file
stringclasses 11
values | source
stringclasses 1
value | topic
stringclasses 11
values | section
stringlengths 1
430
| text
stringlengths 0
49.5k
|
|---|---|---|---|---|
pediatrics.json
|
knowledge
|
pediatrics
|
Challenges unique to pediatric prehospital researchers
|
Many challenges must be overcome when conducting pediatric prehospital research. Many of these are similar to those barriers encountered when conducting general prehospital research and have been covered in other chapters. In addition to these, however, the research population itself presents some challenges which are unique to EMS but which are also common to any pediatric research activity. These include defining a “pediatric” patient, the limited numbers of pediatric patients seen by a typical EMS agency, and the different ethical standards to which pediatric research is held. Specifically, compared to adult studies it can be more difficult to recruit pediatric research participants, to obtain community support for exception from informed consent, and to obtain assent from parents/guardians.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Status of pediatric prehospital research
|
The Institute of Medicine’s (IOM) 2006 report Emergency Care for Children: Growing Pains focused on how pediatric emergency services are (and are not) integrated into the nation’s health care system. Among the issues discussed were emergency care planning, preparedness coordination, funding for pediatric emergency care, training of pediatric emergency care professionals, unique characteristics and needs of pediatric populations, and pediatric emergency care research. The report indicated that, although some progress has been made since the first IOM report on EMS for children was published in 1993, there is still a long way to go to improve the accessibility, quality, and cost of emergency care for children in this country. In addition in its 2009 interim report, the National Commission on Children and Disasters found “death rates due to pediatric injury have dropped by 40 percent since the EMSC program was established. Despite this progress, the gap between adult and pediatric emergency care on not only a day-to-day, but also a disaster basis, is sufficiently large as to require substantial increases in funding for EMSC” and “A significant amount of improvement must still be made to ensure that the emergency care system is prepared for the care of children in both everyday emergencies and disasters.” From the development of the National EMS Research Agenda in 2001 to the publication of the National EMS Research Strategic Plan in 2005, there has been an exponential increase in prehospital research, yet there is still little research that has been conducted on the prehospital care of children. The 2006 IOM report characterizes the state of pediatric emergency care as a multifaceted crisis, affecting all aspects of emergency care. To drive continued improvements in care, the report asserts that pediatric prehospital care research must become a priority. While its own discipline, the intersection of disaster medicine and public health preparedness with prehospital medicine, is clear, the need to understand the role and interventions provided in disasters, terrorism events, and public health emergencies is imperative. The research base for pediatric issues in disaster medicine is severely limited based on the same barriers as other areas of pediatric research combined with the challenges of research in disasters. It is important to note the progress made by the development of some federally funded research networks with the mission of conducting high-quality multicenter collaborative research throughout the United States. One is PECARN, initially funded in 2001; another is the NIH-funded Resuscitation Outcomes Consortium (ROC). Although these networks can potentially conduct pediatric prehospital research, little has emerged to date.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Defining the “pediatric” patient population
|
In order to conduct any research, one must define both inclusion and exclusion criteria. For the inclusion criteria, basic definitions and biographical/demographic information are key. One can easily understand that a clear definition of the age groups under investigation is critical for anyone conducting quality pediatric prehospital research. One must be clear on how the term “pediatric” or “child” will be defined. Whereas the legal definition of a minor in the United States is a person younger than 18 years of age, the definition of “adult” versus “child” can be highly variable in both the hospital and prehospital settings. The definition can range from as young as 8 to as old as 18 and there may different ages for classifying as adult or pediatric based on presentation, such as one for trauma patients and one for all other patients. There may also be variability even within the same EMS system due to individual hospitals having different criteria for what they consider a pediatric versus adult patient. In addition, within pediatrics some studies would require further subcategorization, such as neonatal, toddler, school age, or adolescent. Another problem which often occurs is that although most prospective prehospital trauma studies limit inclusion to adult patients, the definition of “adult” can vary from individuals 15 and older up to those aged 18 years and older. The Centers for Disease Control and Prevention (CDC) statistics, hospitals, and others often use data in which children are considered “adult” at age 15, 14, or even 13. However, the federal Emergency Medical Services for Children (EMSC) program defines “children” as ages 0 through 21 years, in accord with the American Board of Pediatrics, which defines the field of pediatrics as encompassing patients 0 through 21 years of age. There is no common age-based definition of pediatric, which hinders researchers’ ability to compare findings across studies. It is therefore important for the prehospital researcher to very clearly define the study population and, even more importantly, be prepared to address the need when aggregating data to exclude ages which do not meet their inclusion or aggregate some adult data. The upper age range for pediatrics is the source of most debates over inclusion criteria. Although heterogeneity in age may confound a study’s findings due to anatomical, physiological, and developmental differences, it is important to note that postpubertal patients between 15 and 20 years of age, while psychologically different from an adult, are physiologically and anatomically almost identical to young adults. It may be even more important for an investigator to recognize that as a child matures toward mid-adolescence, he or she undergoes many developmental, anatomical, and physiological changes which may make this small age range for some studies very heterogeneous. Therefore, studies must often be stratified by age so that developmental differences do not bias the study results. Also, if there is sufficient sample size, a multivariate analysis could be conducted with age included in the model as a continuous variable.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Sample size
|
When planning for any well-designed research study, and especially a randomized controlled trial or population-based study, the researcher must recognize that no single hospital or EMS agency is likely to have access to sample sizes large enough to answer important questions about critically ill or injured children. The few existing studies on pediatric EMS demographics have shown that these patients account for approximately 10% of EMS call volumes, of whom only 10–20% actually have critical complaints. This presents researchers with a problem in obtaining a sample size sufficiently large to conduct a meaningful study. This challenge is not unique to pediatric prehospital research, however, because it occurs in most pediatric research. One solution is research networks using multicenter study methodologies; when researchers from different institutions pool data, these challenges are successfully met. The large numbers of patients included in the networks allow researchers to carry out trials designed to evaluate rare conditions or complications. The problem is that solutions such as multisite research or establishing collaborative research networks are challenging in any environment, but even more so in prehospital research. Although pediatric emergency medicine networks do exist, true pediatric prehospital research collaborative groups do not. Therefore, there is really no preexisting mechanism to support the multisite research needed to achieve the numbers required for a research study. As a result, researchers frequently must establish their own multisite collaborative networks. Because the accessible sample for pediatric research is limited and multicenter mechanisms are limited at best, it is imperative that, whenever possible, pediatric prehospital researchers use standard definition sets and variables. This will permit combination of data sets and allow metaanalyses to be conducted so that while a single study may not reach significance, the aggregation using metaanalysis methodology could reach significance. One data definition standard that could be used for pediatric prehospital research is the Pediatric Utstein Style. This consensus document is an attempt to provide an organized method of reporting pediatric resuscitation data in the out-of-hospital, emergency department, and in-hospital settings. Further work is needed to establish broader data definition standards for pediatric EMS research.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Epidemiology
|
