Chapter 34 Pediatric Emergencies

Chapt 34 Pediatric Emergencies Growth and Development -Many physical and emotional changes occur during childhood. 1. Childhood extends from birth until age 18. 2. The thoughts and behaviors of children as a whole are often grouped into five stages: a. Infancy: first year of life b. Toddler: ages 1 to 3 years c. Preschool-age child: ages 3 to 6 years d. School-age child: ages 6 to 12 years e. Adolescent: ages 13 to 18 years The infant 1. Infancy is usually defined as the first year of life. a. The first month after birth is called the neonatal or newborn period. 2. 0 to 2 months a. Infants sleep for up to 16 hours a day between feeding times and caregiver interactions. b. Infants cannot tell the difference between parents and strangers. c. Crying is one of the main modes of expression. d. An inconsolable infant, after all obvious needs have been addressed, could be a sign of significant illness. 3. 2 to 6 months a. Persistent crying, irritability, or lack of eye contact can be an indicator of serious illness, depressed mental status, or a delay in development. 4. 6 to 12 months a. May cry if separated from their parents or caregivers b. Persistent crying or irritability can be a symptom of serious illness. 5. Assessment a. Begin assessment by observing the infant from a distance. b. Let the caregiver continue to hold baby during physical assessment. c. Provide as much sensory comfort as possible. d. Do any painful procedures at end of the assessment process. e. Complete each procedure efficiently and avoid interruptions. f. Explain each procedure to the parent or caregiver before you perform it, because the procedure and the infant’s reaction may be upsetting. The toddler 1. After infancy, until 3 years of age, a child is called a toddler. a. Toddlers experience rapid changes in growth and development. 2. 12 to 18 months a. Because they are explorers by nature and not afraid, injuries in this age group increase. b. Because of a lack of molars, they may not be able to fully chew their food, leading to increased risk of choking. 3. 18 to 24 months a. Toddlers at this stage tend to cling to their parents or caregivers and often have an object that comforts them. 4. Assessment e. Toddlers can have a hard time describing or localizing pain. g. Begin your assessment at the feet or away from the location of pain The preschool-age child (ages 3 to 6 years) 1. Foreign body aspiration airway obstruction continues to be a high risk. 2. Assessment a. Can understand directions and be specific in describing painful areas b. Despite increased ability to communicate, much of history must be obtained from caregivers. c. Communicate simply and directly. d. Appealing to the child’s imagination may facilitate the examination process. e. Do not lie to a patient of this age—hard to regain lost trust. h. Use adhesive bandages to cover the site of an injection or other small wound. School-age years (ages 6 to 12 years) 1. At this stage, children begin to understand death is final, but their understanding of what death is and why it occurs is still unrealistic. 2. Assessment a. Assessment begins to be more like an adult assessment. b. To help gain trust, talk to the child, not just the caregiver. c. The child is probably familiar with the process of a physical exam. d. Start with head and work toward the feet, as in an adult assessment. i. Give them simple explanations about what is causing their pain and what will be done about it. Adolescents (ages 13 to 18 years) 1. Physically similar to adults, but they are still children on the emotional level 3. Assessment a. Adolescents can often understand very complex concepts and treatment options. b. Allow adolescents to be involved in their own care. c. An EMT of the same gender should perform the physical examination, if possible, to lessen the stress of the event. d. Allow the adolescent to speak openly and ask questions. e. Risk-taking behaviors are common at this age. Anatomy and Physiology The respiratory system 1. Anatomy of the pediatric airway differs from an adult’s: ***** a. Pediatric airway is smaller in diameter and shorter in length. b. Lungs are smaller. c. Heart is higher in the chest. d. Glottic opening is higher/positioned more anteriorly, and the neck appears to be nonexistent. f. Occiput is larger and rounder, which requires more careful positioning of the airway. g. Tongue is larger relative to the size of the mouth and in a more anterior location in the mouth. The tongue can easily block the airway. h. Long, floppy, U-shaped epiglottis in infants and toddlers is larger than in the adult. j. Upper airway has a narrowing funnel shape compared to the cylinder shape of the lower airway. k. Diameter of trachea in infants is about the same as a drinking straw. l. Children have an oxygen demand twice that of an adult. n. Gastric distention can interfere with movement of the diaphragm and lead to hypoventilation. o. Breath