32: Pediatric Assessment and Management

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 (1 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 (2 of 3)

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 Assessmentand 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 Examand 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 SevereAirway 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 AirwayObstruction 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.