While it is vital to define what is the pediatric population, it is also key to conducting research to know the epidemiology of the population studied. Information such as sex, age ranges, disease and injury prevalence, ethnic variation, and types of requests for prehospital assistance is essential. This information allows the researcher to determine areas where research may be needed. It is also vital to determine whether a study is feasible. For example, if one knows the epidemiology of the population one wishes to study, one can perform calculations such as power analysis to determine if there is even the possibility of the research results reaching significance and whether it can be conducted within that system or, as described above, may require multicenter studies. Lastly, this information allows one to know whether the study population is a true reflection of the actual population and thus can be extrapolated.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Institutional review board approval
|
Other chapters cover the issue of obtaining institutional review board (IRB) approval and the unique obstacles faced by prehospital researchers. Ethical issues regarding pediatric patients can be even more controversial and challenging. For example, a child younger than 18 years of age cannot legally give consent as a research participant; the child must give his or her assent to participate and have a parent or guardian provide consent. Further, when children are research participants, IRB members may be more hesitant to approve studies that involve waiver of or exception from informed consent. This is ostensibly because pediatric subjects are considered a more vulnerable population, but there may also be an element of cultural and moral reluctance to “experiment on children.” In addition, expedited review processes often preclude a study population involving children due to them being considered a vulnerable population. Lastly, in some prehospital research where consent is not feasible, while a difficult hurdle, researchers may use mechanisms allowed for consent in emergency situations. As other chapters have described, this approach includes many specific processes including community consultation and significant exclusion provisions. While not technically impossible, obtaining such an approval for a study involving children who are considered by IRB rules a vulnerable population and who in community perception should not be “experiments” is in actuality almost impossible.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Informed consent – pediatric assent
|
Pediatric studies requiring consent are more complicated than adult studies because subject assent is necessary in addition to the consent of a participant's legal guardian. This means that, at a minimum, two groups of people must agree to participate in the study. Similar to consents, assent documents must be submitted to the IRB for approval. Depending on the age of the children involved in the study, there may need to be several forms available that are appropriate for each age group. It is also recognized that not all children have the developmental ability to provide assent; children who are too young may not need to give formal written assent. For those who can understand the issues addressed and questions asked, obtaining the child’s assent must be part of the process. Further, the assent document may be more detailed for adolescents than it is for younger children.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Priority areas of research
|
One could ask many questions when conducting pediatric prehospital research. Several groups have tried to prioritize questions to direct researchers to first answer what are considered the most important ones for the field. Examples of these attempts include the Pediatric Emergency Medicine Research Agenda, EMSC priorities, and recent research highlights in the 2006 IOM report. Some examples of areas that are priorities for research include but in no way are limited to the following. Although pediatric skills deteriorate quickly without practice, continuing education in pediatric care for many EMTs is not required by law or standard practice, or availability is extremely limited. The ability of prehospital providers to acquire pediatric skills, the training needed, and the ability to retain these skills has not been widely studied. All prehospital pediatric protocols are based on the assessment by the prehospital provider, yet there are no studies of the accuracy of such assessments. Many medications prescribed for children are “off-label,” meaning they have not been adequately tested or approved by the US Food and Drug Administration for use in pediatric populations. Further study is needed to verify that these medications, including some used in the prehospital setting, are safe and effective in children. Pediatric treatment patterns vary widely among emergency care providers. Many of these providers do not properly stabilize seriously injured or ill children, many undertreat children in comparison with adults, and many fail to recognize cases of child abuse. Investigations into the occurrence of these issues and efforts to mitigate the deficiencies are needed. Many of the challenges faced in pediatric prehospital care are exacerbated in rural areas, where dedicated, well-intentioned prehospital providers often lack any specialized pediatric training or resources. Research into the abilities and effectiveness of those not specifically trained in pediatric care is needed. Traditional hospital-based providers and thus hospital data were used to guide the early development of pediatric neonatal and critical care transport. Much research is needed in this field, on such issues as the criticality of the patients transported, the use of non-hospital-based providers, predictors of when transport is appropriate and will alter outcome, which techniques can be provided during transport and change outcome, and how we effectively educate providers and assure competency. Recognizing the needs of prehospital systems and providers to be prepared and to act in times of disasters, terrorism, and public health emergencies, it is vital that research on the unique needs of children in these situations be undertaken. Finally, in a 2008 publication addressing a PECARN-specific research agenda, Miller et al. provide a ranked list of 16 multicenter EMSC research topics. Priorities for PECARN researchers included respiratory illnesses/asthma, prediction rules for high-stakes/low-likelihood diseases, reduction of medication errors, injury prevention, and acuity scaling. These are all topics that can be answered through the multicenter network and it is hoped will provide answers to some of the important clinical questions they represent.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Moving forward: challenges and opportunities
|
Clearly the researcher who addresses the prehospital care of children has opportunities to gain knowledge and improve care that far outweigh the challenges posed by the nature of this diverse, vulnerable, and complicated population. Several key gaps still remain, most of which have been identified in the IOM reports and, more recently, by PECARN research agenda. In pediatrics as well as in other prehospital research, there are times when traditional clinical research methods based on directed questions and conducted in a limited number of sites to control all the factors do not translate well to the uncontrolled, multitasking EMS environment. Unfortunately, in some cases the inability to conduct research has led to the use of treatments and practices that have never been studied. However, there are now several resources and some databases available to research teams. These include assistance from professional associations such as the American Academy of Pediatrics, American College of Emergency Physicians, National Association of EMS Physicians, and Emergency Nurses Association as well as academic institutions, state departments of health and EMS, federal agencies (e.g. the federal EMSC program housed at the Maternal and Child Health Bureau, the Agency for Health Care Research and Quality, the CDC’s National Center for Health Statistics and National Center for Injury Prevention and Control, and the National Institute for Child Health and Human Development), and federally funded resource centers and research collaborations (e.g. PECARN). There are fewer excuses in the 21st century to exclude children from prehospital research and myriad compelling reasons to include this population and improve the care of children in the prehospital setting.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Introduction
|
Approximately half of the EM responses to calls for pediatric patients are for medical complaints. Calls for medical complaints outnumber traumatic calls in patients under 5 years. Seizures and respiratory distress are common pediatric medical complaints. Other less common conditions, such as shock, cardiac arrest, and apparent life-threatening events (ALTE), require careful education and training. Controversies exist over management of the pediatric airway, and there is still a need to address the research agendas calling for improved evidence for out-of-hospital pediatric care.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Respiratory and airway problems
|