sounds are more easily heard because of their thinner chest walls. p. Less air is exchanged with each breath, so detection of poor air movement or complete absence of breath sounds may be more difficult The circulatory system 1. Important to know the normal pulse ranges when evaluating children. a. An infant’s heart can beat 160 times or more per minute. b. Children are able to compensate for decreased perfusion by constricting vessels in the skin. c. Signs of vasoconstriction include pallor (early sign), weak distal pulses in the extremities, delayed capillary refill, and cool hands or feet. The nervous system 1. Compared to an adult nervous system, the pediatric nervous system is immature, underdeveloped, and not well protected. a. Head-to-body ratio of infant and young child is disproportionately larger. b. Occipital region of head is larger, which increases the momentum of the head during a fall. c. The subarachnoid space is relatively smaller, leaving less cushioning for the brain. d. Brain tissue and cerebral vasculature are fragile and prone to bleeding from shearing forces. 2. Pediatric brain also requires a higher amount of cerebral blood flow, oxygen, and glucose than does adult brain tissue. a. This means that the pediatric brain is at risk for secondary brain damage from hypotension and hypoxic events. The gastrointestinal system 1. Abdominal muscles are less developed in pediatric patients. a. Less protection from trauma b. Liver, spleen, and kidneys are proportionally larger and situated more anteriorly, so they are prone to bleeding and injury. The musculoskeletal system 1. Open growth plates allow bones to grow during childhood. a. As a result of open growth plates, bones are softer and more flexible, making them prone to stress fractures. b. Bone length discrepancies can occur if there is injury to a growth plate. 2. The bones of an infant’s head are flexible and soft. a. Soft spots are located at the front and back of the head 3. The thoracic cage in children is highly elastic and pliable because it is primarily composed of cartilaginous connective tissue. a. The ribs and vital organs are less protected by muscle and fat. The integumentary system 1. The integumentary system of the pediatric population differs in a few ways: a. The skin is thinner with less subcutaneous fat. b. Composition of skin is thinner and tends to burn more deeply and easily with less exposure. c. Higher ratio of body surface area to body mass can lead to larger fluid and heat losses. Patient Assessment -Scene size-up a. Note the position in which the patient is found. b. Patient may be a safety threat if he or she has an infectious disease. -Primary assessment 1. The objective of the primary assessment is to identify and treat immediate or potential threats to life. 2. Pediatric Assessment Triangle (PAT) *Pg 1228 a. Use the pediatric assessment triangle to determine if pt. is sick (unstable) or not sick (stable) i. Can be performed in less than 30 seconds b. Appearance c. Work of breathing d. Circulation to the skin e. From the PAT findings, you will decide if the pediatric patient is stable or requires urgent care. 3. Hands-on ABCs a. Next, you will perform a hands-on ABCs assessment. b. Assess and treat any life threats as you identify them by following the ABCDE format. c. Airway i. If airway is open and patient can adequately keep it open, assess respiratory adequacy. ii. If patient is unresponsive or has difficulty keeping the airway clear, ensure that it is properly positioned and that it is clear of mucus, vomitus, blood, and foreign bodies. iii. Always position the airway in a neutral sniffing position (see Skill Drill 34-1). d. Breathing i. Look, listen, feel technique ii. Place both hands on the chest to feel for the rise and fall of the chest wall. iii. Belly breathing in infants is considered adequate because of the soft pliable bones of the chest and the strong muscular diaphragm. iv. Bradypnea (decrease in respiratory rate) is an ominous sign and indicates impending respiratory arrest. e. Circulation i. Must determine if the patient has a pulse, is bleeding, or is in shock ii. In infants, palpate the brachial pulse or femoral pulse. iii. In children older than 1 year, palpate the carotid pulse. iv. Strong central pulses usually indicate that the patient is not hypotensive. v. Weak or absent peripheral pulses indicate decreased perfusion. vi. Tachycardia may be an early sign of hypoxia or shock, or a less serious condition such as fever, anxiety, pain, or excitement. f. Pediatric patients weighing less than 40 pounds who do not require spinal immobilization should be transported in a car seat. g. Mount a car seat to a stretcher h. Follow the seat manufacturer’s instructions to secure a car seat to a captain’s chair. -History taking 1. Your approach to the history will depend on the age of the pediatric patient. a. Historical information for an infant, toddler, or preschool-age child will have