Ch43 Pediatric Emergencies.docx

Chapter Pediatric Emergencies Unit Summary Children are not adults in small bodies They have distinctive anatomical differences medical problems specific to the pediatric population and require precise treatment Upon completion of this chapter the student will have an understanding of the anatomy phyisology psychological development epidemiology pathophysiology and management of pediatric medical and traumatic emergencies National EMS Education Standard Competencies Special Patient Populations Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment disposition plan for patients with special needs Pediatric Emergencies Age-related assessment findings and age-related and developmental stage-related assessment and treatment modifications for pediatric-specific major or common diseases and or emergencies Foreign body upper and lower airway obstruction pp - Lower airway reactive disease pp - Respiratory arrest distress failure pp - Shock pp - Seizures pp - Sudden infant death syndrome SIDS p Gastrointestinal disease pp - Bacterial tracheitis p Asthma p Bronchiolitis pp - Respiratory synctial virus RSV pp - Pneumonia p Croup pp - Epiglottitis p Hyperglycemia pp - Hypoglycemia p Pertussis p Cystic fibrosis p Bronchopulmonary dysplasia pp - Congenital heart disease pp - Hydrocephalus and ventricular shunts pp - Patients With Special Challenges Recognizing and reporting abuse and neglect pp - and see chapter Geriatric Emergencies Health care implications of Abuse pp - and see chapters Geriatric Emergencies and Patients With Special Challenges Neglect pp - and see chapters Geriatric Emergencies and Patients With Special Challenges Homelessness see chapter Patients With Special Challenges Poverty see chapter Patients With Special Challenges Bariatrics see chapter Patients With Special Challenges Technology dependent see chapter Patients With Special Challenges Hospice terminally ill see chapter Patients With Special Challenges Tracheostomy care dysfunction see chapter Patients With Special Challenges Home care see chapter Patients With Special Challenges Sensory deficit loss see chapter Patients With Special Challenges Developmental disability see chapter Patients With Special Challenges Trauma Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment disposition plan for an acutely injured patient Special Considerations in Trauma Recognition and management of trauma in Pregnant patient see chapter Obstetrics Pediatric patient pp - Geriatric patient see chapter Geriatric Emergencies Pathophysiology assessment and management of trauma in the Pregnant patient see chapter Obstetrics Pediatric patient pp - Geriatric patient see chapter Geriatric Emergencies Cognitively impaired patient see chapter Patients With Special Challenges Knowledge Objectives Explain some of the challenges inherent in providing emergency care to pediatric patients and why effective communication with both the patient and his or her family members is critical to a successful outcome p Describe the developmental stages of children including examples of each stage pp - Describe differences in the anatomy physiology and pathophysiology of the pediatric patient as compared with the adult patient and their implications for the health care provider pp - Describe the challenges in dealing with the stressed parents or caregivers of ill and injured children pp - Describe the steps in the primary assessment for providing emergency care to a pediatric patient including the elements of the pediatric assessment triangle PAT hands-on ABCs and transport decision considerations pp - Describe the steps in the secondary assessment including the systematic assessment which may include a full-body examination or a focused assessment on the body part or body system specifically involved pp - Describe the different causes of pediatric respiratory emergencies the signs and symptoms of increased work of breathing the difference between respiratory distress respiratory arrest and respiratory failure and the emergency medical care strategies used in the management of each pp - Describe upper airway emergencies in a pediatric patient including anaphylaxis croup epiglottitis and bacterial tracheitis their possible causes signs and symptoms and steps in the management of a child who is experiencing these conditions pp - List the steps in the management of foreign body airway obstruction of an infant and child pp - Describe lower airway emergencies in a pediatric patient including asthma bronchiolitis pneumonia and pertussis their possible causes signs and symptoms and steps in the management of a child who is experiencing these conditions pp - Discuss other respiratory conditions including cystic fibrosis and bronchopulmonary dysplasia their possible causes signs and symptoms and steps in the management of a child who is experiencing these conditions pp - Discuss the most common causes of shock hypoperfusion in a pediatric patient its signs and symptoms and emergency medical management in the field pp - Describe the procedure for establishing IV access in the pediatric patient pp - Discuss the steps to establish an IO infusion in pediatric patients pp - Describe common pediatric heart rhythm disturbances and how to manage each dysrhythmia pp - Discuss the most common causes of altered mental status AMS in a pediatric patient its signs and symptoms and emergency medical management in the field pp - List the common causes of seizures in a pediatric patient the different types of seizures and their emergency medical management in the field pp - List the common causes of meningitis patient groups who are at the highest risk for contracting it its signs and symptoms special precautions and emergency medical management in the field p Discuss the types of gastrointestinal emergencies that might affect pediatric patients including intussusception Meckel diverticulum and pyloric stenosis pp - Discuss the pathophysiology assessment and management of endocrine emergencies including hyperglycemia hypoglycemia and congenital adrenal hyperplasia pp - Describe conditions in which the pituitary produces inadequate amounts of some or all of its hormones pp - Describe special considerations in patients with childhood immunodeficiencies pp - Discuss hematologic disorders including sickle cell disease hemophilia and thrombocytopenia signs and symptoms special precautions and emergency medical management in the field pp - Discuss toxicologic emergencies in pediatric patients including common sources assessment findings and techniques for emergency medical management including decontamination and antidotes pp - Describe special considerations during the management of a pediatric behavioral or psychiatric emergency including safety precautions and assessment and management techniques pp - Discuss the common causes of a fever emergency in a pediatric patient and management techniques pp - Describe child abuse and neglect and its possible indicators and then describe the medical and legal responsibilities when caring for a pediatric patient who is a possible victim of child abuse pp - Discuss sudden infant death syndrome SIDS including its risk factors patient assessment and special management considerations related to the death of an infant patient p Discuss the common causes of pediatric trauma emergencies and differentiate between injury patterns in adults infants and children p Describe the procedure for performing needle decompression in the pediatric patient pp - List the steps to immobilize an infant and a child pp - Describe the indications for fluid and pain management for a pediatric trauma patient pp - Discuss the significance of burns in pediatric patients common causes and general assessment and management techniques pp - Describe the needs of technology-assisted children including the various types of medical technology used pp - Describe injury patterns and identify potential areas for intervention an prevention p Skills Objectives Demonstrate the steps for removal of an upper airway obstruction with Magill forceps p Demonstrate the steps for inserting an oropharyngeal airway in a child pp - Skill Drill Demonstrate the steps for inserting a nasopharyngeal airway in a child pp - Skill Drill Demonstrate how to perform bag-mask ventilation for an infant or child pp - Skill Drill Demonstrate the steps to perform endotracheal intubation in an infant or a child pp - Skill Drill Describe how to insert an orogastric and nasogastric tube in a pediatric patient including how to prepare the patient the equipment and assess the placement of the tubes pp - Demonstrate how to establish intraosseous access in pediatric patients pp - Skill Drill Demonstrate how to perform needle decompression in a child pp - Skill Drill Demonstrate how to immobilize a child who has been involved in a trauma emergency pp - Skill Drill Demonstrate how to immobilize an infant who has been involved in a trauma emergency pp - Skill Drill Readings and Preparation Review all instructional materials including Chapter of Nancy Caroline s Emergency Care in the Streets Seventh Edition and all related presentation support materials Consider reviewing material from one or more of the following textbooks ahead of time and summarizing the information for use with in-class discussion or other class activities APLS The Pediatric Emergency Medicine Resource by the American Academy of Pediatrics available at www jblearning com ISBN Pediatric Advanced Life Support by the American Heart Association Neonatal Resuscitation Program by the American Academy of Pediatrics Pediatric Trauma Life Support by the International Trauma Life Support Support Materials Lecture PowerPoint presentation Case Study PowerPoint presentation Skill Drill PowerPoint presentations Skill Drill - Inserting an Oropharyngeal Airway Skill Drill - Inserting a Nasopharyngeal Airway Skill Drill - One-Person Bag-Mask Ventilation for a Child Skill Drill - Performing Pediatric Endotracheal Intubation Skill Drill - Pediatric IO Infusion Skill Drill - Pediatric Needle Decompression Thoracentesis for a Tension Pneumothorax Skill Drill - Immobilizing a Child Skill Drill - Immobilizing an Infant Skill Evaluation Sheets Skill Drill - Inserting an Oropharyngeal Airway Skill Drill - Inserting a Nasopharyngeal Airway Skill Drill - One-Person Bag-Mask Ventilation for a Child Skill Drill - Performing Pediatric Endotracheal Intubation Skill Drill - Pediatric IO Infusion Skill Drill - Pediatric Needle Decompression Thoracentesis for a Tension Pneumothorax Skill Drill - Immobilizing a Child Skill Drill - Immobilizing an Infant Enhancements Direct students to visit the companion website to Nancy Caroline s Emergency Care in the Streets Seventh Edition at http www paramedic emszone com for online activities Invite a pediatrician to discuss how to perform a pediatric patient assessment Arrange a visit to a pediatric emergency department intensive care unit and or medical floor Content connections Children are not little as evidenced by their unique anatomical differences emotional development and illnesses Becaue their bodies are generally unaffected by the chronic illnesses of adulthood they can compensate for a longer period of time However students need to be reminded that a critically ill child can decompensate with little or no warning Organize illnesses disease processes and trauma-related injuries according to the appropriate age group This will provide the students the opportunity to link age groups with related health issues and reinforce how anatomy and illness are interrelated Cultural considerations A family s approach to caring for a sick child will be influenced by cultural practices For example the textbook referred to the Eastern practice of coining While this may appear to be an inappropriate reaction for those not familiar with this particular method of healing it is important to be respectful and objective when caring for the child Another area for consideration is how each culture views the death and dying of a child Take the time to research the different cultures within the local community and discuss the various methods of healing and coping techniques for death and dying Teaching Tips Bring children of various ages to class and allow the students to pratice communication and phyiscal assessment tools If possible invite a child who has a chronic illness such as custic fibrosis asthma or congenital heart disease to speak with the students and share how living with the disease affects their life Unit Activities Writing activities Assign each student a different illness or disease specific to pediatrics that was covered in the chapter Have them research and write a paper discussing the pathophysiology and implications for prehospital emergency care Student presentations Have the students present their research findings to the class Group activities Divide the class into small groups and have them arrange a community pediatric health fair to bring awareness to various health issues affecting children Visual thinking Include photos or video clips directly related to pediatric assessment illnesses and treatment in your presentation Pre-Lecture You are the Medic You are the Medic is a progressive case study that encourages critical-thinking skills Instructor Directions Direct students to read the You are the Medic scenario found throughout Chapter You may wish to assign students to a partner or a group Direct them to review the discussion questions at the end of the scenario and prepare a response to each question Facilitate a class dialogue centered on the discussion questions and the Patient Care Report You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper Lecture I Introduction A Children differ from adults in their anatomy physiology and emotions and experience a range of illnesses and injuries that varies across the pediatric age span Children perceive their illness or injury differently than adults Young children may not be able to report what is bothering them Fear or pain may hamper assessment Stressed or frightened parents and caregivers may also pose challenges Your approach to pediatric patients must be based on their age and accommodate their unique developmental and social issues II Developmental Stages A Neonate and infant Neonatal period First month of life Infancy First months of life Respect caregiver s perception that something is wrong a Watch for persistent crying irritability and lack of eye contact b May be a symptom of a serious problem such as i Bacterial infection ii Cardiac problem iii Depressed mental status iv Electrolyte disturbance Nonspecific concerns about behavior feeding sleep pattern or arousability can indicate a serious underlying illness or injury Increased mobility can lead to injury Consider possible abuse with behaviors that don t match developmental stage Considerations for patient assessment include the following a Choose the best location b Keep child warm c Support a young infant s head and neck d Older infants in stable condition will be calmest in a parent s arms e Warm hands stethoscope f Be opportunistic with exam use a soft voice smile g If child is quiet listen to heart and lungs first h A pacifier or gloved finger to suck on may quiet a crying child i Jingling keys or shining a penlight may