Cardiopulmonary arrest in the majority of infants and children is respiratory in origin. Appropriate and timely treatment of a child in respiratory distress may prevent respiratory and subsequent cardiac arrest. Many respiratory diseases are unique to children; however, the underlying treatment is the same as for adults: maintenance of the airway and adequate oxygenation and ventilation. Evaluation of the very young patient with respiratory complaints should take place in the parent’s/guardian’s arms if possible. The respiratory rate can increase with fear, and an anxious child may resist therapy and become more distressed. Signs of respiratory distress include a child in tripod position or refusing to lie down, nasal flaring or retractions, and grunting or head bobbing in infants. Interventions may be accomplished more easily with the parent’s assistance. Moving a child from a position of comfort might worsen the respiratory distress. During transport, a child in respiratory distress should be safely restrained in an upright position, unless specific treatments require the supine position. All children in respiratory distress require supplemental high-flow oxygen, such as a face mask at 12–15L/min. The 'blow-by O₂' method administers oxygen by holding the face mask 1–2 inches in front of the child’s face, and is useful when a face mask increases the child’s agitation and work of breathing. If the child is cyanotic, oxygen with assisted bag-valve-mask (BVM) ventilation may be required. The airway should be managed in the least invasive way possible – supraglottic devices and endotracheal intubation (ETI) should be used only if BVM ventilation fails. Anatomical differences in infants and children affect airway management. The occiput is proportionally larger and causes neck flexion in the supine position. Placing a towel roll under the shoulders can improve airway alignment. The tongue is large relative to the oral cavity and is a source of upper airway obstruction. Children have larger tonsils and adenoids. Attempts at nasopharyngeal airway placement or intubation may cause bleeding. During endotracheal intubation, the straight blade is preferred to the curved blade due to the weaker hyoepiglottic ligament and relatively large and floppy epiglottis. The trachea is narrow, increasing the effect of even small decreases in the airway size due to secretions, edema, or external compression. The subglottic region and the non-distensible cricoid cartilage are the narrowest portion of the pediatric airway, unlike in adults, where the vocal cords are the narrowest portion. Wheezing is a frequent EMS pediatric encounter. First-line treatment for acute asthma episodes includes bronchodilators, such as the beta-agonist albuterol, and the anticholinergic ipratropium. Other therapy may include corticosteroids, IV magnesium sulfate, and epinephrine (nebulized or IM injection). Continuous positive airway pressure (CPAP) should be administered for severe respiratory distress of any cause. Bag-valve-mask ventilation should be utilized in children with respiratory failure. It is very difficult to manage ventilation in asthmatic patients who are intubated; therefore, intubation should only occur when high-quality BVM ventilation fails. Other respiratory processes such as bronchiolitis, pneumonia, and airway foreign bodies can cause wheezing. Bronchiolitis is associated with a large amount of mucus production and airway edema, and neonates are at risk of apnea. The airway should be maintained by suctioning the nose and/or mouth when excessive secretions are present. Bronchodilators may be ineffective in bronchiolitis but albuterol should be administered to all children in respiratory distress with signs of bronchospasm. Nebulized epinephrine should be administered if the above treatments fail. Pneumonia usually presents with fever and cough, associated with dyspnea, tachypnea, chest pain, and/or vomiting. Prehospital interventions include oxygen and ventilatory support by the least invasive means. IV access should be obtained if the patient’s status warrants treatment of dehydration with IV fluids. Suspected foreign body airway obstruction is managed according to AHA/ILCOR guidelines. Laryngotracheobronchitis, or croup, causes a characteristic barking cough and can present with stridor. Nebulized epinephrine should be administered to all children in respiratory distress with signs of stridor and can be repeated with unlimited frequency for ongoing distress. Patients who receive nebulized epinephrine should be transported to a receiving facility for continued observation. While key history and physical exam findings can lead the provider to the correct treatment guideline, a key principle should be to treat respiratory distress first, by ensuring an open airway and providing supplemental oxygen, and then consider the differential diagnosis.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Controversies over airway management
|
The current literature highlights shortcomings associated with prehospital pediatric ETI. Few studies show improved outcomes, and several studies describe worsened outcomes. ETI and intubation medications may inadvertently interact with other physiological processes key to resuscitation. Adverse events and errors are frequent. Significant system-level barriers limit training and clinical experiences for prehospital providers and students, and ETI is a complex procedure, requiring a significant amount of training to learn and maintain proficiency. Fortunately, few situations necessitate prehospital ETI. One review documented that ETI was attempted in only 0.7% of all calls for children less than 15 years of age. Paramedics were unable to intubate 18% of these patients. A review from a largely rural state documented that fewer than half of the state’s paramedics attempt at least one pediatric intubation per year; only 2% of providers attempted any pediatric intubation during the 5-year study period. A large prospective controlled trial comparing BVM ventilation to ETI in pediatric medical and trauma patients under 13 years of age demonstrated no survival or neurological outcome benefits in the ETI group. The ETI group had longer scene and total prehospital times. In a review of the National Pediatric Trauma Registry, mortality and abnormal functional outcome scores were more likely in children who were intubated in the prehospital setting versus the hospital setting, controlling for injury severity scores. Observed versus expected rate of mortality was higher for patients intubated in the prehospital setting across all injury severities. Supraglottic airway devices have not been studied in pediatric patients in the prehospital setting; however, use by prehospital providers on pediatric high-fidelity simulators has been studied. Of the available devices, the laryngeal mask airway is available in a range of sizes that allows its use in all ages, including neonates. The King airway device (KingSystems, Noblesville, IN) is limited in pediatric use due to available sizes. The smallest size is recommended for patients as small as 3 feet tall or 12 kg, making them unavailable for patients under the age of approximately 2 years. One key fact remains: proficiency in pediatric BVM ventilation is mandatory for all prehospital providers. The method of airway support used in the system should be based on the skill level of the providers, equipment and medications available, ongoing training and experience, transport times, and medical oversight.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Apparent life-threatening events
|
Apparent life-threatening events (ALTE) may present as a call to 9-1-1 from a frantic parent stating that his or her child has stopped breathing or turned blue. The child may have already recovered to baseline status. An ALTE is defined as 'an episode that is frightening to the observer and that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging. In some cases, the observer fears that the infant has died. Apparent life-threatening event is a diagnosis usually reserved for infants up to age 12 months. ALTE has a reported incidence of 1–9 infants per 1,000 live births, but accounts for 7.5% of infant EMS encounters, 2% of hospitalized children, and 0.7% of infant ED visits. ALTE is more common in younger infants less than 3 months. The literature reports mortality associated with ALTE as being anywhere between <1% and 6%. Greater than 80% of these patients will recover quickly and be well-appearing at the time of evaluation, with no signs of distress. Nearly all will have normal vital signs. The on-scene evaluation for children with ALTE should include close examination of the patient and surroundings for evidence of occult trauma, and a blood glucose measurement. Despite the patient’s well appearance, all those with a chief complaint consistent with ALTE should be transported to the hospital. At least 75% of patients presenting to the ED with ALTE are admitted to hospital. Thirteen percent may need significant intervention during hospitalization. It is prudent to recommend contact with direct medical oversight for caregivers who are refusing medical care and/or transport. The differential diagnosis of ALTE is broad, encompassing gastrointestinal, respiratory, neurological, cardiac, and metabolic disorders. Serious illness causing an ALTE is difficult to exclude during a brief EMS evaluation. Of the very serious causes of ALTE, child abuse has been found in as many as 11% of cases, metabolic disease in 1.5%, ingestion of drugs or toxins in 1.5%, meningitis in 0.5–1%, and cardiac problems in 0.8%. One study noted that a call to 9-1-1 for ALTE was associated with an almost five times greater odds of abusive head trauma being diagnosed as the cause of the ALTE, clearly emphasizing the high index of suspicion EMS providers must have when responding to these calls. Long-term prognosis for infants with ALTE is generally very good. Recurrence of ALTE has been reported as being as high as 24%. ALTE has not been shown to be a risk factor for subsequent sudden infant death syndrome (SIDS).