to be obtained from the parent or caregiver. d. When interviewing the parent/caregiver or older child about the chief complaint, obtain the following: NOI or MOI 2. SAMPLE history a. SAMPLE history for pediatric patient is the same as an adult’s. b. Questions should be based on pediatric patient’s age and developmental stage of life. c. The process for obtaining OPQRST is the same for children and adults. -Secondary assessment 1. Physical examinations a. A secondary assessment of the entire body should be used when pediatric patients have the potential for hidden illnesses or injuries (unresponsive or have a significant MOI). i. Use the DCAP-BTLS mnemonic. c. A focused assessment should be performed on pediatric patients without life-threatening illnesses or injuries. d. Infants, toddlers, and preschool-age children who do not have life-threatening illness or injuries should be assessed starting at the feet and ending at the head. e. School-age children and adolescents can be assessed using the head-to-toe approach. 2. Vital signs i. Normal heart rates vary with age in pediatric patients. ii. Blood pressure is usually not assessed in pediatric patients younger than 3 years. b. Assessment of the skin is a better indication of a pediatric patient’s circulatory status. c. It is important to use appropriately sized equipment when assessing a pediatric patient’s vital signs. d. The formula 70 + (2 × age in years) = systolic blood pressure is a useful tool to determine blood pressure in children 1 to 10 years of age. e. Respiratory rates may be difficult to interpret. i. Count respirations for at least 30 seconds and then double that number (if counted for 30 seconds) -Reassessment 1. Reassess the pediatric patient’s condition as necessary. a. Obtain vital signs every 15 minutes for a child in stable condition. b. Obtain vital signs every 5 minutes for a child in unstable condition. c. Continually monitor respiratory effort, skin color and condition, and level of consciousness or interactiveness. Respiratory Emergencies and Management Respiratory emergencies 1. Respiratory problems are the leading cause of cardiopulmonary arrest in the pediatric population. a. Failure to recognize and treat declining respiratory status will lead to death. b. During respiratory distress, the pediatric patient is working harder to breathe and will eventually go into respiratory failure if left untreated. 2. In the early stages of respiratory distress, you may note changes in the pediatric patient’s behavior, such as combativeness, restlessness, and anxiety. 3. Signs and symptoms of increased work of breathing 4. As the pediatric patient progresses to possible respiratory failure: a. Efforts to breathe decrease, The chest rises less with inspiration. c. The body has used up all its available energy stores and cannot continue to support the extra work of breathing. d. Changes in behavior will also occur until the pediatric patient demonstrates an altered level of consciousness. Airway obstruction 1. Children can obstruct their airway with any object they can fit into their mouth. 2. In cases of trauma, teeth may have been dislodged into the airway. 3. Blood, vomitus, or other secretions can also cause mild or severe airway obstruction. 4. Infections, including pneumonia, croup, epiglottitis, and bacterial tracheitis, can also cause airway obstructions. a. Infection should be considered if patient has congestion, fever, drooling, and cold symptoms. b. Croup is an infection in the airway below the level of the vocal cords. c. Epiglottitis is an infection of the soft tissue in the area above the vocal cords. 5. Obstruction by a foreign object may involve the upper or lower airway. a. Obstruction may be partial or complete. b. Signs and symptoms frequently associated with a partial upper airway obstruction include decreased or absent breath sounds and stridor. c. Signs and symptoms of a lower airway obstruction include wheezing and/or crackles. 6. The best way to auscultate breath sounds in a pediatric patient is to listen on both sides of the chest at the level of the armpit. 7. Immediately begin treatment of a pediatric patient with an airway obstruction. Asthma 1. A condition in which the smaller air passages (bronchioles) become inflamed, swell, and produce excessive mucus, which leads to difficulty breathing. 2. A true emergency if not promptly identified and treated b. Common causes for an asthma attack 3. Signs and symptoms of asthma 4. Treatment of pediatric patient with asthma Pneumonia 2. Pneumonia is a general term that refers to an infection of the lungs. 3. Presentation in the pediatric patient 4. Treatment of pneumonia in the pediatric patient 5. Diagnosis of pneumonia must be confirmed in the hospital. Croup 1. Croup (laryngotracheobronchitis) is an infection of the airway below the level of the vocal cords, usually caused by a virus. a. Typically seen in children between ages 6 months and 3 years b. Easily passed between children 2. The disease starts with a cold, cough, and a low-grade fever that develops over 2 days. a. The hallmark signs of croup are stridor and a seal-bark cough. 