distract an older infant j No small objects i Risk of aspiration B Toddler Toddler period includes ages to years a Includes the terrible twos b Not capable of reasoning c Poorly developed sense of cause and effect d Language development is occurring rapidly e Growing ability to crawl walk run and climb f Painful procedures may make lasting impressions Use the Pediatric Assessment Triangle PAT to measure the child s interactions with the caregiver vocalizations and mobility Strategies for examining a toddler include the following a Examine a toddler in stable condition on parent s lap i Avoids separation anxiety b Get down to the child s level c Talk to the child d Have a parent assist when possible to deal with stranger anxiety e Use play and distraction when possible i For example listen to a doll s chest first f Offering choices helps child feel in control i Answer to yes no questions is likely to be No g Consider saving upsetting or painful steps for last h Be flexible full head-to-toe exam may not be possible C Preschool-age child Ages to years Rapidly becoming verbal and active a Can understand directions b Generally able to tell you what hurts c Choose words carefully preschoolers are literal d Use plain language provide lots of reassurance fears are common Curious want to cooperate Respect modesty by keeping them covered Let child participate or hold equipment that is safe a Offer simple choices i Avoid yes no questions Avoid procedures on the dominant hand or arm Tantrums may occur when they feel a lack of control Set limits on behavior if the child acts out D School-age child middle childhood Ages to years Capable of abstract thought understand cause and effect School is important focus on popularity and peer pressure a Children with chronic illness or disabilities can be self-conscious Understanding of death may increase anxiety They may have their own ideas about medical care By age years anatomy and physiology are similar to those of adults a Breasts develop between ages and years b Menstrual period begins between ages and years c Testicles increase in the size around age years d May be self-conscious about body image Ask child to describe history leading to - - call and symptoms Explain steps in simple language answer questions Offer appropriate choices and control reassurance encouragement Provide simple explanations about causes and treatment of pain Respect modesty Asking about school pets and so on may provide a distraction a Ask caregiver s advice in choosing a topic Rewarding the child after completing a procedure can help E Adolescence Ages to years Can be difficult struggling with independence as well as social and personal issues With respect to CPR and foreign body airway obstruction procedures once secondary sexual characteristics have developed breasts or facial axillary hair treat an adolescent as an adult During assessment address and reassure the patient a Alienating the patient may interfere with assessment and treatment b Encourage questions and involvement c Address all concerns and fears d Provide accurate information a teen may become alienated and uncooperative if you are suspected of being misleading e Respect patient privacy f If possible address the adolescent without a caregiver present i Especially about sensitive topics such as sexuality or drug use ii Patient may want friends present Let patient have as much control as appropriate Maintain scene safety III Pediatric Anatomy Physiology and Pathophysiology A Anatomic and physiologic differences can create difficulties with your assessment if you do not understand them B The head Infants and young children s heads are large relative to the rest of their bodies a An infant s head is two thirds its adult size b Large surface area means more mass relative to the rest of the body c Important factor in the incidence of head injuries i Tend to lead with their head in a fall d Traumatic brain injury is the leading cause of death and significant disability in pediatric trauma patients Take care when positioning the airway because of proportionally larger occiput a Seriously injured younger than years Place a thin layer of padding under the back to obtain neutral position b Seriously ill younger than years Place a folded sheet under occiput to obtain sniffing position Large head means more surface area for heat loss a Keep covered for warmth During infancy the anterior and posterior fontanelles are open a Areas where the infant s skull bones have not fused together b Allow compression of the head during birth and rapid growth of the brain c Posterior fontanelles close by age months d Anterior fontanelles close by age year e Important anatomic landmark when assessing a sick or injured infant i Bulging suggests increased intracranial pressure ii Sunken fontanelles suggest dehydration C The neck and airway Children have short stubby necks a Can be difficult to feel carotid pulse or see jugular veins Airway is much smaller than an adult airway a More prone to obstruction by i Foreign body inhalation ii Inflammation with infection iii Disproportionately large tongue During the first few months of life infants are obligate nose breathers a Nasal obstruction with mucus can result in significant respiratory distress Epiglottis a Long and floppy b U-shaped c Narrow d Extends at a angle into the airway e Difficult to visualize the vocal cords during intubation Narrowest part of a young child s airway occurs at the level of the cricoid cartilage a Below the vocal cords rather than at the vocal cords as in adults b Influences your choice of endotracheal ET tubes Remember the following a Keep nares clear with suctioning in infants younger than months b Tracheal cartilage is softer and more collapsible avoid hyperextension of neck i May result in reverse hyperflexion kinking of the trachea ii May displace the tongue posteriorly obstructing the airway c Keep the airway clear of all secretions i Even a small amount of particulate matter may cause obstruction d Use care when managing the airway eg inserting airway adjuncts i Jaw is smaller ii Soft tissues are delicate and prone to swelling e Correct positioning can often maintain airway and negate the use of adjuncts D The respiratory system Tidal volume is slightly smaller than in adults but metabolic oxygen demand is doubled Functional residual capacity is smaller a Result is proportionally smaller oxygen reserves Functional residual capacity Volume of air in the lungs following exhalation a Also referred to as oxygen reserve Infants breath faster than older children a Lungs can better handle oxygen exchange as child ages b to breaths min is normal for newborns c Rate for teens is closer to adult range Higher respiratory rate and oxygen demand raise risk for effects from inhaled toxins a Proportionately larger amount of toxic fumes typically inhaled b Causes symptoms sooner Infants use the diaphragm not chest muscles during inspiration a Any pressure on the abdomen of an infant or young child can block diaphragm movement cause respiratory compromise Young children experience muscle fatigue much more quickly than older children a Can lead to respiratory failure if a child has had to breathe hard for long periods Infants and children especially during respiratory distress are highly susceptible to hypoxia because of a Decreased functional residual capacity b Increased oxygen demand c Easily fatigued respiratory muscles Infants and children will develop hypoxia rapidly with apnea and ineffective bagging a Can spiral into cardiovascular collapse b Use a larger bag if needed c Use only enough pressure to achieve visible chest rise in order to avoid pneumothorax d Bag s volume should have no less than - mL E The cardiovascular system You must know normal pulse rate ranges for children a Children rely mainly on pulse rate to maintain adequate cardiac output and compensate for decreased oxygenation b Infant s pulse rate can be beats min or more when compensating for injury or illness Children have limited but vigorous cardiac reserves a Proportionally larger circulating blood volume compared with adults b Absolute blood volume is less approximately mL kg c Ability to constrict blood vessels vasoconstriction keeps vital organs perfused Injured children can maintain blood pressure for longer periods than adults even though they are in shock hypoperfusion a Proportionally larger volume of blood loss must occur in children before hypotension develops Suspect shock when an infant or child presents with tachycardia Bradycardia usually indicates severe hypoxia a Manage aggressively Hypotension in a child is an ominous sign a Often indicates impending cardiopulmonary arrest Constriction of the blood vessels can be so profound that blood flow to the periphery of the body diminishes a Signs of vasoconstriction can include i Weak peripheral for example radial pulses ii Delayed capillary refill in children younger than years iii Pale cool extremities The heart a Circulation in the fetus is very different than in the newborn i Large right-sided forces on the electrocardiogram ECG are normal in young infants b During the first year of life the ECG axis and voltages shift to reflect left ventricular dominance c Cardiac output is rate dependent in infants and young children i Relatively poor ability to increase stroke volume is reflected in their normal pulse rates and in rate response to physiologic stress and hypovolemia d Pediatric mediastinum is more mobile than adults i High risk of injury to mediastinal organs ii May not be immediately evident on exam e Cardiac tamponade can present with muffled heart tones f Cardiac contusions can cause dysrhythmias F The nervous system Continually develops throughout childhood Until it is fully developed neural tissue and vasculature are fragile easily damaged prone to bleeding from injury Brain and spinal cord are not as well protected in children a Takes less force to cause brain and spinal cord injuries b Brain injuries are frequently more devastating Subarachnoid space is relatively smaller than adult s a Less cushioning effect for the brain b Head momentum may cause bruising and damage i Eg shaken baby syndrome Pediatric brain requires nearly twice the cerebral blood flow as an adult s a Makes even minor injuries significant b Increases risk of hypoxia i Hypoxia and hypotension exacerbate head injuries causing ongoing damage Brain continues to develop rapidly after birth a Responses become more organized and purposeful The spinal column a Develops along with the child b In young children the cervical spine fulcrum is higher because head is heavier i Closer to C -C c As child grows fulcrum descends to adult level i Around C through C d Infant who sustains blunt head trauma involving acceleration-deceleration forces is at high risk for a fatal high cervical spinal injury e School-age child will likely sustain a lower cervical spinal injury may be paralyzed Vertebral fractures and spinal cord injuries in young children are uncommon a Spinal ligaments and joint capsules are more lax i Increased mobility and cord injury in the absence of identifiable vertebral bony fracture or dislocation b Vertebral bodies are aligned anteriorly and can slide forward i Potential for cord damage with significant forward flexion Thoracic and lumbar spinal injuries are relatively uncommon a Seen in children in association with specific mechanisms i Seat belt-associated lumbar spine injuries often associated with abdominal injury ii Compression fracture due to axial loading in a fall b With a significant mechanism of injury MOI i Assume cervical spine injury ii Transport with spinal immobilization G The abdomen and pelvis Abdominal injuries are the second leading cause of serious trauma in children after head injuries Abdominal organs are situated more anteriorly a Less protected by ribs b Closer together as compared with an adult Organs eg liver and spleen are relatively large a Vulnerable to blunt trauma Abdominal distention in a healthy infant is due to two factors a Weak abdominal muscles b Larger solid organs Liver and spleen extend below rib cage in young children a Less bony protection b Rich blood supply so injuries can result in large blood losses Kidneys are also more vulnerable to injury a More mobile b Less well supported Duodenum and pancreas are likely to be damaged in handlebar injuries Even seemingly insignificant forces can cause serious internal injury a Multiple organ injuries are common Pelvic fractures are relatively rare a Generally seen only with high-energy MOIs b Risk increases in adolescence when skeleton and MOIs become more like those of adults H The musculoskeletal system Reaching adult height requires active bone growth Growth plates ossification centers of a child s bones a Made of cartilage b Relatively weak c Easily fractured Bones of growing children are weaker than their ligaments and tendons a Makes fractures more common than sprains Joint dislocations without associated fractures are not common Most growth plates will be closed by late adolescence Growth plate fractures a Can be seen with low-energy MOIs b May be lacking the degree of tenderness swelling and bruising usually associated with a broken bone Immobilize all sprains or strains and suspect fractures a Growth plate injuries may result in poor bone growth I The chest and lungs Chest trauma Third leading cause of serious injury in pediatric trauma Child s chest wall is quite thin a Less musculature and subcutaneous fat to protect ribs and organs Ribs are more pliable and flexible than an adult s a Can lead to significant intrathoracic injury with minimal external findings Children have fewer rib fractures and flail chest events Injuries to thoracic organs may be more severe a Pliable rib cage and fragile lung tissue are more easily compressed during blunt trauma b Children are more vulnerable to i Pulmonary contusions ii Cardiac tamponade iii Diaphragmatic rupture Lungs are prone to pneumothorax from excessive pressures during bag-mask ventilation Thin chest wall makes it easy to hear heart and lung sounds a However pneumothoraces and esophageal intubations are often missed due to sounds readily transmitted throughout the chest Rib cage is more compliant making retractions easy to see Look for signs of chest injuries with suspected chest trauma a Note that signs of pneumothorax or hemothorax in children are often subtle b May not see signs such as jugular vein distention c May be difficult to determine tracheal deviation J The integumentary system Infants and children have a Thinner more elastic skin b Larger body surface area BSA weight ratio c Less subcutaneous fatty tissue These factors contribute to a Increased risk of injury following exposure to temperature extremes b Increased risk of hypothermia can complicate resuscitative efforts and dehydration c Increased severity of burns i Many burns that would be minor or moderate in adults are severe in children Relatively large surface area predisposes infants and young children to hypothermia K Metabolic differences Limited stores of glycogen and glucose are rapidly depleted as a result of injury or illness a Be suspicious of hypoglycemia b Check blood glucose levels with lethargy seizures or decreased activity Children are highly susceptible to