|
pediatrics.json
|
knowledge
|
pediatrics
|
Seizures and seizure mimics
|
Seizures account for 10% of pediatric calls to 9-1-1. They often are associated with anxiety on the part of the family and bystanders. The EMS physician should be concerned about the cause of the seizure as well as field treatment; however, providers should not diagnose the cause of the seizure before initiating appropriate therapy and transport. For actively seizing patients, a blood glucose level should be measured. A blood glucose of <45 mg/dL in neonates or <60 mg/dL in infants, children, and adolescents should be treated with IV dextrose or IM glucagon. Hypoglycemic pediatric patients should be transported to the hospital, even if they return to baseline mental status after treatment. Febrile seizures occur in 5% of the population and are strictly defined as occurring between ages 6 months and 6 years. Simple febrile seizures are generalized seizures lasting less than 15 minutes and not associated with focal neurological findings. Complex febrile seizures, defined as focal, lasting longer than 15 minutes, or recurring within 24 hours, carry a higher association with serious bacterial infection. Fever associated with seizures can be the result of heat illness or toxin exposure. Patients with epilepsy have a lower seizure threshold during the course of a febrile illness and may have breakthrough seizures at that time. If a high fever is suspected as the cause of seizure, the child can be cooled with wet towels en route, not with ice or cold packs. A list of conditions that mimic seizures can be found in Table 54.2. Notable pediatric-specific conditions include breath-holding spells, which are common in toddlers and usually associated with a painful or temperamental episode. In the neonatal period, benign myoclonus, sleep myoclonus, and jitteriness or exaggerated Moro reflex can mimic motor seizures. Sandifer syndrome is episthotonic posturing associated with gastroesophageal reflux.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Shock
|
Many providers equate shock with hypotension, which may be useful for adults but presents problems when caring for children. Normal blood pressure varies with age and restoring adequate intravascular volume by the administration of 20 mL/kg of a crystalloid (normal saline or Ringer’s lactate) should be initiated quickly (over 5–20 minutes). This can be accomplished by using a 30–60 mL syringe to push fluids through an IV or IO line. If a child’s weight is unknown, a length-based resuscitation tape should be used for fluids, drug dosing, and equipment size. Patients in hypovolemic shock may require up to 60 mL/kg of crystalloid fluid resuscitation. If cardiogenic shock is suspected, smaller fluid boluses of 5–10 mL/kg should be used. In diabetic ketoacidosis with compensated shock, a bolus of 10–20 mL/kg should be administered over 1 hour. If signs of pulmonary edema or worsening tissue perfusion are noted during fluid resuscitation, IV fluids should be stopped. Serum glucose should be measured. A major difficulty in these situations may be the ability of the provider to establish IV access. It has been demonstrated that it is very difficult and time-consuming to establish IV access in young ill children. In some situations, rather than waste precious moments of transport time, it may be useful to 'load and go' and search for access en route. Another method is to limit the number of attempts or time allowed for IV access before IO cannulation is attempted in the appropriate patient. In children with cardiac lesions, where there is mixing of the pulmonary and systemic circulations, careful attention must be directed to the child’s clinical response to interventions. While oxygen is considered empiric therapy for patients in shock, supplemental oxygen relaxes pulmonary vascular resistance and can lead to increased left-to-right shunting. This decreases systemic blood flow, worsening metabolic acidosis. Providers must ascertain from caregivers what the patient’s baseline oxygen saturations are, and should not provide supplemental oxygen that raises saturations above the patient’s baseline. Obtaining an accurate blood pressure in a child can be difficult. Due to children’s unique physiology, when hypotension is present, the body’s compensatory mechanisms have failed and providers should recognize that the child is in a critical condition and at significant risk of death. While compensated shock may persist for hours, once the patient is hypotensive, cardiopulmonary failure may occur within only minutes. Heart rate, initially and on repeated assessments, is the key parameter for recognition of compensated shock. Tachycardia without fever, anxiety, or hypoxia requires immediate intervention. Heart rate varies with age and knowledge of the norms is needed. Assessing pulse quality and comparing peripheral to central pulses is an easy clinical assessment of stroke volume. Delayed capillary refill (>2 seconds) and skin that appears pale, mottled, cool, or diaphoretic are also common signs of shock. A change in the level of consciousness demonstrates the effects of shock on the brain. Although this may be subtle, in children as young as 2 months, irritability or failure to recognize the parents is a sign of cerebral hypoperfusion. A decreasing level of consciousness is an ominous sign. Other parameters to assess include muscle tone and pupillary responses. Shock in children tends to result from hypovolemia, which most commonly occurs in gastroenteritis/dehydration and trauma. Other forms of shock include distributive (maldistribution of blood as occurs in sepsis, anaphylaxis, or spinal cord injury), cardiogenic (resulting from an arrhythmia, congestive heart failure, congenital heart disease, or post arrest), and obstructive (impaired cardiac output due to obstruction of blood flow as from a tension pneumothorax or cardiac tamponade).