3. Croup often responds well to the administration of humidified oxygen. a. Bronchodilators are not indicated for croup and can make the child worse. Epiglottitis 1. Epiglottitis (supraglottitis) is an infection of the soft tissue in the area above the vocal cords. a. Bacterial infection is the most common cause. 2. Since the development of a vaccine against one organism that causes epiglottitis, the incidence of this disease has dramatically decreased. 3. In preschool- and school aged children especially, the epiglottis can swell to two to three times its normal size. 4. Children with this infection look ill, report a very sore throat, and have a high fever. Bronchiolitis 1. Specific viral illness of newborns and toddlers, often caused by respiratory syncytial virus (RSV) 2. More common in premature infants and results in copious secretion that may require suctioning a. Occurs during the first 2 years of life and is more common in males b. Most widespread in winter and early spring c. Bronchioles become inflamed, swell, and fill with mucus. d. Airways of infants and young children can easily become blocked. 3. Look for signs of dehydration, shortness of breath, and fever. 4. Treatment of bronchiolitis in the pediatric patient Pertussis 1. Pertussis, also known as whooping cough, is a communicable disease caused by a bacterium that is spread through respiratory droplets. 2. As the result of vaccinations, this potentially deadly disease is less common in the United States. 3. The typical signs and symptoms are similar to a common cold. a. As the disease progresses, the coughing becomes more severe and is characterized by the distinctive whoop sound heard during inspiration. b. Infants infected with pertussis may develop pneumonia or respiratory failure. 4. To treat pediatric patients, keep the airway patent (open) and transport. 5. Pertussis is contagious, so follow standard precautions, including wearing a mask and eye protection. Airway adjuncts 1. Devices that help to maintain the airway or assist in providing artificial ventilation, including: a. Oropharyngeal and nasopharyngeal airways b. Bite blocks c. BVMs 2. Oropharyngeal airway a. Designed to keep the tongue from blocking the airway and makes suctioning easier b. Should be used for pediatric patients who are unconscious and in possible respiratory failure c. See Skill Drill 34-2. 3. Nasopharyngeal airway a. Usually well tolerated and not as likely to cause vomiting b. Used for responsive pediatric patients c. Used in association with possible respiratory failure d. Rarely used in infants younger than 1 year e. Should not be used in pediatric patients with nasal obstruction or head trauma f. See Skill Drill 34-3. g. Potential problems Oxygen delivery devices 1. In treating infants and children who require more than the usual 21% oxygen found in room air, you have several options. a. Blow-by technique at 6 L/min provides more than 21% oxygen concentration. b. Nasal cannula at 1 to 6 L/min provides 24% to 44% oxygen concentration. c. Nonrebreathing mask at 10 to 15 L/min provides up to 95% oxygen concentration. d. BVM (with oxygen reservoir) at 10 to 15 L/min provides nearly 100% oxygen concentration. 2. Use of a nonrebreathing mask, a nasal cannula, or a simple face mask is indicated only for pediatric patients who have adequate respirations and/or tidal volumes. a. Children with respirations of fewer than 12 breaths/min or more than 60 breaths/min, altered level of consciousness, and/or an inadequate tidal volume should receive assisted ventilations with a BVM. 3. Blow-by method a. Blow-by method is not nearly as effective as face mask or nasal cannula for delivering oxygen b. Does not provide high concentration of oxygen, but it is better than no oxygen 4. Nasal cannula a. Some pediatric patients prefer the nasal cannula; others find it uncomfortable. 5. Nonrebreathing mask a. Delivers up to 90% oxygen to the pediatric patient and allows them to exhale all carbon dioxide without rebreathing it. 6. Bag-valve mask a. Indicated for pediatric patients who have respirations that are either too slow or too fast, who are unresponsive, or who do not respond in a purposeful way to painful stimuli. 