hypothermia due to lowered glucose a Large BSA weight ratio further increases risk Newborns lack the ability to shiver way of producing heat a Hypothermia is a serious risk i May predispose the newborn to spontaneous bleeding in the head Significant hypovolemia and electrolyte derangements are more common as a result of severe vomiting and diarrhea Keep the child warm during transport prevent the loss of body heat a Cover the head source of significant heat loss Newborns requiring aggressive resuscitation after delivery should not be overly warmed because this can worsen their neurologic outcome IV Parents of Ill or Injured Children A Most children will have at least one caregiver present meaning you will be dealing with more than one patient even if only the child is ill or injured Serious illness or injury to a child is one of the most stressful situations for caregivers a They may react with anger or fear Establishing a rapport with caregivers is vital a They are a source of important information and assistance b Children look to their parents when they are frightened and often mimic their response i Calming a parent may help the patient Approach caregivers in a calm quiet professional manner a Enlist their help in caring for the child b Explain what you are doing c Provide honest reassurance and support d Do not blame the parent e Transport at least one caregiver with the child Comfort an emotional parent but remember that your first priority is the child a Do not let a distraught or aggressive parent interfere with your care b Enlist the help of other family members or law enforcement if needed V Pediatric Patient Assessment A Your assessment like your general approach will differ somewhat with pediatric patients You may need to adapt your assessment skills Use age-appropriate equipment Review age-appropriate vital signs B Scene size-up On the way to the scene prepare for a pediatric scene size-up equipment use and assessment a Collect information from dispatch b Take appropriate standard precautions i Observe for hazards ii Resist the temptation for hasty assessment because you know the patient is a child a Personal safety is your priority c Note child s position d Look for clues to MOI or NOI i Helps guide assessment and management priorities ii Should enable you to determine severity e When a child is unable to communicate or is unresponsive assume MOI was significant enough to cause head or neck injuries i Immobilize spine with a cervical collar ii Place a pad under head and or shoulders to facilitate airway management f Note any pills medicine bottles alcohol drug paraphernalia or household chemicals that would suggest toxic exposure or possible ingestion g Carefully observe the scene or vehicle if involved for clues to the potential severity of any injuries h Do not discount the possibility of abuse i The following should increase your suspicion for abuse i Conflicting information from parents or caregivers ii Bruises or other injuries that are not consistent with the MOI described iii Injuries that are not consistent with the child s age and developmental abilities j Note parents or caregivers interaction with the child i Do they appear to be appropriately concerned angry or indifferent ii Does the child seem comforted by their presence or scared by them C Primary assessment Use the Pediatric Assessment Triangle to form a general impression a After ensuring scene safety begin with your general impression of how the patient looks sick-not sick classification b Pediatric Assessment Triangle PAT helps you form a from-the-doorway impression and distinguish between sick and not-sick patients i Standardized approach with three elements appearance work of breathing and circulation a - to -second assessment that paints an accurate clinical picture of cardiopulmonary status and level of consciousness b Conducted prior to assessing ABCs c Does not require touching the patient d Rapid hands-off systematic approach to observing an ill or injured child e Helps establish urgency for treatment or transport c Appearance i First element of PAT ii Often the most important factor in determining the severity of illness need for treatment and response to therapy iii Reflects adequacy of ventilation oxygenation brain perfusion body homeostasis and central nervous system CNS function iv TICLS tickles mnemonic highlights the most important features of a child s appearance a Tone b Interactiveness c Consolability d Look or gaze e Speech or cry v You can also evaluate level of consciousness by using the AVPU scale modified as necessary for the child s age vi Observe from a distance allowing child to interact with caregiver vii Use TICLS mnemonic while observing from the doorway viii Delay touching the patient until you have formed a general impression your touch may agitate the child ix Unless a child is unconscious or critically ill take your time in assessing appearance by observation x Abnormal appearance may result from numerous physiologic abnormalities a Inadequate oxygenation or ventilation as in respiratory emergencies b Inadequate brain perfusion as from cardiovascular emergencies c Systemic abnormalities or metabolic derangements such as with poisoning infection or hypoglycemia d Acute or chronic brain injury xi A child with a grossly abnormal appearance is seriously ill and requires immediate life-support interventions and transportation a The remainder of PAT plus hands-on assessment ABCs may help identify the cause severity and need for treatment and transportation d Work of breathing i Often a better assessment of oxygenation and ventilation status than auscultation or respiratory rate ii Reflects child s attempt to compensate for abnormalities in oxygenation ventilation a Proxy for effectiveness of gas exchange iii Hands-off assessment includes listening for abnormal airway sounds and looking for signs of increased breathing effort iv Some abnormal airway sounds can be heard without a stethoscope and can indicate the likely physiology and anatomic location of the breathing problem a For example snoring muffled or hoarse voice or stridor can indicate obstruction at the level of the oropharynx glottis or supraglottic structures or glottis or subglottic structures respectively b May result from croup bacterial upper airway infections bleeding or edema v Lower airway obstruction is suggested by abnormal grunting or wheezing vi Grunting is a form of auto-PEEP positive end expiratory pressure a A way to distend lower respiratory air sacs or alveoli to promote maximum gas exchange b Involves exhaling against a partially closed glottis c Short low-pitched sound d Best heard at the end of exhalation e Often mistaken for whimpering f Suggests moderate to severe hypoxia g Seen with lower airway conditions such as pneumonia and pulmonary edema h Reflects poor gas exchange because of fluid in the lower airways and air sacs vii Wheezing is a musical tone caused by air being forced through constricted or partially blocked small airways a Often occurs during exhalation only b Can occur during inspiration and expiration during severe asthma attacks c Often heard only by auscultation though severe obstruction may result in wheezing that is audible without a stethoscope viii Abnormal positioning and retractions are physical signs of increased work of breathing a Easily assessed without touching the patient ix Sniffing position Child is trying to align the axes of the airways to improve patency and increase air flow a Often reflects a severe upper airway obstruction x Child who refuses to lie down or leans forward on outstretched arms tripoding is creating the optimal mechanical advantage to use accessory muscles of respiration xi Retractions The recruitment of accessory muscles of respiration to provide more muscle power to move air into the lungs in the face of airway or lung disease or injury a To observe expose the chest b More useful measure of work of breathing in children than in adults because a child s chest wall is less muscular so inward excursion of skin and soft tissue between the ribs is more apparent c May be evident in the supraclavicular area above the clavicle the intercostal area between the ribs or substernal area under the sternum xii Head bobbing Form of retractions seen only in infants a Use of neck muscles to help breathing during severe hypoxia b Neck extends during inhalation head falls forward during exhalation xiii Nasal flaring Exaggerated opening of the nostrils during labored inspiration a Indicates moderate to severe hypoxia xiv Combine the characteristics of work of breathing to make your general assessment of oxygenation and ventilation status a Abnormal airway sounds b Abnormal positioning c Retractions d Nasal flaring xv Together with appearance work of breathing suggests a Severity of illness b Likelihood that the cause is in the airway or is a respiratory process e Circulation to skin i Goal of rapid circulatory assessment Determine adequacy of cardiac output and core perfusion ii When cardiac output diminishes the body shunts circulation from nonessential areas eg skin toward vital organs a Circulation to skin reflects overall status of core circulation iii Three characteristics considered a Pallor b Mottling c Cyanosis iv Pallor paleness may be the initial sign of poor circulation or the only visual sign with compensated shock a Indicates reflex peripheral vasoconstriction that is shunting blood toward the core b May also indicate anemia or hypoxia v Mottling reflects vasomotor instability in the capillary beds demonstrated by patchy areas of vasoconstriction and vasodilation a May also be a physiologic response to a cold environment vi Cyanosis a bluish discoloration of the skin and mucous membranes is the most extreme visual indicator of poor perfusion or poor oxygenation a Acrocyanosis blue hands or feet in an infant younger than months is distinct from cyanosis Normal finding when a young infant is cold b True cyanosis is seen in the skin and mucous membranes Late finding of respiratory failure or shock vii After assessing appearance and work of breathing look for pallor mottling cyanosis viii Combine the three pieces of PAT to estimate severity of illness and the likely underlying pathologic cause a Abnormal appearance with poor circulation may indicate shock from a cardiovascular cause f Stay or go i Use PAT findings to determine whether patient is stable or requires urgent care ii If unstable a Assess ABCs b Treat life threats c Transport immediately iii If stable perform the entire patient assessment process Hands-on ABCs a After PAT complete primary assessment i Assess ABCs and mental status ii Prioritize care and need for transport b Manage threats to ABCs as you find them i Prioritize sequence of life-support interventions to reverse critical physiologic abnormalities c ABC steps are the same as with adults but with differences related anatomy physiology and signs of distress i If you suspect cardiac arrest which is rare the order is CAB ii Chest compressions would be the priority d Also assess disability and exposure e Early in the assessment estimate child s weight i Much of your care will depend on child s size ii Best method is pediatric resuscitation tape measure Broselow tape or length-based resuscitation tape a Also provides medication doses and equipment sizes b Estimates weight and height in pediatric patients weighing up to lb kg c To use follow these steps Measure child s length from head to heel with the tape red portion at the head Note the weight in kilograms that corresponds to the measured length at the heel If child is longer than the tape use adult equipment and medication doses From the tape identify appropriate equipment sizes and medication doses f Airway i PAT may suggest an airway obstruction based on abnormal airway sounds and increased work of breathing ii Determine whether the airway is open and patient has adequate chest rise with breathing iii Check for mucus blood or a foreign body in the mouth or airway iv If there is potential obstruction from the tongue or soft tissues position the airway and suction as necessary v Determine whether airway is open and patent partially obstructed or totally obstructed vi Do not keep the suction tip or catheter in the back of a child s throat too long because young patients are extremely sensitive to vagal stimuli and the pulse rate may plummet g Breathing i Breathing component of primary assessment involves the following a Calculate the respiratory rate b Auscultate breath sounds c Check pulse oximetry for oxygen saturation ii Verify the respiratory rate per minute by counting the number of chest rises in seconds and then doubling that number iii Healthy infants may show periodic breathing or variable respiratory rates with short periods of apnea s a Counting for only to seconds may give a falsely low respiratory rate iv Interpreting the respiratory rate requires knowing the normal values for the child s age and putting the respiratory rate in context with the rest of the primary assessment a Rapid respiratory rates may reflect high fever anxiety pain or excitement b Normal rates may occur in a child who has been breathing rapidly with increased work of breathing and is becoming fatigued c Serial assessment may be useful trend may be more accurate than a single value v Auscultate breath sounds with a stethoscope over the midaxillary line to hear abnormal lung sounds during inhalation and exhalation vi Listen for extra breath sounds such as inspiratory crackles wheezes or rhonchi a Rhonchi often indicate harsh breath sounds or sounds that may be transmitted from the upper airways vii If you cannot determine whether the sounds are being generated in the lungs or upper airway hold the stethoscope over the nose or trachea and listen a Listen for adequacy of air movement b Diminished breath sounds may signal severe respiratory distress c Auscultation over the trachea may help distinguish stridor from other sounds viii Check pulse oximetry reading to determine oxygen saturation while child breathes ambient air a Place the probe on a young child s finger same as adult b Infants or young children may try to remove the probe it may be helpful to place the probe on a toe possibly with a sock covering it c Greater than saturation while breathing room air indicates good oxygenation ix Evaluate pulse oximetry reading in the context of PAT and primary assessment a A child with a normal pulse oximetry reading may be expending increasing amounts of energy and increasing work of breathing to maintain oxygen saturation b Primary assessment would identify the respiratory distress and point to the need for immediate intervention despite the normal oxygen saturation level h Circulation i Integrate information from PAT about circulation with pulse rate quality and skin CTC color temperature and condition plus capillary refill time to obtain an overall assessment of circulatory status ii Listen to the heart or feel pulse for seconds double the number to get pulse rate iii It is important to know normal pulse rates based on age iv Interpret the pulse rate within the context of the overall history and primary assessment v Tachycardia may indicate early hypoxia or shock or a less serious condition such as fever anxiety pain or excitement vi Feel