Restoring adequate intravascular volume by the administration of 20mL/kg of a crystalloid (normal saline or Ringer's lactate) should be initiated quickly (over 5-20 minutes). This can be accomplished by using a 30-60 mL syringe to push fluids through an IV or IO line. If a child’s weight is unknown, a length-based resuscitation tape should be used for fluids, drug dosing, and equipment size. Patients in hypovolemic shock may require up to 60 mL/kg of crystalloid fluid resuscitation. If cardiogenic shock is suspected, smaller fluid boluses of 5-10 mL/kg should be used. In diabetic ketoacidosis with compensated shock, a bolus of 10-20mL/kg should be administered over 1 hour. If signs of pulmonary edema or worsening tissue perfusion are noted during fluid resuscitation, IV fluids should be stopped. Serum glucose should be measured.
A major difficulty in these situations may be the ability of the provider to establish IV access. It has been demonstrated that it is very difficult and time-consuming to establish IV access in young ill children. In some situations, rather than waste precious moments of transport time, it may be useful to “load and go” and search for access en route. Another method is to limit the number of attempts or time allowed for IV access before IO cannulation is attempted in the appropriate patient.
In children with cardiac lesions, where there is mixing of the pulmonary and systemic circulations, careful attention must be directed to the child’s clinical response to interventions. While oxygen is considered empiric therapy for patients in shock, supplemental oxygen relaxes pulmonary vascular resistance and can lead to increased left-to-right shunting. This decreases systemic blood flow, worsening metabolic acidosis. Providers must ascertain from caregivers what the patient's baseline oxygen saturations are, and should not provide supplemental oxygen that raises saturations above the patient's baseline.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Cardiac arrest
|
Out-of-hospital cardiac arrest (OHCA) is a rare occurrence in childhood, with an incidence of 2.6–19.7 annual cases per 100,000 pediatric population. Survival rates for children who suffer OHCA are 6–12%, and overall intact neurological survival is reported to occur in 4%. In contrast to adults, cardiac arrest in infants and children is usually the end result of respiratory failure or shock, and not of primary cardiac etiology. It is important to emphasize this principle when considering all pediatric prehospital emergencies and educating providers. Despite recent AHA recommendations to teach 'Circulation-Airway-Breathing,' when treating children, airway and ventilation skills are critical to preventing the need for cardiopulmonary resuscitation (CPR). Sudden cardiac arrest (SCA) is much less common in children than in adults. Predisposing conditions for SCA in children include anatomical anomalies, genetic mutations causing channelopathies, and myocarditis, though these may not be diagnosed at the time of SCA. Blunt trauma to the chest and drug intoxication are also associated with SCA. Many cases of SCA in children occur during exercise. SCA in children should be treated as in adults, with immediate high-quality CPR and early defibrillation. The highest incidence of pediatric OHCA occurs in infants, where the majority of cases are unwitnessed. Survival to hospital discharge is higher for patients with witnessed arrests: 13% versus 4.6% for unwitnessed arrest. Favorable neurological outcomes are more common in adolescents than in younger children and adults. Return of spontaneous circulation (ROSC) is achieved in 30% of children with OHCA. Survival to hospital discharge after ROSC is 31–38%, with 31–54% of these survivors having good Cerebral Performance Category scores. The initial rhythm in pediatric cardiac arrest is asystole in 78–80%, pulseless electrical activity (PEA) in 12–13%, and ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in only 4-8%. The most common first documented rhythm in traumatic cardiac arrest is PEA, and in adolescent arrests is VT/VF. Traumatic cardiac arrest is associated with higher morbidity and mortality than non-traumatic cardiac arrest, although survival to hospital discharge is 5–18%, and neurologically favorable outcomes occur in 1–8%. Bystander CPR rates for pediatric patients in cardiac arrest vary greatly (8–85%), but average 30%. A Japanese nationwide prospective study of pediatric cardiac arrest compared patients receiving traditional CPR versus chest compression-only CPR from bystanders. Forty-seven percent of patients received bystander CPR; these patients had significantly higher rates of favorable neurological outcome 1 month after OHCA. Traditional CPR was associated with five times higher odds of a favorable outcome for OHCA from non-cardiac causes and had similar outcomes to chest compression-only CPR for OHCA from cardiac causes. American Heart Association Pediatric Advanced Life Support guidelines recommend early defibrillation for VF and pulseless VT. A dose attenuator is recommended for use with an automated external defibrillator (AED) for children up to 25 kg (approximately 8 years of age). In infants <1 year of age, an AED with a dose attenuator may be used but a manual defibrillator is preferred. If neither is available, a regular AED may be used. There is insufficient evidence to make a recommendation for or against the use of vasopressin for cardiac arrest in children. Therapeutic hypothermia has not been proven to be of benefit in pediatric cardiac arrest. Review of 18 non-randomized studies showed no effect on mortality or good neurological outcome. Ongoing randomized controlled trials may provide definitive evidence in the future. Until there is evidence showing benefit of hypothermia after pediatric cardiac arrest, EMS should not routinely cool children after ROSC. There is evidence that hypothermia improves survival and neurodevelopment in newborns with moderate-to-severe hypoxic ischemic encephalopathy from intrapartum asphyxia. It has been shown that paramedics are uncomfortable terminating CPR in children. Decisions on if and when to terminate resuscitation in the field should be determined by the medical director, ideally with consultation from local pediatric providers. A model offline protocol for termination of resuscitation in children does not exist, and there are very few resources to help guide the medical oversight of this difficult situation. No reliable predictors of outcome have been identified to guide when to terminate resuscitative efforts. Some variables associated with survival are duration of CPR, number of doses of epinephrine, age, witnessed versus unwitnessed arrest, and the first rhythm.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Conclusion
|
Although pediatric calls account for only a small percent of EMS runs, they cause anxiety for providers. Some factors, such as training and appropriate equipment, can be addressed beforehand; other aspects cannot. The physician's level of comfort when providing direct medical oversight on pediatric calls will be discerned by the prehospital care providers. Patient assessment skills are the cornerstone of therapy because treatment and triage decisions are based on this information. Providing oxygen is basic but decisions regarding IV access, medications, and airway interventions should be based on the age of the child, transport time, and the information related by the prehospital care providers. Frequent reassessment should be performed en route; in many cases, a child will be stabilized on arrival in the ED due to prehospital care and expertise.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Epidemiology of prehospital pediatric care
|