7. One-person BVM ventilation on a pediatric patient 8. Two-person BVM ventilation on a pediatric patient a. This procedure is similar to one-person BVM ventilation except that one rescuer holds the mask to the patient’s face and maintains the head position and the other ventilates. Cardiopulmonary arrest 1. Cardiac arrest in infants and children is most often associated with respiratory failure and arrest. Circulation Emergencies and Management -Shock 1. Shock is a condition that develops when the circulatory system is unable to deliver a sufficient amount of blood to the organs of the body. a. Results in organ failure and eventually cardiopulmonary arrest 2. Common causes of shock in pediatric patients 3. Pediatric patients respond differently than adults to fluid loss. a. They may respond by increasing their heart rate, increasing respirations, and showing signs of pale or blue skin. 4. Signs of shock in children 5. Begin treating shock by assessing the ABCs, intervening as required. a. If there is an obvious life-threatening external hemorrhage, the order becomes CAB c. Pediatric patients in shock often have increased respirations but do not demonstrate a fall in blood pressure until shock is severe. 6. Anaphylaxis a. Anaphylaxis, also called anaphylactic shock, is a life-threatening allergic reaction that involves a generalized, multisystem response to an antigen. b. Signs and symptoms (airway swelling and dilation of blood vessels) c. Treatment of pediatric patient with anaphylactic shock Bleeding disorders 1. Hemophilia is a congenital condition in which the patient lacks one or more of the normal clotting factors of blood. a. Most forms are hereditary and are severe. b. Predominantly found in male population c. Bleeding may occur spontaneously. d. All injuries become serious because blood does not clot. Neurologic Emergencies and Management -Altered mental status (AMS) 1. AMS is an abnormal neurologic state in which the pediatric patient is less alert and interactive than is age appropriate. a. Understanding normal developmental or age-related changes in behavior and listening carefully to the caregiver’s opinion are key. b. The mnemonic AEIOU-TIPPS reflects the major causes of AMS c. Signs and symptoms vary from simple confusion to coma. d. Management focuses on the ABCs and transport. Seizures 1. A seizure is the result of disorganized electrical activity in the brain. a. Common causes of seizures b. May manifest in a variety of ways, depending on the age of the child c. Seizures in infants can be very subtle, consisting only of an abnormal gaze, sucking motions, or “bicycling” motions. d. In older children, seizures are more obvious and typically consist of repetitive muscle contractions and unresponsiveness. i. Once a seizure stops, the patient’s muscles relax, becoming almost flaccid or floppy, and the breathing becomes labored. ii. The longer and more intense the seizures are, the longer it will take for this imbalance to correct itself. 2. Management Meningitis 1. Inflammation of tissue (meninges) that covers the spinal cord and brain 2. Being able to recognize a pediatric patient with meningitis is an important skill to have. a. Some individuals are at greater risk: i. Males, Newborn infants, Compromised immune systems by AIDS or cancer 3. Signs and symptoms of meningitis vary, depending on age of the patient. 4. Neisseria meningitidis is a bacterium that causes a rapid onset of meningitis symptoms, often leading to shock and death. a. Children with N. meningitidis typically have small, pinpoint, cherry-red spots or a larger purple/black rash on the face or body. 5. All pediatric patients with suspected meningitis should be considered contagious. b. If exposed to saliva or respiratory secretions, you should receive antibiotics. 6. Treatment of child with suspected meningitis Gastrointestinal Emergencies and Management -Never take a complaint of abdominal pain lightly, because a large amount of bleeding may occur within the abdominal cavity without any outward signs of shock. 1. Monitor for signs and symptoms of shock, including an altered mental status. -Complaints of gastrointestinal origin are common in pediatric patients. 1. May be from ingestion of certain foods or unknown substances 2. In most cases, the pediatric patient will be experiencing abdominal discomfort with nausea, vomiting, and/or diarrhea. 3. Appendicitis is also common. 4. If you suspect appendicitis, promptly transport to the hospital for further evaluation. 5. Obtain a thorough history from the primary caregiver. In particular, ask questions such as: Poisoning Emergencies and Management -Poisoning is common among children. 1. Can occur by ingesting, inhaling, injecting, or absorbing a toxic substance 2. Common sources of poisoning in children 3. Signs/symptoms of poisoning vary depending on the substance and the age and weight of the child a. The patient may appear normal at first, or may be confused, sleepy, or unconscious. b. Some substances only take one pill to be lethal in a small child. 5. After you have completed your primary assessment, ask the parent or caregiver the following questions: a. What is the substance(s) involved? 6. Contact Poison Control for assistance in identifying poisons. 7. Treatment of a poisoned pediatric patient (not much can do unless its an opiate) Dehydration Emergencies and Management -Dehydration occurs when fluid losses are greater than fluid intake. 1. Vomiting and diarrhea are the most common causes of dehydration. a. If left untreated, dehydration can lead to shock and death. 