for the pulse to ascertain the rate and quality of pulsations a If you cannot find a peripheral distal pulse that is radial or brachial feel for a central pulse that is femoral or carotid b Check the femoral pulse in infants and young children and the carotid pulse in older children and adolescents vii Start CPR if there is no pulse viii After checking the pulse rate do a hands-on evaluation of skin CTC a Check whether the hands and feet are warm or cool to the touch b Check capillary refill time in the fingertip toe heel or pads of the fingertips Normal time is seconds or less c Put CTC information in context because cool extremities and delayed capillary refill are commonly seen in a child in a cool environment i Disability i Use the AVPU scale or Pediatric Glasgow Coma Scale to assess level of consciousness ii Assess pupillary response to a beam of light to assess brainstem response a Note if dilated constricted reactive or fixed iii Evaluate motor activity looking for symmetric movement of the extremities seizures posturing or flaccidity iv Combine this information with PAT results to determine neurologic status v Inadequate treatment of pain is common with children and has many adverse effects a Pain causes morbidity and misery for the child and caregivers b It interferes with your ability to accurately assess physiologic abnormalities c Children who do not receive appropriate analgesia may be more likely to have exaggerated pain responses to subsequent painful procedures d Post-traumatic stress may be more common among children who experience pain during an illness or injury vi Assessment of pain must consider developmental age a The ability to identify pain improves with age b In infants and preverbal children it may be difficult to distinguish crying and agitation due to hypoxia hunger or pain c Further assessment and discussion with caregivers are essential d Pain scales such as the Wong-Baker FACES scale may prove helpful vii Remaining calm and providing quiet professional reassurance to parents and child is critical for managing pediatric pain and anxiety viii Techniques for reducing pain include a Distraction techniques with toys or stories b Visual imagery techniques and music c Sucrose pacifiers in neonates ix Pharmacologic methods for reducing pain are available in a number of EMS systems a Eg acetaminophen opiates benzodiazepines and nitrous oxide x Weigh the benefits of analgesics or anxiolytics against risks including potential route of administration a Respiratory depression bradycardia hypoxemia and hypotension are potential side effects of sedatives b Intravenous medications are often most effective but require establishing IV access which is a painful procedure xi Assessment and management of pain and anxiety is part of vital sign assessment and field care a Requires a thorough understanding of nonpharmacologic techniques drugs potential drug contraindications and complications and management of complications j Exposure i Proper exposure is needed to complete the primary assessment a At least partial undress to assess the work of breathing and circulation ii Perform a rapid exam of the entire body to look for unsuspected injuries and anatomic abnormalities iii Avoid heat loss especially in infants a Cover child as soon as possible b Keep temperature in the ambulance high c Use blankets when necessary Transport decision a After completing the primary assessment and beginning resuscitation when necessary you must make a crucial decision immediate transport or continued assessment and treatment on scene i Immediate transport is imperative if the emergency call is for trauma and the child has one of the following a Serious MOI b Physiologic abnormality c Potentially significant anatomic abnormality d Scene is unsafe ii In these cases manage all life threats and begin transport iii Attempt vascular access on the way to the ED iv If the call is for an illness the decision to stay or go is less clear and depends on the following factors a Expected benefits of treatment b EMS system regulations c Comfort level d Transport time D History taking If the child seems to be in physiologically unstable condition you may decide to transport immediately and conduct history taking and secondary assessment en route to the ED a Goals i Elaborate on chief complaint OPQRST ii Obtain patient history SAMPLE E Secondary assessment The secondary assessment is systematic and may include a full-body examination or a focused assessment and a complete set of baseline vital signs using monitoring devices as appropriate a Full-body examination i For infants toddlers and preschool-age children start at the feet and end at the head ii For older children use the head-to-toe approach iii Tailor the exam to the child s age and developmental stage The extent of the examination will depend on the situation and may include the following a Head i The younger the infant or child the larger the head is in proportion to the rest of the body increasing the risk for head injury with deceleration eg motor vehicle crashes ii Look for bruising swelling and hematomas iii Significant blood can be lost between the skull and scalp of a small infant iv Fontanelle a Bulging suggests elevated intracranial pressure caused by meningitis encephalitis or intracranial bleeding b Sunken appearance suggests dehydration b Pupils i Note size equality and reactivity to light ii Response is a good indication of brain function particularly with trauma c Nose i Young infants prefer to breathe through their nose so nasal congestion with mucus can cause respiratory distress ii Gentle bulb or catheter suction of the nostrils may bring relief d Ears i Look for drainage from the ear canals ii Leaking blood suggests a skull fracture iii Check for bruises behind the ear or Battle sign a late sign of skull fracture iv Pus may indicate an ear infection or perforation of the eardrum e Mouth i In the trauma patient look for active bleeding and loose teeth ii Note the smell of the breath a Some ingestions are associated with identifiable odors such as hydrocarbons b Acidosis as in diabetic ketoacidosis may impart an acetone-like smell f Neck i Examine the trachea for swelling or bruising ii Note if the patient cannot move his or her neck and has a high fever a May indicate bacterial or viral meningitis g Chest i Examine for penetrating injuries lacerations bruises or rashes ii With injury feel the clavicles and every rib for tenderness and or deformity h Back i Inspect for lacerations penetrating injuries bruises or rashes i Abdomen i Inspect for distention ii Palpate gently watch for guarding or tensing of the abdominal muscles a May suggest infection obstruction or intra-abdominal injury iii Note tenderness or masses iv Look for seat belt abrasions or bruising j Extremities i Assess for symmetry ii Compare both sides for color warmth size of joints swelling and tenderness iii Put each joint through full range of motion while watching the eyes of the pediatric patient for signs of pain unless there is obvious deformity suggesting a fracture k Capillary refill in children younger than years i Normal time should be seconds or less ii Assess by blanching the finger or toenail beds soles of the feet may also be used iii Cold temperatures will increase capillary refill time making it a less reliable sign l Level of hydration i Assess skin turgor a Note the presence of tenting a condition in which the skin slowly retracts after being pinched and pulled away slightly from the body ii In infants note whether the fontanelles are sunken or flat iii Ask parent how many diapers the infant has soiled over the last hours iv Determine whether the child is producing tears when crying v Note the condition of the mouth a Is the oral mucosa moist or dry Attempt to take the child s blood pressure on the upper arm or thigh although accurate measurement may be difficult due to lack of cooperation and need for proper cuff size a Make sure the cuff has a width two thirds the length of the upper arm or thigh b One formula for determining the lower acceptable limit in children ages to years minimal systolic blood pressure X age in years i Eg a -year-old should have a minimal systolic blood pressure of ii Lower rate indicates decompensated shock iii Given the technical difficulty make one attempt a If unsuccessful move on to the rest of the assessment F Reassessment Includes the following a PAT b Patient priority c Vital signs i Unstable condition Every minutes ii Stable condition Every minutes d Assessment of the effectiveness of interventions i Eg medications administered splints applied bleeding controlled e Reassessment of the focused exam areas Reassess all patients to observe their response to treatment guide ongoing treatments and track the progression of identified pathologic and anatomic problems a New problems may also be identified b May guide the choice of transport destination and communications with medical oversight or ED staff VI Pathophysiology Assessment and Management of Respiratory Emergencies A You will frequently encounter respiratory problems in children who range from mildly ill to near death In pediatrics respiratory failure and arrest precede the majority of cardiopulmonary arrests by contrast a primary cardiac event is the usual cause of sudden death in adults Early identification and intervention can stop the progression from respiratory distress to cardiopulmonary failure and help to avert much pediatric morbidity and mortality B Respiratory arrest distress and failure First determine severity a Distress failure or arrest b Keep anatomic and physiologic respiratory differences in mind Respiratory distress entails increased work of breathing to maintain oxygenation and or ventilation a A compensated state in which increased work of breathing results in adequate pulmonary gas exchange b Classified as mild moderate or severe c Hallmarks i Retractions suprasternal intercostal subcostal ii Abdominal breathing iii Nasal flaring iv Grunting Respiratory failure a Patient can no longer compensate for underlying pathologic or anatomic problem by increased work of breathing i Hypoxia and or carbon dioxide retention occur b Signs may include i Decreased or absent retractions due to chest wall muscle fatigue ii Altered mental status due to inadequate oxygenation and ventilation of the brain iii Abnormally low respiratory rate c A decompensated state d Requires urgent intervention e Assist ventilations if tidal volume or respiratory effort is inadequate Respiratory arrest a Patient is not breathing spontaneously b Administer immediate bag-mask ventilation with supplemental oxygen to prevent cardiopulmonary arrest c Resuscitation of a child is often successful usually fails with cardiopulmonary arrest Use PAT to determine severity before touching the patient a Appearance gives clues about the adequacy of CNS oxygenation and ventilation i If a child with trouble breathing is sleepy assume the child is hypoxic b Assess work of breathing by noting the following i Patient s position of comfort ii Presence or absence of retractions iii Grunting or flaring c A patient who prefers to sit upright in the sniffing position or to use arms for support is trying to optimize breathing mechanics d Deep retractions herald the use of accessory muscles e Look for pallor or cyanosis provides further information on adequacy of oxygenation For respiratory emergencies focus on the child s airway and breathing a Assess the airway i Listen for stridor in awake patients ii Check for obstruction in obtunded patients b Assess breathing i Determine respiratory rate ii Listen to the lungs for adequacy of air entry and abnormal breath sounds iii Check pulse oximetry c With respiratory rate too low may be more worrisome than too high d Abnormal breath sounds may identify the anatomic or pathologic abnormality and suggest a likely diagnosis For example i Symmetric diffuse wheezing implies bronchospasm and possibly asthma ii Diffuse rhonchi rales and wheezing in an infant or toddler are typical signs of lower airway inflammation associated with bronchiolitis e Stridor with clear lung fields is consistent with upper airway obstruction often due to croup f Poor air entry with decreased breath sounds is an ominous sign that must be addressed immediately g Determine oxygen saturation by assessing pulse oximetry via a finger or toe or in a small infant around the foot Determining whether the patient is in respiratory distress failure or arrest will indicate the urgency for treatment and transport a Obtain SAMPLE history on scene or during transport depending on patient s stability With a primary respiratory complaint respiratory distress is most common and requires only generic treatment a Position of comfort supplemental oxygen b Choice of oxygen delivery method depends on the severity of illness and developmental level i Young children may become agitated by a nasal cannula or face mask ii Crying and thrashing increase metabolic demands and oxygen consumption weigh benefits against potential cost iii Allowing a caregiver to deliver blow-by oxygen to a calm toddler may be your best choice if there are no signs of respiratory failure As a child becomes fatigued respiratory distress may progress to respiratory failure a During reassessment electronically monitor pulse rate respiratory rate and oxygen saturation level b A significant change or trend requires prompt attention c Reassess frequently to evaluate the effects of treatment C Upper airway emergencies Foreign body aspiration or obstruction a Infants and toddlers put objects in their mouths and have a high risk of foreign body aspiration b Small objects and food item can obstruct a young child s relatively pliable trachea i Frequent items Peanuts hot dogs grapes balloons small toys c Swallowed foreign bodies can cause respiratory distress i Rigid esophageal foreign body can compress the relatively pliable trachea ii Tongue Large relative to the upper airway frequently causes mild upper airway obstruction with decreased LOC and diminished muscle tone iii Suspect foreign body aspiration with signs of mild or severe airway obstruction d An awake patient with stridor increased work of breathing and good color on the PAT has mild upper airway obstruction i Auscultation may reveal fair to good air entry ii Presence of unilateral wheezing may tip you off to a foreign body lodged in a mainstem bronchus e A patient with severe airway obstruction is likely to be cyanotic and unconscious when you arrive due to profound hypoxia i If the child has spontaneous respiratory effort you will hear poor air entry ii You may not hear stridor owing to minimal air flow through the trachea f Typical SAMPLE history Previously healthy child with a sudden onset of coughing choking or gagging while eating or playing g Initial management of mild airway obstruction i Position of comfort ii Providing supplemental oxygen as tolerated iii Transport to an appropriate facility iv Avoid agitating the child stimulus could worsen the situation h Monitor continuously and reassess frequently to ensure the problem does not worsen i Removing a foreign body airway obstruction in responsive infants i Deliver five back slaps and five chest thrusts a Hold the infant face down body resting on your forearm