Despite the fact that pediatric calls account for only 13% of ambulance runs, they provoke a disproportionate degree of concern and anxiety for prehospital care providers and, in turn, medical oversight physicians. A recent study by the Pediatric Emergency Care Applied Research Network (PECARN) from 14 EMS ground agencies across 11 states found that the most common chief complaints were traumatic injury (29%), general illness (10%), respiratory distress (9%), behavioral/psychiatric disorder (8.6%), seizure (7.45%), pain/non-chest/non-abdomen (6.5%), abdominal pain/problems (4.5%), and asthma (3.9%). Prehospital care providers may be uncomfortable with pediatric patients. This can be due to limited knowledge and skills obtained during initial training, infrequent field experience, or a lack of continuing education. It can also be due to weight-based drug doses and equipment size variations in children. In addition, empathy in treating ill and injured children plays a large role. NAEMSP model pediatric protocols were developed so they would not have to be started from scratch in each system. The particular protocol or algorithm chosen should be based on several factors including the structure of the system (e.g. one-tiered versus two-tiered; EMT versus paramedic), scope of practice decisions, transport times, continuing education requirements, skills retention, system quality improvement, and, of course, resources.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Evaluation of children
|
Evaluation is an area in which children are truly different. An accurate assessment of a pediatric patient is the key to proper field evaluation and treatment and, in turn, appropriate direct medical oversight. Evaluation should be tailored to each child in terms of age, size, and developmental level.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Pediatric Assessment Triangle
|
A useful learning tool that may be beneficial for providers is the Pediatric Assessment Triangle (PAT), which looks at Appearance, work of Breathing, and Circulation – a variation on the classic ABCs of primary assessment. This tool was developed by the Pediatric Education for Paramedics Task Force and has been incorporated into the Pediatric Education for Prehospital Professionals (PEPP) program and Advanced Pediatric Life Support (APLS) course. The PAT allows the prehospital provider to develop a general impression of the child and determine if life support is needed urgently. The three parts of the triangle are done by watching and listening to the patient and do not require equipment. They can be accomplished from across the room and can be completed in 30–60 seconds.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Appearance
|
This is the most important component as it determines the severity of injury or illness. It consists of five characteristics, the TICLS mnemonic: Tone, Interactiveness, Consolability, Look/gaze, and Speech/cry. Assessment of tone includes: Is the child moving vigorously or is he limp? Interactiveness reflects how alert the child is: does she react to a voice or an object? Does the child reach for a toy or is he uninterested? Is the child consolable; can she be comforted? Look/gaze: Does the child look at the EMS provider or caregiver, or does the child have a blank expressionless face? Speech/cry: Is the cry or voice strong or weak?
|
pediatrics.json
|
knowledge
|
pediatrics
|
Work of Breathing
|
This portion of the tool can give the provider a quick indication of oxygenation and ventilation and can be done without a stethoscope. The characteristics to note include: abnormal airway sounds such as grunting, wheezing, or muffled phonation; abnormal positioning such as the tripod position, sniffing position, or refusing to lie down; presence and location of retractions; presence of nasal flaring.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Circulation to the skin
|
This helps determine the adequacy of perfusion to vital organs, using three characteristics: pallor, which reflects inadequate blood flow; mottling, which is due to vasoconstriction; cyanosis, which is blue coloration of the skin and mucous membranes. If there is an abnormality in one or more aspects of the triangle, this can help the provider decide how severely ill or injured the child is and the most likely physiological abnormality. For example, abnormal appearance and breathing point to a respiratory problem, whereas abnormal appearance and circulation point to a circulatory disorder. Abnormalities in all three areas point to a critically ill child who requires rapid scene interventions.
The next step in patient assessment is the ABCDEs: A – Airway: Assessment of the patient’s airway should include: Is it patent? Is the child maintaining his or her own airway or is assistance needed in the form of airway positioning: jaw thrust, chin-lift, oral airway, nasal airway, bag-mask, or endotracheal (ET) tube? B – Breathing: Respiratory rate varies with age and can be very difficult to obtain in a crying child. Children in respiratory distress will usually breathe fast but as they tire, the rate will decrease, which is an ominous sign. When one listens to the chest, are there any adventitious sounds (grunting, stridor, wheezing, rales, rhonchi) or no sounds (no air movement)? Depending on available equipment, the use of a pulse oximeter can help determine oxygen saturation and the need for supplemental oxygen and/or assisted ventilation. C – Circulation: Determining heart rate and strength of peripheral pulses (radial) can be accomplished together. Heart rate varies with age and can also increase with fever and anxiety, but a heart rate below the normal range is worrisome and can imply hypoxia or pending arrest. If peripheral pulses are weak, central pulses should be checked as a means of assessing circulation. Capillary refill, which should be less than 2 seconds, can be assessed with the evaluation of the temperature and color of the extremity. Cold, blue, pale, or mottled extremities indicate poor circulation and shock. Although obtaining a blood pressure is part of the vital signs, in children it is often inaccurate because of the wrong size cuff or a fighting child. A normal blood pressure in the face of some of the above abnormalities should not make a prehospital care provider comfortable. In fact, hypotension in a child is a late finding of shock. D – Disability: This is a brief assessment of level of consciousness (mental status). The key is a quick assessment done initially as general appearance, so this is a recheck. It is not necessary to memorize a pediatric Glasgow Coma Scale, as a rapid assessment uses the mnemonic AVPU: Awake, responsive to Voice, responsive to Pain, and Unresponsive. E – Exposure: Although parts of the ABCDEs require that parts of the body be exposed for a complete assessment, it is necessary to ensure that all of the child’s body has been examined to fully evaluate any abnormalities. At the same time, it is also important to prevent heat loss and hypothermia.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Vital signs
|
One of the most challenging aspects for prehospital care providers in the assessment of infants and children is that their vital signs change with age, so it is difficult to remember what is within a normal range. Having a table with appropriate vital signs for age is an easy way to solve this problem.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Heart rate
|
A child’s heart rate decreases with age. Counting an infant’s very fast heart rate can be difficult by auscultation in a screaming child. It is often easier to feel the pulse as this is not as threatening. In an infant, the brachial pulse can be used while in a child or adolescent, the radial pulse is useful. While counting the pulse, one can also assess pulse quality (strong versus weak). A fast heart rate can be due to fever, pain, anxiety, or fear but can also be due to shock or hypoxia. Watching the trend of the heart rate is also useful once you intervene, to see if the patient is improving. Any heart rate >220 in an infant or >180 in a child deserves prompt action. While this may be due to sinus tachycardia, it is also important to determine if this is supraventricular tachycardia. A slow heart rate (<60) in a symptomatic child (altered mental status, hypoxia, poor pulse quality) should prompt cardiopulmonary resuscitation (CPR).