2. Infants and children are at greater risk than adults for dehydration because their fluid reserves are smaller than those in adults. a. Life-threatening dehydration can overcome an infant in a matter of hours. 3. Dehydration can be mild, moderate, or severe. 4. Signs of mild dehydration **Pg 1259 5. Signs of moderate dehydration 6. Signs of severe dehydration -Treating dehydration in the pediatric patient Fever Emergencies and Management -Simply defined, a fever is an increase in body temperature, usually in response to an infection. 1. Temperatures of 100.4°F (38°C) or higher are considered abnormal. 2. Fever is rarely life threatening, but fever with rash can be sign of serious condition, such as meningitis. 3. Common causes of fever in pediatric patients 4. Fever is the result of an internal body mechanism in which heat generation is increased and heat loss is decreased. 5. An accurate body temperature is an important vital sign for pediatric patients. 6. Depending on the source of infection, the pediatric patient may present with signs of respiratory distress; shock; a stiff neck; a rash; skin that is hot to the touch; flushed cheeks; seizures; and, in infants, bulging fontanelles. a. Assess the patient for other signs and symptoms such as nausea, vomiting, diarrhea, decreased feedings, and headache. 7. Provide rapid transport and manage the patient’s ABCs. Febrile seizures 1. Febrile seizures are common in children between the ages of 6 months and 6 years. a. Most pediatric seizures are result of fever alone, which is why they are called febrile seizures b. Typically occur on the first day of a febrile illness c. Characterized by generalized tonic-clonic seizure activity d. Last less than 15 minutes with little or no postictal state e. May be a sign of a more serious problem, such as meningitis 2. Assess ABCs, provide cooling measures with tepid water, and provide prompt transport. a. All patients with febrile seizures need to be seen in the hospital setting. Drowning Emergencies and Management -In drowning emergencies, you must always take steps to ensure your own safety. 1. Drowning is the second-most-common cause of unintentional death among children aged 1 to 4 years in the United States. a. Children often fall into swimming pools and lakes, but many drown in bathtubs and even puddles or buckets of water. b. Older adolescents drown when swimming or boating; alcohol is frequently a factor. 2. Principal condition that results from drowning is lack of oxygen. a. Even a few minutes without oxygen affects the heart, lungs, and brain. b. Submersion in icy water can lead to hypothermia. c. Diving into water increases the risk of neck and spinal cord injuries. 3. Signs and symptoms will vary based on type and length of submersion. -Management of drowning emergencies Pediatric Trauma Emergencies and Management -Unintentional injuries are the number one killer of children in the United States. 1. Quality of care in the first few minutes after a child has been injured can have an enormous impact on that child’s chances for complete recovery. 2. The muscles and bones continue to grow well into adolescence. a. For this reason, coupled with their risk-taking approach to activities, adolescents are prone to fractures of the extremities. 3. A fracture of the femur is rare in pediatric patients, but when it does occur, it is a source of major blood loss. 4. Older children and adolescents are prone to long bone fractures (femur and humerus) because they tend to take more risks during physical activities. Physical differences 1. Children are smaller than adults, and therefore the location of their injuries may differ from that of an adult’s for the same type of crash. 2. Children’s bones and soft tissues are less well developed than those of an adult, and therefore the force of an injury affects these structures differently. a. Because a child’s head is proportionally larger than an adult’s, it exerts greater stress on the neck structures during a deceleration injury. Psychologic differences 1. Children are often injured because of their underdeveloped judgment and their lack of experience. 2. Always assume the child has serious head and neck injuries. Injury patterns 1. It is important for the EMT to understand the special physical and psychologic characteristics of children and what makes them more likely to have certain kinds of injuries. 