Support the head and face with your hand keep the head lower than the rest of the body b Deliver five back blows between the shoulder blades with the heel of your hand c Place your free hand behind the head and back and bring the infant upright on your thigh sandwiching the infant s body between your two hands and arms The head should remain below the level of the body d Give five quick chest thrusts in the same location and manner as for chest compressions using two fingers placed on the lower half of the sternum For larger infants or if you have small hands you can place the infant in your lap and turn the whole body as a unit between back blows and chest thrusts e Check the airway If you can see the foreign body remove it If not repeat the cycle as often as necessary Do not stick your fingers in the mouth to remove an object unless you can see the object f If the infant becomes unresponsive begin CPR with compressions remembering to look in the airway before ventilations each time j Removing a foreign body airway obstruction in unresponsive infants i If the infant loses consciousness look inside the mouth ii If you see the object remove it iii If not start CPR beginning with chest compressions compressions if two rescuers are present and the patient is an infant or child iv If there is no pulse or the pulse rate is less than beats min begin CPR v Continue compressions always looking in the mouth and attempting ventilations until the obstruction is relieved vi Then assess for a pulse k Removing a foreign body airway obstruction in children i The abdominal thrust maneuver Heimlich maneuver a Most effective method with a responsive adult or child b Aims to increase the pressure in the chest creating an artificial cough that may force a foreign body from the airway c Use until the obstructing object is expelled or child becomes unresponsive ii If the child becomes unresponsive a Position supine and perform chest compressions compressions if two rescuers are present and the patient is an infant or child b Open the airway and look in the mouth attempting to remove the foreign body only if you can see it c After looking in the mouth attempt to ventilate the patient d If the first breath does not produce visible chest rise reopen the airway and reattempt to ventilate e If both breaths fail to produce visible chest rise continue chest compressions f If you are unable to relieve a severe airway obstruction in an unresponsive patient with these basic techniques proceed with direct laryngoscopy visualization of the airway with a laryngoscope for the removal of the foreign body g Insert the laryngoscope blade into the mouth If you see the foreign body carefully remove it from the upper airway with Magill forceps iii Steps for removal of an upper airway obstruction with Magill forceps a With the patient s head in the sniffing position open the mouth and insert the laryngoscope blade b Visualize the obstruction and retrieve it with the Magill forceps c Remove the object with the Magill forceps d Attempt to ventilate the patient Anaphylaxis a Potentially life-threatening allergic reaction b Triggered by exposure to an antigen foreign protein c Food especially nuts shellfish eggs and milk and bee stings are among the most common causes i Can also occur with antibiotics and other medications d Exposure to the antigen stimulates the release of histamine and other vasoactive chemical mediators from white blood cells leading to multiple organ system involvement e Onset of symptoms generally occurs immediately after exposure i May include hives respiratory distress circulatory compromise and gastrointestinal symptoms vomiting diarrhea abdominal pain f Mild anaphylaxis Child may experience only hives and some wheezing g Severe anaphylaxis Child may be in respiratory failure and shock when you arrive h PAT may reveal an anxious child i Many adults describe a sense of impending doom at the onset of anaphylaxis i Severe anaphylaxis i Child may be unresponsive due to respiratory failure and shock ii May have increased work of breathing due to upper airway edema or bronchospasm and poor circulation iii Primary assessment will usually reveal hives iv Other findings may include a Swelling of the lips and oral mucosa b Stridor and or wheezing c Diminished pulses j If the child has a known allergy the SAMPLE history may reveal recent contact with or ingestion of the potentially offending agent including consumption of prepared foods containing traces of eggs nuts and milk at day care or school k Gold standard treatment for anaphylaxis is epinephrine i Alpha-agonist effect decreases airway edema by vasoconstriction and improves circulation by increasing peripheral vascular resistance ii Beta-agonist effect causes bronchodilation resulting in improved oxygenation and ventilation iii Give by the intramuscular IM route at a dose of mg kg of the solution to a maximum dose of mg iv Dose may be repeated as necessary every minutes v If several doses are needed the child may require a continuous IV epinephrine drip l In addition to epinephrine treatment of anaphylaxis should include the following i Supplemental oxygen ii Fluid resuscitation for shock iii Diphenhydramine for its antihistamine effect dose to mg kg IV to a maximum of mg iv Bronchodilators for wheezing m Many children with a history of anaphylaxis will have been treated with IM epinephrine by a caregiver before EMS activation n Given the short half-life of this drug the child should be transported even if asymptomatic on your arrival Croup laryngotracheobronchitis a Viral infection of the upper airway b Most common cause of upper airway emergencies in young children c Parainfluenza virus is the pathogen most commonly responsible for croup but respiratory syncytial virus RSV influenza and adenovirus have also been implicated d The virus is transmitted by respiratory secretions e Primarily affects children age years and younger f Most cases occur in fall and winter g The virus has an affinity for the subglottic space the narrowest part of the pediatric airway and causes edema and progressive airway obstruction h Turbulent air flow through the narrowed subglottic airway causes the hallmark sign of croup stridor i Most cases are mild j EMS may be called when symptoms come on abruptly often in the middle of the night or if symptoms cause moderate to severe respiratory distress k PAT typically reveals an alert infant or toddler with the following i Audible stridor with activity or agitation ii Barky cough iii Some increased work of breathing iv Normal skin color l If a child with a history compatible with croup is sleepy or obtunded or has significant respiratory distress or cyanosis be concerned about critical airway obstruction m On your primary assessment breath sounds will likely be clear over the lung fields although you may hear stridor originating at the level of the subglottic space n Pathophysiology largely involves the upper airway so hypoxia is uncommon i Its presence signals critical obstruction need for immediate treatment o SAMPLE history usually reveals several days of cold symptoms and low-grade fever followed by barky cough stridor and trouble breathing p The cough and respiratory distress are often worse at night q Initial management is the same as for most respiratory emergencies i Position of comfort ii Avoid agitating the child iii Use of cool mist or nebulized saline is controversial iv Nebulized epinephrine is the treatment of choice with any of the following a Stridor at rest b Moderate to severe respiratory distress c Poor air exchange d Hypoxia e Altered appearance r Nebulized epinephrine i Works by causing vasoconstriction and decreasing upper airway edema ii Available in two formulations racemic epinephrine and L - epinephrine a The dose for racemic epinephrine is mL mixed in mL of normal saline b The dose for L -epinephrine is to mg kg of the solution maximum mg per dose this form can be diluted with normal saline to bring the volume to mL iii Although only a small amount is absorbed via the nebulized route side effects may include tachycardia agitation tremor and vomiting s Croup and respiratory failure i Nebulized epinephrine alone may not be adequate ii Assisted ventilation with bag-mask ventilation may be necessary it will often overcome upper airway obstruction t Advanced airway placement i Rarely needed ii If performed choose an ET tube one-half to one size smaller than normal for age or size to accommodate the subglottic edema u Children requiring nebulized epinephrine or assisted ventilation need to be transported immediately Epiglottitis a Life-threatening inflammation of the supraglottic structures usually due to bacterial infection b Now rare in children due to vaccine against Haemophilus influenzae type B c Sporadic cases reported among adolescents adults and unimmunized children d Classic presentation is easily distinguishable using PAT i Child will look sick be anxious and sit upright in the sniffing position with the chin thrust forward to allow for maximal air entry ii May be drooling because of an inability to swallow secretions iii Work of breathing is increased iv Pallor or cyanosis may be evident e Signs of a significant airway obstruction include the following i Stridor heard on auscultation over the neck ii Muffled voice iii Decreased or absent breath sounds iv Hypoxia f SAMPLE history will reveal a sudden onset of high fever and sore throat in preschool or school-age children g Symptoms progress rapidly children are generally sick for only a few hours before they come to medical attention h Ask about immunizations if you suspect epiglottitis i Your goal is to get the child to an appropriate hospital with a maintainable airway j Risk for acute airway obstruction and respiratory arrest so minimize scene time and do not attempt procedures that might agitate the child k Allow the patient to assume a position of comfort provide supplemental oxygen only if tolerated l Do not attempt to look in the mouth because this can precipitate complete airway obstruction and do not insert an IV line m Be prepared with a bag-mask device and an ET tube one to two sizes smaller than anticipated in the event of complete obstruction during transport n ET intubation is difficult because of the extreme distortion of the airway anatomy o Alert personnel at the receiving facility to the suspected diagnosis and the patient s condition p Some uncommon conditions can also cause upper airway obstruction including i Retropharyngeal abscess ii Peritonsillar abscess iii Tracheitis iv Diphtheria q May include fever stridor difficulty handling secretions and respiratory distress r Assessment and management will be the same as for croup Bacterial tracheitis a Invasive exudative bacterial infection of the soft tissues of the trachea b Typically presents with cough stridor and respiratory distress of varying degree with a history of a preceding viral infection c Toddlers are at increased risk of complications due to their relatively narrow airway diameter and may present in extremis d Patients are often febrile and may prefer the sniffing position e Place in a position of comfort provide supplemental oxygen as tolerated f Do not look in the mouth i Can precipitate complete airway obstruction g Do not insert an IV line h Try to keep the patient as calm and comfortable as possible i Have bag-mask device ET tube one to two sizes smaller than anticipated j Alert the receiving facility of the potential need to intubate a difficult airway D Lower airway emergencies Pathophysiology in upper airway emergencies involves restriction of air flow into the lungs inhalation Pathophysiology of lower airway respiratory emergencies involves restriction of air flow out of the lungs exhalation Asthma a Most common chronic illness of childhood b Most common respiratory complaint encountered by prehospital providers i An estimated to of children are affected many are treated in the ED ii Incidence and mortality of this disease are increasing c Disease of the small airways d Three main components lead to obstruction and poor gas exchange i Bronchospasm ii Mucus production iii Airway inflammation e Lower airway inflammation in asthma results in hypoxia because of ventilation-perfusion mismatch i Blood flowing to parts of the lung is poorly oxygenated f Triggers for asthma attacks include i Upper respiratory infections ii Environmental allergies iii Exposure to cold iv Changes in the weather v Secondhand smoke g Clinical signs include i Frequent cough ii Wheezing iii More general signs of respiratory distress h Primary assessment will vary based on the degree of obstruction and the presence or absence of respiratory fatigue i Mild to moderate respiratory distress i Child will be awake and alert sometimes preferring a seated posture ii Although increased work of breathing may be evident by retractions and nasal flaring circulation will seem normal j Signs of severe respiratory distress and impending respiratory failure include i Decreasing alertness ii Tripod position iii Deep retractions iv Cyanosis k Primary assessment will reveal shortness of breath as evidenced by the following i Inability to speak in full sentences ii Increased respiratory rate iii Prolonged expiration phase iv Wheezes noted on auscultation l Expiratory wheezing alone may be heard with mild to moderate asthma attacks m Wheezing may be heard on inspiration and expiration with moderate to severe disease n Decreased air movement and the absence of wheezes suggest severe lower airway obstruction and respiratory fatigue i Immediate treatment is needed to prevent respiratory arrest o SAMPLE history should reveal the frequency and severity of previous asthma attacks as reflected by ED visits and hospitalizations p Previous admission to an intensive care unit or intubation for asthma increases the risk for severe possibly fatal attacks q Medication history should identify any preventive treatment controller medications and any rescue medications administered by the caregiver before your arrival r Inhaled steroids are the most common controller medications s Inhaled albuterol is the most common beta- agonist drug used as a rescue medication t Initial management remains basic respiratory care i Position of comfort supplemental oxygen ii Gold standard treatment bronchodilators beta-agonists that relax smooth muscles in the bronchioles decreasing bronchospasm and improving air movement and oxygenation u Bronchodilators may be delivered by nebulizer or metered-dose inhaler MDI with a spacer-mask device v Unit doses of mg of albuterol premixed with mL of normal saline i Often used for nebulization ii Acceptable starting dose for most young children w For a larger child or a child of any age who is in severe distress consider mg of albuterol as the initial dose x If nebulized albuterol is used four puffs are equivalent to mg administered by nebulizer y Children with moderate to severe respiratory distress can be given treatments as often as needed during transport including back-to-back nebulizer treatments z Although albuterol is relatively safe potential side effects include tachycardia tremor and mild hyperactivity aa An isomer of albuterol levalbuterol reportedly has fewer side effects and is likely an acceptable alternative to albuterol bb