

• Infants are obligate nose breathers• 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

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

Another type of sniffing position…Another type of sniffing position…

Suctioning

• Suctioning• Blood, vomit, small particulate matter

from airway• 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

• Nasopharynx• 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

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

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

• -Neonatal – Pediatric - Child• Consider trauma

• 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

Infants and ChildrenAssessment

• 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

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

Approach to Evaluation“Hands on”

• “Hands on” Approach• Assess breath sounds

• Present• Absent• Stridor or wheezing

• Assess circulation• 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

Common ProblemsPartial Airway Obstruction

• Partial Airway Obstruction• Infants who are alert and sitting

• S/S• 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

Common ProblemsComplete Airway Obstruction

• Complete Airway Obstruction• -Total blockage of airway -OR-• Partial obstruction with -AMS – Cyanosis

• S/S• No crying/speaking and cyanosis• Childs cough becomes ineffective• Increased resp difficulty with stridor• Loss of consciousness• AMS

• Emergent clearing of airway• Infant procedures• Child procedures

• Attempt artificial ventilation with BVM and good seal

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

Upper v Lower Respiratory Presentations

• Upper Airway Obstruction • Stridor on inspiration

• Lower Airway Disease • Wheezing and breathing

effort on exhalation • Rapid breathing without

stridor • Complete Airway

Obstruction• No crying• No speaking• Cyanosis• No coughing

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

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

Common ProblemsSeizures

• General comments:• 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

• Assessment• Assess for injuries incurred by

seizure activity• Caused by

• 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?

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

Common ProblemsAltered 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

Common ProblemsPoisoning

• 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

Common ProblemsFever

• 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

Common ProblemsShock

• Shock• General comments:

• Rarely a primary cardiac event• Common Causes:

• Diarrhea and dehydration• Trauma• Vomiting• Blood loss• Infection• Abd injuries

• Less common causes:• 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

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

Common ProblemsWater 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

Common ProblemsSIDS

• 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

Infants and ChildrenTrauma

• Injuries are the #1 COD in infants/children• Blunt injury is mot common• Pattern of injury if different from adults

• Motor Vehicle Passengers• Unrestrained = Head/Neck injuries• Restrained= Abdomen and spinal injuries

• Struck with riding bicycle• Head, Spine, Abd injury

• Falls from heights• Injuries to head/neck

• Burns• Sport injuries

• Head/neck• Child abuse

Infants and ChildrenTrauma: Specific Body Regions

• Head• 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

• Chest• Soft very pliable ribs• May have injuries without external signs

• Abdomen• 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

Other ConsiderationsPASG, 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

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

Abuse and Neglect

• Abuse• Improper or excessive action so as to injure or cause harm

• Neglect• Giving insufficient attention/respect to an individual who has a right to that attention

• S/S of Abuse• 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• 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

Virginia Child Abuse Hotline

• In State• (800) 552-7096

• Out of State• (804) 786-8536

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

Infants and ChildrenSpecial 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

Infants and ChildrenSpecial Needs Children

• Central Lines• Complications

• Cracked line• Infection• Clotting off• Bleeding

• Care• 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

Family Response

• Multiple patients• Child cannot be cared for in isolation

from family• 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

• Transport in position of comfort• Hold O2, etc

• Parents are EXPERTS on what is normal and abnormal for their child

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

That does it…