2. Vehicle collisions a. Children playing or riding a bicycle can dart out in front of motor vehicles without looking. b. Children involved in these types of injuries typically sustain high-energy injuries to the head, spine, abdomen, pelvis, or legs. 3. Sport activities a. Children, especially those who are older/adolescents, are often injured in organized sports activities b. Head and neck injuries can occur after high-speed collisions in contact sports such as football, wrestling, ice hockey, field hockey, soccer, or lacrosse. c. Remember to immobilize cervical spine when caring for children with sport-related injuries. Injuries to specific body systems 1. Head injuries a. Head injuries are common in children because the size of a child’s head in relation to the body is larger than that of an adult. b. An infant also has a softer, thinner skull, which may result in injury to the brain tissues. c. The scalp and facial vessels can bleed very easily and may cause a great deal of blood loss if not controlled. d. Nausea and vomiting are common signs and symptoms of a head injury in children. 2. Chest injuries a. Usually the result of blunt rather than penetrating trauma b. Chest wall flexibility in children can produce a flail chest. 3. Abdominal injuries a. Abdominal injuries are common in children. b. All children with abdominal injuries should be monitored for signs and symptoms of shock, including a weak, rapid pulse; cold, clammy skin; decreased capillary refill; confusion; and decreased systolic blood pressure. c. If the patient shows signs and symptoms of shock, prevent hypothermia by keeping the patient warm with blankets. If the patient has bradycardia, ventilate. 4. Burns a. Burns to children are generally considered more serious than burns to adults. i. Infants and children have more surface area relative to total body mass, which means greater fluid and heat loss. ii. Children also do not tolerate burns as well as adults do. iii. Children are also more likely to go into shock, develop hypothermia, and experience airway problems. b. The most common ways in which children are burned are: i. Exposure to hot substances, such as scalding water in the bathtub ii. Hot items on a stove iii. Exposure to caustic substances such as cleaning solvents or paint thinners iv. Older children are more likely to be burned by flames from fire. c. Infection is a common problem following a burn injury in a child. i. Sterile techniques should be used in handling skin of children w/ burn wounds d. You should consider the possibility of child abuse in any burn situation. e. Severity of burns i. Minor: Partial-thickness burns involving less than 10% of body surface ii. Moderate: Partial-thickness burns involving 10% to 20% of body surface iii. Severe: Any full-thickness burn; a partial-thickness burn involving more than 20% of body surface; or any burn involving the hands, feet, face, airway, or genitalia f. Pediatric patients are managed in the same manner as adults. 5. Injuries of the extremities a. Children have immature bones with active growth centers. b. Growth of long bones occurs from the ends at specialized growth plates. i. Growth plates are potential weak spots. ii. Incomplete or greenstick fractures can occur. c. Generally, extremity injuries in children are managed in the same manner as those in adults. i. Painful deformed limbs with evidence of broken bones should be splinted. 6. Pain management a. The first step in pain management is recognizing that the patient is in pain. b. As some pediatric patients will be nonverbal or have a limited vocabulary, look for visual clues and use the Wong-Baker FACES pain scale. c. You are limited to the following pain interventions: i. Positioning, Ice packs, Extremity elevation Disaster Management -The JumpSTART triage system was developed for pediatric patients. 1. Intended for patients younger than age 8 years and weighing less than 100 lb. 2. There are four triage categories in the JumpSTART system, designated by colors corresponding to different levels of urgency. 3. Decision points include: a. Able to walk (except in infants) i. Green tag: minor, not in need of immediate treatment b. Presence of spontaneous breathing, with a peripheral pulse, and appropriately responsive to painful stimuli i. Yellow tag: delayed treatment c. Apnea responsive to positioning or rescue breathing; respiratory failure; breathing but without a pulse; or inappropriate painful response i. Red tag: immediate response d. Apneic and without pulse, or apneic and unresponsive to rescue breathing i. Black tag: considered deceased or expectant deceased RPM---> Respiratory rate, perfusion, mental status Child Abuse and Neglect -Child abuse means any improper or excessive action that injures or otherwise harms a child or infant. 1. Includes physical abuse, sexual abuse, neglect, and emotional abuse 2. Over half a million children are victims of child abuse annually. a. Many of these children suffer life-threatening injuries and some die. b. If suspected child abuse is not reported, the abuse is likely to happen again, perhaps causing permanent injury or even death. Signs of abuse 1. As an EMT you will be called to homes because of reported injury to a child. 2. Child abuse occurs in every socioeconomic status, so you must be aware of the patient’s surroundings and document your findings objectively. a. It is common for EMTs to be called to testify in abuse cases; it is essential to record all findings, including any statements made by caregivers or others on the scene. 