Children with moderate to severe respiratory distress may also benefit from inhaled ipratropium an anticholinergic bronchodilator cc Studies have shown that the combination of albuterol and ipratropium which may be mixed and delivered together by nebulizer is more effective than albuterol given alone dd The dose of ipratropium given is based on the patient s weight i Less than kg A mg unit dose nebulized or one puff by MDI ii More than kg A mg unit dose nebulized or two puffs by MDI ee If a child is in severe respiratory distress is obtunded or has markedly diminished air movement on auscultation a dose of epinephrine may be required i Will cause immediate relaxation of bronchial smooth muscles opening the airways to allow bronchodilators to work ii Dose is mg kg of epinephrine injected IM iii Single doses should not exceed mg iv Initiate bronchodilator therapy immediately after administering the epinephrine ff Assisted ventilation is problematic for patients with an asthma exacerbation i High inspiratory pressures force air into the lungs but exhalation is compromised by bronchospasm mucus production and inflammation ii Leads to air trapping and a high risk of pneumothorax and pneumomediastinum iii Should be undertaken only if the patient has respiratory failure and has failed to respond to IM epinephrine and high-dose bronchodilators iv If performed use slow rates to allow time for adequate exhalation Goal is adequate oxygenation Bronchiolitis a Inflammation or swelling of the small airways bronchioles in the lower respiratory tract due to viral infection b Most common source is respiratory syncytial virus RSV also newer virus metapneumovirus c Highest frequency in winter d Primarily affects infants and children younger than years e Highly contagious f Severity ranges from mild to moderate respiratory distress with hypoxia and respiratory failure g Younger infants are at particularly high risk for episodes of apnea associated with RSV infection which may not be associated with severe respiratory distress h Signs and symptoms can be difficult to distinguish from those of asthma i One clue is age Asthma is rare in children younger than year ii An infant with a first-time wheezing episode in late fall or winter likely has bronchiolitis i Characteristic findings during primary assessment include i Mild to moderate retractions ii Tachypnea iii Diffuse wheezing iv Diffuse crackles v Mild hypoxia j Child is in danger of respiratory failure and requires immediate transport in the following cases i Sleepy or obtunded ii Severe retractions iii Diminished breath sounds iv Moderate to severe hypoxia oxygen saturation less than k Greatest risk for respiratory failure and arrest is in infants with the following characteristics i First months of life ii History of prematurity iii Underlying lung disease iv Congenital heart disease v Immunodeficiency l Management is entirely supportive i Position of comfort ii Supplemental oxygen m Although bronchodilator therapy has not proved effective in the majority of cases inhaled albuterol or nebulized racemic epinephrine mL of a solution for inhalation may be given as a therapeutic trial for moderate to severe respiratory distress n Be prepared to assist ventilation with bag-mask ventilation or ET intubation if needed Pneumonia a Common disease process that infects the lower airway and the lung b In pediatric patients it is commonly seen in infants toddlers and preschoolers c Often caused by a virus in infants and toddlers d Incidence of bacterial pneumonia increases as children get older e Children with pneumonia typically have a recent history of a cough or cold or a lower airway infection ie bronchiolitis f Often pediatric patients will present with unusually rapid breathing or will breathe with grunting or wheezing sounds g Additional signs and symptoms include i Nasal flaring ii Tachypnea iii Crackles iv Chest pain v Hypothermia or fever h Patient may exhibit unilateral diminished breath sounds i Assess work of breathing by observing for signs of accessory muscle usage j Infants may not tolerate pneumonia as well as older children or adults i Increased oxygen demand and less reserve amounts k Primary treatment is supportive i Monitor airway and breathing status ii Administer supplemental oxygen if required l Follow standard precautions i Consider placing a mask on the child if tolerated m Vascular access is generally not indicated i If condition warrants medication therapy establish IV or intraosseous IO access en route to the hospital Pertussis a Also known as whooping cough b Highly contagious potentially deadly disease c Caused by a bacterium that is spread through respiratory droplets d Less common in the United States due to vaccinations though immunization rates have fallen e Typical signs and symptoms are similar to a common cold coughing sneezing and a runny nose f Coughing becomes more severe and is characterized by the distinctive whoop sound heard during the inspiratory phase i The cough can be so severe that it can cause postcough vomiting conjunctival hemorrhage and cyanotic hypoxia g Keep the airway patent and transport to the ED h Follow standard precautions including wearing a mask and eye protection E Other respiratory conditions Cystic fibrosis CF a Genetic disease that primarily affects the respiratory and digestive systems b The most common life-shortening hereditary disease among people of European descent c Chronic production of copious amounts of thick mucus in the respiratory and digestive tracts i Susceptible to recurrent respiratory infections that require hospitalization ii Requires a strict regimen of aerosol treatments mucus management and pulmonary exercise d Pediatric patients may present with tachypnea chest pain and crackles i May be difficult to separate acute exam findings from chronic disease e Assess work of breathing by observing for signs of accessory muscle usage tachypnea and nasal flaring f Provide supplemental oxygen as needed g Vascular access is generally not needed Bronchopulmonary dysplasia a Spectrum of lung conditions found in premature neonates who required long periods of high-concentration oxygen and ventilator support i Ranges from mild reactive airways to debilitating chronic lung disease b As we are able to save smaller and smaller infants some are left with severely damaged lungs occasionally requiring long-term ventilator support c Barotrauma from ventilators was considered the primary cause but studies point to the role of high-concentration oxygen in damaging the lungs d Children may use home ventilators have tracheostomies or have chronic lung disease e High risk for recurrent pulmonary infections including pneumonias bronchiolitis and tracheitis f Many patients will be on home oxygen i Important to ask caregivers about baseline oxygen requirements tracheostomy secretions and ventilator settings ii Note any acute changes that have occurred with illness g Remember the ABCs of airway management h Positioning the airway with a head-tilt chin-lift or jaw-thrust maneuver or with a nasopharyngeal or oropharyngeal airway may help overcome the obstruction and distress i Consider bag-mask ventilation and positive airway pressure j Continuous positive airway pressure CPAP or bi-level positive airway pressure BiPAP may be beneficial k Ultimately patients with bronchopulmonary dysplasia may require intubation for severe distress or respiratory failure i When intubating consider the patient s size and weight when choosing an ET tube ii May need a smaller tube than you would typically pick based on age iii Weight-based system may be helpful a Eg pediatric resuscitation tape measure l Children with desaturations require oxygen therapy m If bronchospasm is present bronchodilators such as albuterol may be tried i Improvement may not be seen since the mechanism could be related to the underlying lung disease n Ipratropium may be beneficial and should be considered o Oral and IM steroids can be considered acutely i Eg prednisone or dexamethasone ii Avoid with concern for overwhelming infection F General assessment and management of respiratory emergencies Infants and young children with severe tachypnea and retractions in association with hypoxia bradycardia or altered mental status are in respiratory failure and need immediate intervention to prevent respiratory arrest A respiratory rate too slow for age in a child with a history of respiratory distress should also raise concerns for respiratory fatigue and failure Airway management a Airway is first step in managing any respiratory emergency b Check for obstruction c Position airway using head-tilt chin-lift or jaw-thrust maneuver d In a young infant place a small roll under the shoulders to align the airway e Airway adjunct may be helpful if patient is unresponsive and cannot maintain a patent airway f Nasal or oral airway will help to maintain an open airway improve bag-mask ventilation and may avert the need for an advanced airway i Choose appropriately sized equipment Oropharyngeal airway a Designed to keep the tongue from blocking the airway b Makes suctioning the airway easier c Use with patients who are unresponsive and cannot maintain their own airway spontaneously d Do not use with patients who are conscious or have a gag reflex i May stimulate vomiting increasing the risk of aspiration e Do not use with children who have ingested a caustic corrosive or petroleum-based product f Avoid injuring the hard palate as you insert the airway i Rough insertion can cause bleeding that may aggravate airway problems and cause vomiting g If the oropharyngeal airway is too small the tongue may be pushed back into the pharynx obstructing the airway h If it is too large it may obstruct the larynx i To properly insert an oropharyngeal airway refer to Skill Drill - Nasopharyngeal nasal airway a Usually well tolerated it s not as likely as the oropharyngeal airway to cause vomiting b Used for conscious patients and patients with altered levels of consciousness c In pediatric patients it is typically used in association with respiratory failure d Also a good choice for maintaining an airway in patients who are experiencing a seizure or who are in a postictal state e Rarely used for children younger than year because of the small diameter of their nares which tend to become easily obstructed by secretions f To properly insert a nasopharyngeal airway refer to Skill Drill - g Several problems are possible i Diameter that is too small may become obstructed by mucus blood vomitus or soft tissues of the pharynx ii If airway is too long it may stimulate the vagus nerve and slow the pulse rate it may also enter the esophagus causing gastric distention iii Inserting the airway in responsive patients may cause spasm of the larynx and result in vomiting h Do not use with facial trauma because the airway may tear soft tissues and cause bleeding into the airway i Do not use with moderate to severe head trauma because it could increase intracranial pressure ICP Oxygenation a Assessing ventilatory and oxygenation status is part of breathing assessment b All patients with respiratory emergencies should receive supplemental oxygen c Two most common delivery methods with pediatric patients i Blow-by technique ii Nonrebreathing mask d Blow-by technique does not deliver high concentrations of oxygen i Best used when only a small amount of supplemental oxygen is needed or when the patient cannot tolerate wearing the mask needed for higher oxygen delivery ii Oxygen tubing a mask a cup or a similar device can be used for delivery iii Child or caregiver can hold the device near the patient s face iv Do not use a Styrofoam cup because it may blow fluorocarbons into the child s airway v Goal is to increase oxygen concentration immediately around the mouth and nose e For children in significant respiratory distress or respiratory failure or for older children a nonrebreathing mask is the preferred delivery method i Patient does not rebreathe exhaled air lower oxygen concentration ii Can deliver up to oxygen iii Fit the mask appropriately and use high flow rates to L min to achieve the maximum oxygen concentration Bag-mask ventilation a If respiratory effort is not improved with airway positioning or an airway adjunct start assisted ventilation using a bag-mask device i Always the first step in assisted ventilation ii Definitive airway management for many patients iii Critical skill may avert the need for ET intubation which has a much higher complication rate b May need to try a variety of mask sizes to find the one that gives the optimal seal c Do not hesitate to change providers hand position or technique if difficulty with ventilation continues d Avoid excessive tidal volumes and rate to minimize gastric distention vomiting and aspiration e Deliver breaths at a rate of to breaths min for infants and children i One breath every to seconds ii Squeeze bag only until you see chest rise f Do not overdistend the chest g Follow these steps with an infant or child i Ensure that you have the appropriate equipment in the right size a Mask should extend from the bridge of the nose to the cleft of the chin avoiding compression of the eyes b Mask is transparent so you can observe for cyanosis and vomiting c Mask volume should be small to decrease dead space and avoid rebreathing however the bag should contain at least mL of air d Use an infant bag rather than a neonatal bag for children older than year e Older children and adolescents may need an adult-size bag f Make sure that there is no pop-off valve on the bag if there is one make sure that you can hold it shut as necessary to achieve adequate chest rise ii Maintain a good seal with the mask on the face a An inadequate seal will result in inadequate tidal volume delivery and a decreased concentration of delivered oxygen b Consider airway adjuncts nasal and oral pharyngeal airways in tandem with bag-mask ventilation iii Ventilate at the appropriate rate and volume using a slow gentle squeeze until the chest visibly rises a One second per breath b Do not hyperventilate h Errors in technique can result in gastric distention or a pneumothorax i Too much volume with each breath ii Squeezing the bag too forcefully iii Ventilating at too fast a rate i Even with the best technique patient may regurgitate and aspirate stomach contents j An inadequate mask-to-face seal or improper head position can lead to inadequately delivered tidal volume and hypoxia k To properly perform one-person bag-mask ventilation for a child refer to Skill Drill - l Two-person bag-mask ventilation i Requires two rescuers a One to maintain an adequate mask-to-face seal and maintain the patient s head position b One to ventilate the patient ii Usually more effective at maintaining a tight seal delivering adequate tidal volume iii Not possible to perform a one-handed jaw-thrust maneuver and maintain spinal immobilization so ventilating the trauma patient is a two-person skill Endotracheal intubation a Defined as passing an ET tube through the glottic opening and sealing the tube with a cuff inflated against the tracheal wall b Consider only if adequate oxygenation and ventilation cannot be achieved with good bag-mask technique or if transport times are long c Advantage Provides a definitive airway and decreased