|
pediatrics.json
|
knowledge
|
pediatrics
|
Respiratory rate
|
A child's respiratory rate also decreases with age. When counting respirations, especially in infants, it is important to count for 30 seconds, then double the number, as very young infants may have periodic breathing (short periods of apnea of 5 seconds, followed by rapid breathing). Try to count respirations when the child is calm, as crying does not provide an accurate respiratory rate. A child's respiratory rate can be elevated due to fever, pain, fear, or anxiety, as well as respiratory distress. It is important to assess the respiratory rate with additional information provided by the PAT such as signs of increased work of breathing (e.g. retractions, abnormal airway sounds). Beware of a slow respiratory rate, as this can signal respiratory failure.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Blood pressure
|
Blood pressure determination is often difficult in a child due to lack of proper cuff size or agitation of the child caused by the cuff tightening. The proper size cuff has a width two-thirds the length of the upper arm (or thigh). In children under age 3 years, it may be difficult to obtain an accurate blood pressure, so use of other information such as heart rate, pulse quality, and capillary refill time (normally less than 2–3 seconds) can provide needed information about the child's condition. (An infant or young child with a rapid heart rate, weak pulses, and delayed capillary refill is in shock whether the blood pressure is normal or not.) In a child, it is often difficult to obtain both the systolic and diastolic blood pressure due to movement, so obtaining a systolic pressure by palpation (rather than auscultation) is useful. For children older than 1 year of age, the systolic blood pressure should be greater than 70 + (2 × age of child in years). If it is less than this, there is hypotension.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Pain
|
Pain is now considered the fourth vital sign but once again, assessing pain in children is not easy. A crying infant can be in pain, hungry, or just wet. A toddler may not understand the word “pain” but recognize “boo-boo” or “owie.” In older children, use of self-reporting scales such as the visual analog scale (VAS) (e.g. 0 no pain to 10 the worse pain in my life) is possible; however, language barriers may prevent understanding. The Wong-Baker FACES scale has been used in hospital settings. There are other scales, including the FLACC observational scale and CHEOPS, which use observations on the infant/child’s cry, facial expression, and leg movement to provide a total score. The Oucher and Faces Pain Scale-revised use a 0–10 score that has the child match his or her facial expression, similar to the Wong-Baker FACES scale. No matter which scale is used, once pain is assessed and treated, it should be reassessed to see if the pain has decreased.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Weight measurement
|
While parents may know their child’s weight in pounds, medication dosing in children is by kilograms. While it is possible to mentally divide the weight in pounds by 2.2 to get kilograms, it may be easier and more reliable to use a calculator or phone application. If the parent does not know the child’s weight or no parent/caregiver is available, there are a few tools one can use. The easiest is a length-based tape that takes the child’s length and provides a weight in kilograms. The Broselow Pediatric Emergency Tape is the one commonly in use. This tape goes from 3 to 36 kg and should be placed with the red portion at the child’s head, and the weight is measured at the child’s heel. A benefit of this device is that it provides equipment size as well as medication doses in mg, except for resuscitation medications that are in mL. Other formulas for weight include: 1–10 years: (age × 2) + 10 (kg), or for those >10 years: (age × 2) + 20 kg, and Luscombe and Owens (3 × age + 7). The midarm circumference formula (weight (kg) = (mid-arm circumference [cm]−10) × 3) was useful to estimate body weight in Chinese children. Another device called the MERCY Tape is based upon weight estimation using the mid-upper arm circumference and humeral length, and estimates weight more accurately in obese children than the Broselow tape. A recent concern is that the Broselow tape underestimates a child’s weight due to the obesity epidemic in the US. The length-based tape assumes lean body mass, and the weight given is the 50th percentile for any measured length. Resuscitation drugs (epinephrine) have a small volume of distribution and clearance, which is associated with lean body mass, not the actual body weight. Lean body weight is similar to ideal body weight, so these drugs are best dosed by ideal body weight. Those drugs that are lipid soluble are best dosed by actual body weight, but if a child is overweight, toxicity can occur if the drug has a narrow therapeutic window. In realistic terms, if the calculated drug dose for an obese child is greater than the adult dose, use the adult dose. In addition, length is the best predictor of equipment size needed as well, so adding a few kilograms to the weight estimated by the Broselow tape is not recommended!
|
pediatrics.json
|
knowledge
|
pediatrics
|
Specialized equipment needs
|
As mentioned above, children of different ages and sizes require different sized equipment. The length-based tape or computer or telephone applications can provide this information, but they are all useless unless you have the right equipment in your ambulance. Numerous organizations, including NAEMSP, recently revised the 2009 Policy Statement: Equipment for Ground Ambulances. This new policy includes a list of core equipment for both BLS and ALS ambulances, for adults and children. While states may mandate equipment or allow EMS regions or medical directors to dictate what equipment is carried based on scope of practice and other factors, this consensus document represents the latest guidelines.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Developmental approach
|
Another important consideration in taking care of pediatric patients is the various developmental levels. A 6-month-old crying infant cannot tell you where it hurts while an injured 15 year old can, but may not disclose important information in front of his or her parents or friends. Understanding some of the developmental characteristics of children can assist you in your evaluation of the patient.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Infants
|
Infants under 2 months have a very limited repertoire. They cannot tell the difference between you and their caregivers by sight, but may turn to their mother's voice. When evaluating them, it is important to keep them warm, allow the parents to hold them if possible, and speak in a soothing voice. Those from 2 to 6 months can make eye contact and recognize their caregivers. They are also more active, and those older than 3 months can roll over. They may follow objects or light with their eyes, and they bring objects to their mouths, so don't offer anything small! Once again, evaluate them in a parent's lap, and try to get down to their level (squat down or evaluate them when you are on your knees). Those between 6 and 12 months are gaining gross motor skills, which include going from sitting by themselves to crawling, to cruising (walking while holding onto an object), and some can walk by 12 months. Their verbal skills are still limited, saying only a few simple words (mama, dada). A key development during this time is that they experience stranger anxiety. This means that they know you are not their parent/caregiver, and do not like to be separated from them. Once again, during your evaluation keep the child with the parents and, if possible, during transport, keep the parents in eyesight or within voice range. Other tips for evaluating infants is allowing parents to offer a pacifier, toy, or blanket, and allowing the parents to remove or lift the infant's clothes. Evaluate them based on their activity level: if they are calm, listen to the heart rate and respiratory rate first. If not, save this for later as they become more accustomed to you. Perform the most uncomfortable or distressing part of the exam last.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Toddlers
|
Toddlers are considered ages 1–3, and are gaining verbal and fine and gross motor skills rapidly. They can walk, run, play with toys, and feed themselves. Some say only a few words but others speak in phrases, and definitely say “no” They are very fearful of strangers, curious but not aware of danger, and very opinionated. On the other hand, they are playful and enjoy make-believe. During your evaluation, use the toddler’s name and talk to them in a friendly tone of voice. Use distraction and play to gain their confidence and cooperation. Ask the parent/caregivers to help with the exam. Speak in simple terms and give the patient limited choices. If there is a critical portion of the exam, do that first, then work from toes to head. Despite their small size, they can put up quite a fight during your exam and therefore a combination of patience and parental assistance may be needed.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Preschoolers
|
Preschoolers include those 3–5 years of age. They are very mobile, speak in sentences and have a large vocabulary. They are creative thinkers but also illogical. They have many misconceptions about bodily functions and illness, and fear being left alone. Evaluation tips include distraction (use one of their toys to demonstrate what you will be doing), choosing your words carefully, and allowing the patient to participate in the exam (hold the stethoscope or let them listen to their heart).