3. Ask yourself the following questions: a. Is the injury typical for the developmental level of the child? b. Is the MOI reported consistent with the injury? 4. The mnemonic CHILD ABUSE may help you remember the points to look for. 5. Bruises→ Observe the color and location of any bruises. 6. Burns a. Burns to the penis, testicles, vagina, or buttocks are usually inflicted by someone else. b. Burns that encircle a hand or foot to look like a glove are usually inflicted by someone else. 7. Fractures a. Fractures of the humerus or femur do not normally occur without major trauma. b. Falls from a bed are not usually associated with fractures. 8. Shaken baby syndrome a. Infants may sustain life-threatening head trauma by being shaken or struck in the head. b. Shaking tears blood vessels in the brain, resulting in bleeding around the brain. 9. Neglect a. Neglect is refusal or failure on the part of the caregiver to provide life necessities. b. Children who are neglected are often dirty or too thin or appear developmentally delayed because of lack of stimulation. Symptoms and other indicators of abuse 1. Abused children may appear withdrawn, fearful, or hostile. a. You should be concerned if a child does not want to discuss how an injury occurred. 2. Occasionally, the parent or caregiver will reveal a history of “accidents.” a. Be alert for conflicting stories or a lack of concern from the caregiver. b. The abuser may be a parent, caregiver, relative, or friend of the family. 3. EMTs in all states must report suspected abuse. a. Most states have special forms to do so. b. Supervisors are generally forbidden to interfere with the reporting of suspected abuse. c. Law enforcement and child protection services will determine whether there is abuse. Sexual abuse 1. Children of any age and of either gender can be victims of sexual abuse. a. Maintain an index of suspicion regardless of the patient’s social or economic situation. 2. Assessment a. Should be limited to determining the type of dressing any injuries require b. Treat any bruises or fractures as well. c. Do not examine the genitalia unless there is evidence of bleeding or there is any injury that must be treated. d. Don’t allow child to wash, urinate, or defecate before physician completes physical exam e. Ensure that an EMT or police officer of the same gender remains with the child, unless locating one will delay transport. Sudden Infant Death Syndrome -The death of an infant or a young child is called sudden infant death syndrome (SIDS) when, after a complete autopsy, the death remains unexplained. 1. About 3,500 infants die of SIDS annually. a. The American Academy of Pediatrics recommends that a baby be placed on his or her back on a firm mattress, in a crib that is free of bumpers, blankets, and toys. b. The CDC recommends having the baby sleep in the same room, but not the same bed, chair, or sofa, as an adult. 2. Although it is impossible to predict SIDS, risk factors include: a. Mother younger than age 20 years b. Mother smoked during pregnancy c. Low birth weight 3. Death as the result of SIDS can occur at any time of day 4. You will face with three tasks: a. Assessment of the scene b. Assessment and management of the patient c. Communication and support of the family Patient assessment and management 1. An infant who has been a victim of SIDS will be pale or blue, not breathing, and unresponsive. 2. Common causes for such a condition 3. Begin with assessment of the ABCs. a. Provide interventions as necessary. b. Depending on how much time has passed, patient may show signs of postmortem changes. c. If child shows these signs, call medical control. d. If there is no sign of postmortem changes, begin CPR immediately. 4. As you assess the patient, pay special attention to any marks or bruises on the child before performing any procedures. a. Note any intervention that was done before your arrival. Scene assessment 1. Carefully inspect the environment, noting the condition of the scene where the infant was found. 2. Your assessment of the scene should concentrate on the following: a. Signs of illness, including medications, humidifiers, or thermometers b. The general condition of the house c. Signs of poor hygiene d. Family interaction e. The site where the infant was discovered Apparent life-threatening event 1. Infants who are not breathing and are cyanotic and unresponsive when found sometimes resume breathing and color with stimulation. a. These children have had what is called an apparent life-threatening event (ALTE). b. Classic ALTE is characterized by i. A distinct change in muscle tone ii. Choking or gagging c. After the event, the child may appear healthy and show no signs of illness or distress. i. You must complete a careful assessment and provide rapid transport to the ED. d. Pay strict attention to airway management. e. Assess the infant’s history and environment