risk of aspiration d However significant failure and complication rates in the prehospital setting e Potential complications include i Damage to teeth and oral structures ii Aspiration of gastric contents iii Bradycardia due to a vagal response iv Bradycardia due to hypoxemia from prolonged attempts v Increased ICP vi Incorrect placement f Incorrect placement of the ET tube into the right mainstem bronchus may result in hypoxia and inadequate ventilation g A potentially catastrophic complication is an unrecognized esophageal intubation h Indications in pediatric patients are the same as those in adults i Cardiopulmonary arrest ii Respiratory failure or arrest iii Traumatic brain injury iv Unresponsiveness v Inability to maintain a patent airway vi Need for prolonged ventilation vii Need for ET administration of resuscitative medications if no IV or IO access available i Remember the differences between adult and pediatric airways j Equipment for endotracheal intubation i Pediatric-specific equipment is mandatory including a Range of laryngoscope blades sizes to b ET tubes sizes for field deliveries of premature infants to ii Tube size selection is based on the child s age iii Any size of laryngoscope handle can be used although many paramedics prefer the thinner pediatric handles iv Straight Miller or Wis-Hipple blades make it easy to lift the floppy epiglottis to provide a direct view of the vocal cords v If a curved Macintosh blade is used the tip of the blade is positioned in the vallecula to lift the jaw and epiglottis to visualize the vocal cords vi The appropriately sized blade extends from the patient s mouth to the tragus of the ear vii Acceptable means of measuring include using the length-based resuscitation tape measure or following these general guidelines a Premature newborn size straight blade b Full-term newborn to year size straight blade c years to adolescent size straight blade d Adolescent or older size straight or curved blade viii Use a length-based resuscitation tape measure to choose the appropriate ET tube size or for children older than year use this formula for uncuffed ET tubes Age in years Size of tube in mm ix If using a cuffed ET tube size down half a size For example a -year-old child would need a -mm uncuffed ET tube or a cuffed ET tube x Always have a tube that is one size smaller and one that is one size larger than expected available for situations in which there is variability in upper airway diameter xi For patients who are younger than to years you may choose to use uncuffed ET tubes although a noninflated cuffed tube is acceptable a Cuff at the cricoid ring may be unnecessary to obtain a seal in young children b Possibility of ischemia and damage to the mucosa of the trachea at this location when cuffs are inflated at high pressures xii The appropriate depth for insertion is to cm beyond the vocal cords a Record this depth as the mark at the corner of the child s mouth xiii Uncuffed tubes often have a black glottic marker at the tube s distal end to use as a guide a When you see this line go through the vocal cord stop xiv Cuffed tubes When the cuff is just below the vocal cords stop xv Insert tube to a depth that is equal to three times the inside diameter of the tube Depth of insertion is important to avoid right mainstem intubation or unplanned extubation xvi Pediatric stylets will fit into tubes sized to mm adult stylets are used for tubes mm or larger a Use of a stylet is based on personal preference b If you use a stylet insert it into the ET tube stopping at least cm from the end of the tube c A stylet that protrudes beyond the end of the tube can damage the oral mucosa and vocal cords xvii With stylet in place bend ET tube into a gentle upward curve a In some cases bending the tube into the shape of a hockey stick is beneficial k Preparing for and performing endotracheal intubation i Preoxygenate do not hyperventilate with a bag-mask device and supplemental oxygen for at least to minutes before you attempt intubation using the squeeze release release technique a Adequate preoxygenation cannot be overemphasized respiratory failure or arrest is the most common cause of cardiopulmonary arrest in the pediatric population ii During this time ensure that the child s head is in the proper position a Neutral position with suspected spinal trauma b Sniffing position without trauma iii Insert an airway adjunct if needed to ensure adequate ventilation iv Because stimulation of the parasympathetic nervous system and bradycardia can occur during intubation apply a cardiac monitor if one is available v Use a pulse oximeter before during and after the intubation attempt to monitor patient s pulse rate and oxygen saturation vi Have suction handy vii To properly perform pediatric endotracheal intubation refer to Skill Drill - viii If an intubated child deteriorates use the DOPE mnemonic to identify the potential problem and institute an appropriate intervention a Displacement b Obstruction c Pneumothorax d Equipment failure l Complications of endotracheal intubation are essentially the same as for adults i Unrecognized esophageal intubation a Frequently monitor tube position especially after any major patient move b Use continuous waveform capnography ii Induction of emesis and possible aspiration a Always have suctioning available iii Hypoxia resulting from prolonged intubation attempts a Limit pediatric intubation attempts to seconds b Monitor cardiac rhythm and oxygen saturation during intubation iv Damage to teeth soft tissues and intraoral structures a Technique is critical Orogastric and nasogastric tube insertion a During positive-pressure ventilation it is common to inflate the stomach and lungs with air and liquid b Gastric distention slows downward movement of the diaphragm and decreases tidal volume i Makes ventilation more difficult ii Necessitates higher inspiratory pressures iii Increases risk of patient vomiting and aspirating stomach contents into the lungs c Invasive gastric decompression Placement of a nasogastric NG tube or orogastric OG tube to decompress the stomach by removing the contents with suction making assisting ventilation easier i Contraindicated in unresponsive children with a poor or absent gag reflex and an unsecured airway ii Instead perform ET intubation first to decrease risk of vomiting and aspiration d Preparation of equipment i You will need the following a Appropriately sized NG or OG tube b - to -mL syringe with a funnel-tipped adapter for manual removal of stomach contents through the tube c Mechanical suction d Adhesive tape e Water-soluble lubricant ii To prepare patient and equipment take the following steps a Select proper tube size Determine with a pediatric resuscitation tape measure or use a tube size twice the uncuffed ET tube size that the child would need For example a child who needs a -mm uncuffed ET tube requires a F OG or NG tube b Measure the tube on the patient Tube length should be the same as the distance from the lips or tip of the nose depending on whether the OG or NG route is used to the earlobe plus the distance from the earlobe to the xiphoid process c Mark this length on the tube with a piece of tape When the tip of the tube is in the stomach the tape should be at the lips or nostril d Place patient in a supine position e Assess the gag reflex If patient is unresponsive and has a poor or absent gag reflex perform ET intubation before gastric tube placement f In a trauma patient maintain in-line stabilization of the cervical spine if a neck injury is possible Choose the OG route of insertion if the patient has a severe head or midfacial injury g Lubricate the end of the tube e OG tube insertion i Follow these steps to insert an OG tube in an infant or child a Insert the tube over the tongue using a tongue blade if necessary to facilitate insertion b Advance the tube into the hypopharynx then insert it rapidly into the stomach c If the child begins coughing or choking or has a change in voice immediately remove the tube it may be in the trachea f NG tube insertion i Follow these steps to insert an NG tube in an infant or child a Insert the tube gently through the naris directing the tube straight back along the nasal floor Do not angle the tube superiorly If the tube does not pass easily try the opposite naris or a smaller tube Never force the tube b Advance the tube into the stomach c If NG passage is unsuccessful use the OG approach g Assessing placement of OG and NG tubes i Follow these steps to confirm successful placement of an NG or OG tube a Check tube placement by aspirating stomach contents Use a syringe with an appropriate adapter to quickly instill to mL of air through the tube while auscultating over the left upper quadrant If you hear a rush of air or gurgling over the stomach the placement is correct b If correct placement cannot be confirmed remove the tube c Secure the tube to the bridge of the nose or to the cheek using adhesive tape d Aspirate air from the stomach using a - to -mL catheter-tipped syringe or connect the tube to mechanical suction at a low continuous suction of to mm Hg or to the intermittent setting h Complications of OG or NG tube insertion i Potential complications include a Placement of tube into the trachea resulting in hypoxia b Vomiting and aspiration of stomach contents c Airway bleeding or obstruction d Passage of tube into the cranium ii The last complication can occur if you insert an NG tube with severe head or midfacial trauma tube may be passed through the fracture into the brain G Cardiopulmonary arrest In infants and children most often associated with respiratory failure and arrest Decreasing oxygen concentrations affect children differently than adults a Adult becomes hypoxic and the heart gets irritable sudden cardiac death occurs from dysrhythmia i Often in the form of ventricular fibrillation ii Thus defibrillation is the treatment of choice b Child becomes hypoxic and the heart slows down becoming more and more bradycardic i Heart beats slower and becomes weaker with each beat until no pulse is felt c Survival rate in the prehospital setting is poor and clearly improved by strengthening the links in the chain of survival d Survival rate from respiratory arrest is e Child who is breathing poorly with a slowing pulse rate must be ventilated with high concentrations of oxygen early to try to oxygenate the heart and avoid development of cardiac arrest VII Pathophysiology Assessment and Management of Shock A Shock is inadequate delivery of oxygen and nutrients to tissues to meet metabolic demand and you may encounter three types in both children and adults hypovolemic distributive and cardiogenic Determine the cause of shock and quickly determine whether the child is in a compensated or decompensated state a Compensated shock i Child has critical abnormalities of perfusion but the body is for the moment able to maintain adequate perfusion to vital organs by shunting blood from the periphery increasing the pulse rate and increasing the vascular tone ii Normal appearance tachycardia and signs of decreased peripheral perfusion such as cool extremities with prolonged capillary refill iii Timely intervention is needed to prevent child from decompensating b Decompensated shock i State of inadequate perfusion mechanisms to improve perfusion are no longer sufficient to maintain a normal blood pressure ii Includes hypotension a Relative to the age of the child iii Child will be profoundly tachycardic and show signs of poor peripheral perfusion iv May have an altered appearance reflecting inadequate perfusion of the brain v Because children typically have strong cardiovascular systems they are able to compensate for inadequate perfusion by increasing the pulse rate and peripheral vascular resistance more efficiently than adults vi Hypotension is a late and ominous sign urgent intervention is needed to prevent cardiac arrest vii Initial management Position of comfort supplemental oxygen viii After primary assessment make a transport decision based on the severity of the problem ix Start resuscitation on scene for any child who shows signs of decompensated shock x Rapid transport is imperative but risk of deterioration to cardiac arrest is too high to permit a load-and-go approach B Hypovolemic shock Most common cause of shock in infants and young children with loss of volume occurring due to illness or trauma a Because of their small blood volume mL kg body weight a combination of excessive fluid losses and poor intake in an infant or a young child with gastroenteritis stomach flu can result in shock relatively quickly b The same vulnerability exists with hemorrhage from trauma Patient will often appear listless or lethargic and may have compensatory tachypnea May appear pale mottled or cyanotic In medical shock you may see signs of dehydration such as a Sunken eyes b Dry mucous membranes c Poor skin turgor d Delayed capillary refill with cool extremities In an injured child the site of bleeding may be identified Allow the child to remain in a position of comfort administer supplemental oxygen and keep the child warm Apply direct pressure to stop any external bleeding Volume replacement is the mainstay of treatment for hypovolemic shock whether medical or traumatic in origin With compensated shock you can attempt to establish IV or IO access en route Gather all equipment before beginning this step a Catheters preferably an over-the-needle catheter are available in pediatric sizes of and gauge i A butterfly needle is a temporary alternative if an over-the-needle catheter is unavailable this stainless steel needle stays in the vein predisposing it to infiltration Many IV access sites are the same in adults and children a Most common Dorsum of the hand and antecubital fossa b In children veins in the foot may also be used c Scalp veins external jugular veins less common Procedure for establishing IV access is as follows a Choose the appropriate fluid examine the bag for clarity and expiration date i No floating particles in fluid and appropriate for child s condition b Choose appropriate drip set and attach it to the fluid i Macrodrip set eg gtt mL for a child who needs volume replacement ii Microdrip set eg gtt mL for a child who needs a medication infusion c Fill drip chamber by squeezing it d Flush or bleed tubing to remove any air bubbles by opening the roller clamp i Make sure no errant bubbles are floating in the tubing e Tear the tape before venipuncture or have a commercial device available f Apply gloves before making contact with patient Secure the appropriate limb to minimize movement during the procedure ie use of an arm board Palpate a suitable vein Veins should be springy when palpated Stay away from areas that are hard when palpated g Apply the constricting band to inches above intended site h Cleanse the area with an alcohol pad in a circular motion from the inside out Use a second alcohol pad to wipe straight down the center i Choose the appropriately sized catheter and twist to break the seal Do not advance catheter upward because this may cause the needle to shear the catheter Examine catheter and discard if you discover any imperfections Occasionally you will find burrs on the edge of the catheter j Insert the catheter at an angle of approximately with the bevel up while applying distal traction with your other hand i Traction will stabilize the vein and help to keep it from rolling as you insert the catheter k Observe for flashback as blood enters the catheter The clear chamber at the top of the catheter should fill with blood when the catheter enters the vein If you note only a drop or two you should gently advance the catheter farther into the vein l Occlude the catheter to prevent blood leaking while removing the stylet Hold the hub while withdrawing the needle so as not to pull the catheter out of the vein m Immediately dispose of all sharps in the proper container n Attach the prepared IV line Hold the hub of the catheter while connecting the IV line o Remove constricting band p Open the IV line to ensure fluid is flowing and the IV is patent i Observe for any swelling or infiltration around the IV site ii If the fluid does not flow check whether the constriction band has been released iii If infiltration is noted immediately stop the infusion and remove the catheter while holding pressure over the site with a piece of gauze to prevent bleeding q Secure the catheter with tape or a commercial device Wrap the IV tubing with extra gauze to prevent the child from pulling out the IV catheter Once IV access is established fluid resuscitation should begin with isotonic fluids only such as normal saline or lactated Ringer s a Begin with mL kg then reassess the patient s status b Warm IV fluids when possible can counteract the effects of systemic hypothermia from environmental exposure blood loss or open wounds c Multiple fluid boluses may be necessary during transport Address volume resuscitation separately from hypoglycemia a With shock due to medical illness perform a bedside glucose check b Treat with dextrose-containing fluid only for a documented low blood glucose level c Hypoglycemia is unlikely in shock due to acute injury In decompensated shock with hypotension begin initial fluid resuscitation on scene a Evaluate sites for IV access b If this is unsuccessful begin IO infusion c When an IO needle is placed correctly it will rest in the medullary canal the space within the bone that contains bone marrow d An IO infusion is contraindicated if a secure IV line is available or if a fracture or possible fracture exists in the same bone in which you plan to insert the IO needle e Anything that can be administered through an IV line can be administered through an IO line such as isotonic fluids medications f IO needles are usually double needles consisting of a solid-bore needle inside a sharpened hollow needle i Double needle is pushed into the bone usually the proximal tibia with a screwing twisting action away from the joint to avoid disruption of the growth plate ii Once the needle pops through the bone the solid needle is removed leaving the hollow steel needle in place iii The EZ-IO uses a drill mechanism for quick and safe IO insertion and can be used on any age patient including adults a Comes with two standard needle sizes pink pediatric to kg weight and blue adult greater than kg weight b Standard IV tubing is attached to this catheter g IO lines require full and careful immobilization because they rest at a angle to the bone and are easily dislodged i Stabilize the IO needle thereby ensuring adequate flow in the same manner that you would any impaled object h Several complications may be associated with IO infusion i Compartment syndrome ii Failed infusion iii Growth plate injury iv Bone inflammation caused by infection osteomyelitis v Skin infection vi Bony fracture i Proper technique will help to minimize these complications j To properly establish a pediatric IO infusion refer to Skill Drill - k As with IV administration administer mL kg boluses of isotonic fluid via IO infusion to treat hypovolemia reassessing after each bolus and repeating as needed based on physiologic response i As much as mL kg may be needed during transport to improve blood pressure pulse rate mental status and peripheral perfusion l Rapidly transport the patient C Distributive shock Decreased vascular tone develops a Results in vasodilation and third spacing of fluids due to increased vascular permeability i Leakage of plasma out of blood vessels into surrounding tissues ii Results in a drop in effective blood volume and functional hypovolemia May be due to a Sepsis b Anaphylaxis c Spinal cord injury Sepsis accounts for most pediatric cases Early in distributive shock child may have warm flushed skin and bounding pulses a Result of peripheral vasodilation Signs symptoms of late distributive shock much like hypovolemic shock Fever is a key finding in septic shock Urticarial rash and wheezing may be noted in anaphylaxis Neurologic deficits are apparent in shock due to spinal cord injury Frontline treatment is volume resuscitation a Child is in a state of relative hypovolemia In a child with apparent sepsis who remains persistently hypotensive despite mL kg of isotonic fluid vasopressor support to improve vascular tone may be considered Anaphylactic shock should be treated immediately with IM epinephrine a mg kg of solution b Maximum dose mg c Repeat as needed every minutes If several doses are needed child may require low-dose continuous epinephrine IV drip Decisions about timing of IV access transport a Same considerations as hypovolemic shock Additional therapies for anaphylactic shock include a Diphenhydramine i to mg kg IV ii Max of mg b AND methylprednisone i mg IV ii Max of mg c OR dexamethasone to decrease ongoing exacerbation i mg kg ii Max of mg D Cardiogenic shock Result of pump failure a Normal intravascular volume b Poor myocardial function Uncommon in the pediatric population May be present in children with the following a Underlying congenital heart disease b Myocarditis c Rhythm disturbances Important to recognize cardiogenic shock from history or primary assessment a Treatment is different from that for hypovolemic or distributive shock Signs and symptoms can include a Listless or lethargic appearance like hypovolemic or distributive shock b Increased work of breathing i Due to congestive heart failure and pulmonary edema c Impaired circulation d Pale mottled cyanotic or clammy skin e Abnormal pulse rate or rhythm or findings of a murmur or gallop f Enlarged liver g Sweating with feeding h History of congenital heart disease Initial management includes a Position of comfort i Often sitting upright b Supplemental oxygen c Transport Transport destination is critical a Facility needs to be capable of pediatric critical care Supplemental oxygen a May not increase SpO in children with particular types of congenital heart disease b Parents will often alert you to this fact Consider establishing IV access en route Err on the side of fluid resuscitation unless you are sure of diagnosis a History of congenital heart disease b Afebrile c No history of volume loss If you suspect cardiac dysfunction a Administer a single isotonic fluid bolus slowly b Monitor patient carefully to assess its effect The following will confirm suspicion of cardiogenic shock a Increased work of breathing b Drop in oxygen saturation c Worsening perfusion after a fluid bolus Inotropic agents may be needed to improve cardiac contractility and improve perfusion a Rarely administered in the field VIII Pathophysiology Assessment and Management of Cardiovascular Emergencies A Cardiovascular emergencies are relatively rare in children and are often related to volume or infection rather than a primary cardiac cause unless the child has congenital heart disease Through the primary assessment you can quickly identify a cardiovascular emergency understand the likely cause and institute potentially lifesaving treatment B Dysrhythmias Rhythm disturbances can be classified based on whether the pulse rate is a Too slow bradysrhythmias b Too fast tachydysrhythmias or c Absent pulseless The signs and symptoms are often nonspecific a Eg patient or caregiver may report fatigue irritability vomiting chest or abdominal pain palpitations and shortness of breath If rhythm disturbance is suspected quickly move through the primary assessment supporting the airway and breathing as necessary ECG or rhythm strip will help identify the underlying rhythm and determine management Address reversible causes of dysrhythmias such as hypoxemia The decision to stay on scene to obtain additional history and perform a secondary assessment will be dictated by overall physiologic status Bradysrhythmias a Condition in which the pulse rate is lower than normal for age b Most often occurs secondary to hypoxia in children rather than as a result of a primary cardiac problem such as heart block c First-line treatment Airway management supplemental oxygen assisted ventilation as needed i Treat any underlying respiratory problem d Less common causes of bradycardia include congenital or acquired heart block and toxic ingestion of beta blockers calcium channel blockers or digoxin e Elevated ICP can also cause bradycardia and should be considered in children with the following i Ventricular shunts ii History of head injury iii Suspected child abuse without a consistent injury history f Initiate electronic cardiac monitoring as part of primary assessment g If the child is asymptomatic no further treatment is indicated in the field h Healthy athletic adolescents may have sinus bradycardia and should be transported for further evaluation if they are symptomatic ie chest pain dizziness syncope i If the child s pulse rate is lower than normal for age despite oxygenation and ventilation and perfusion is poor begin chest compressions and attempt IV or IO access i For chest compressions to be effective the patient should be on a firm flat surface with the head at the same level as the body ii If you need to carry an infant while providing CPR your forearm and hand can serve as the flat surface j Heart block can be congenital or acquired in varying degrees i First-degree block is an asymptomatic often incidental finding seen on ECG or cardiorespiratory monitoring with slight prolongation of the PR interval a No intervention is needed ii Second-degree heart block may involve a progressive prolongation of the PR interval with a subsequent drop of the QRS complex type I or a random drop of the QRS complex type II a Type II may progress to third-degree heart blocks in which the atrial and ventricular rates are totally uncoordinated b These rhythms can lead to poor perfusion and cardiovascular compromise k Transcutaneous pacing may be used in patients with symptomatic bradycardia or third-degree heart block to provide the patient with adequate circulation until they can be evaluated by a cardiologist Tachydysrhythmias a Sinus tachycardia a pulse rate higher than normal for age is common in children b Although it may be a sign of serious underlying illness or injury it may also be due to fever pain or anxiety c Interpret tachycardia in the context of PAT and the primary assessment i If child appears well but has a fever sinus tachycardia is likely treatment with antipyretics is all that is necessary ii If a child with tachycardia has a history of copious vomiting or diarrhea fluid resuscitation is the appropriate treatment iii If a child with tachycardia appears ill and has poor perfusion with no history of fever trauma or excessive volume loss continue assessment for a primary cardiac cause while initiating resuscitation iv Assessment should include determination of the pulse rate along with interpretation of an ECG or rhythm strip d Tachydysrhythmias are subdivided into two types based on the width of the QRS complex i Narrow complex tachycardia QRS complex is second or less less than two standard boxes on the rhythm strip ii Wide complex tachycardia QRS complex is greater than second more than two standard boxes on the rhythm strip e Narrow complex tachycardia i Sinus tachycardia is the most common dysrhythmia in children ii However supraventricular tachycardia SVT is the most frequent tachydysrhythmia requiring antidysrhythmic treatment iii You may identify sinus tachycardia based on the presence or absence of P waves pulse rate and history of preceding illness or injury a Treatment is geared toward the underlying cause and may include oxygen fluids splinting and analgesia iv SVT involves abnormal conduction pathways and can be identified by a Narrow QRS complex b Absence of P waves c Unvarying pulse rate of more than beats min in an infant or more than beats min in a child v Child may have a history of SVT or exhibit nonspecific signs and symptoms including irritability vomiting and chest or abdominal pain a Parents of young infants may report poor feeding for several days vi Treatment of SVT depends on the patient s perfusion and overall stability vii If the child is in stable condition consider attempting vagal maneuvers while obtaining IV access a Have an older child hold his or her breath blow into a straw with the end crimped over or bear down as if having a bowel movement b With a younger child place an exam glove filled with ice firmly over the midface being careful not to obstruct the nose and mouth c Attempt these techniques only once while continually monitoring the child s rhythm viii If the child has adequate perfusion and vagal maneuvers do not succeed in converting SVT to a sinus rhythm consider administering adenosine a Short half-life must be injected quickly into a vein near the heart usually an antecubital vein b Can be given IO however the higher mg kg dose is frequently needed for SVT when it is administered IO since it takes longer to reach the heart and because of adenosine s short half-life c Administration will be followed by a brief run of bradycardia ventricular tachycardia ventricular fibrillation or asystole which will convert spontaneously to sinus rhythm d Persistence of any of these rhythms is rare but be prepared to switch dysrhythmia algorithms if necessary ix For a child with SVT who has poor perfusion synchronized cardioversion is recommended a Timed administration of electrical energy to the heart to correct a dysrhythmia x If child is generating a regular but ineffective rhythm it is important to time the jolt of electricity with the appropriate phase of the electrical activity corresponds with the R wave on an ECG xi A burst of electricity to the myocardium during the relative refractory period the downward slope of the T wave can precipitate ventricular fibrillation V-fib a potentially lethal effect xii Follow the same steps with synchronized cardioversion as with defibrillation except that you must press the sync button on the defibrillator to alert the machine to time the electrical jolt a The dose of the initial synchronized cardioversion attempt is to joules per kilogram of body weight J kg b If the first dose is unsuccessful a repeated dose of J kg can be given c In the hospital setting sedation is provided before cardioversion but its administration must not delay the procedure in a child in unstable condition xiii Alternative approach to treating the child in SVT with poor perfusion is to give IV adenosine if vascular access is readily available xiv Do not delay synchronized cardioversion if vascular access is not already established xv If child remains in SVT and is in unstable condition or shock or is unconscious