|
pediatrics.json
|
knowledge
|
pediatrics
|
School-aged children
|
School-aged children are those who attend elementary and middle schools. They are independent, talkative, and have a fair understanding of illness and injury. They fear being different from friends and being separated from parents and friends, and do not like loss of control. When ill or injured, this independence is threatened, so the child may be angry and put up resistance to evaluation, especially in front of friends. It is important to establish trust with the patient and explain to them in simple terms what you are going to do, but don’t negotiate. It may be beneficial to give the patient privacy by completing the evaluation in the ambulance, and praise them for their cooperation. You can perform the evaluation in a head-to-toe manner.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Adolescents and teenagers
|
Adolescents can be rational and can express themselves well. They often like to take risks, even though they may understand the possible consequences. Friends take a front seat to parents and they like to appear independent of their parents. When evaluating adolescents, use their name and respect their modesty and privacy. They may not provide all past medical information in front of their friends, and may not divulge drug or alcohol use in front of their parents. Speak directly to them, explain what you are going to do, and be honest. If they are uncooperative, friends may be able to provide some assistance.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Children with special health care needs
|
One of the most important aspects of evaluating a child with special health care needs is to ask a parent or caregiver their developmental level and baseline activities. The child may have physical disabilities but be developmentally normal for age, or have severe impairments in speech and mental abilities. This affects not only their baseline vital signs, weight, and size, but their response to illness and injury. Evaluation includes asking the parent/caregiver what is different from normal, asking them the best approach to the child, and enlisting their help. Ask if they have a special emergency information form, which can provide EMS with past medical history, allergies (especially latex allergy), medications, and where they usually receive their medical care. Ask the parent if they have a “go bag” which has all the special equipment they need for transport and hospital visits. In many cases, these children obtain their care at a children’s hospital farther than the local hospital, and that is where the parents are most comfortable. EMS personnel may need to contact medical oversight for approval if transport to the preferred hospital is outside their protocols.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Consent issues
|
When taking care of pediatric patients, consent issues may arise. While parents commonly provide consent for treatment, if an injury occurs without them, several legal issues can arise. Obtaining informed consent is required by law but children cannot provide informed consent, because they are considered to be minors (less than 18 years of age), unless they are emancipated minors. Emancipated minor laws vary from state to state but in most states, emancipated minors include those who are married, have a child, are pregnant, are on active military duty, or are not living at home and are self-supporting, no matter what their age. The emancipated minor can consent to treatment as well as refuse treatment by EMS. There are emergency situations when no parent or legal guardian is available and the child needs medical care and transport. In this case the emergency exception rule/implied consent is in effect, but the following four conditions must be met: the child’s legal guardian is unavailable or unable to provide consent for treatment or transport; the child is suffering from an emergency condition that places his or her life or health in danger; treatment or transport cannot be delayed until consent can be obtained; only treatment for the emergency condition is administered by EMS. In cases where implied consent is used, excellent documentation is required, including that attempts were made to contact the guardian, the nature of the injury and treatment provided, and why it was an emergency. The EMS provider should contact medical oversight if guardians are not available or if unsure about transporting the patient. Mature minors are those who have been declared adults by the court. The age also varies by state but is usually older than 14 years. A mature minor can refuse treatment and transport for him or herself, as long as he or she is not on a psychiatric hold and is competent to make the decision to refuse. If the guardians refuse transport of a child, a few conditions should be met. They must be alert, mentally competent, and oriented. In these cases, the EMS provider should contact medical oversight to either have a physician control speak to the parent to convince him or her to allow treatment and transport, or get approval for the refusal. If medical oversight feels that emergency treatment and transport are needed, or if the parent is not competent, law enforcement may be needed to take temporary protective custody of the child. Each state differs somewhat in who can take temporary protective custody but law enforcement is one of the groups in all states. A key fact is that, if temporary protective custody is taken, this allows EMS to transport the child to a hospital for a medical evaluation but not to treat a non-life-threatening illness or injury.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Introduction
|
Child maltreatment is a serious public health problem. In 2011, an estimated 3.4 million referrals involving approximately 6.2 million children were made to Child Protective Service (CPS) agencies nationally. An estimated 676,569 children were determined to be victims of abuse or neglect. Of these, 78.5% experienced neglect, 17.6% were physically abused, 9.1% were sexually abused, and approximately 9% experienced emotional or psychological abuse. An estimated 1,570 children died of abuse or neglect in 2011, with a rate of 2.10 per 100,000 in the total US population. Although any child may fall victim to child abuse, the most vulnerable groups are infants, preverbal children, and children with chronic diseases and disabilities.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Role of the prehospital provider
|
Emergency medical services physicians and personnel play an important role in recognizing and reporting child maltreatment. They frequently have the opportunity to assess the scene and home environment as well as the interactions between the child and the caregiver(s). If there are any suspicions for maltreatment, it is vitally important that appropriate interventions are implemented to protect the child as mortality is known to be significantly higher in children who experience repeated episodes of non-accidental trauma. Observations made by prehospital providers can be invaluable to physicians, nurses, other health care providers, child welfare workers, and law enforcement personnel who are charged with evaluating and investigating child maltreatment.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Child maltreatment
|
Child maltreatment involves acts of commission and omission that result in harm or threat of potential harm to a child. Acts of commission involve physical, psychological, and sexual abuse. Acts of omission (neglect) may involve failure to provide adequate food, shelter, medical and dental care, and education. A caregiver may also fail to provide adequate supervision or may expose a child to a dangerous or injurious environment, which may be considered neglect.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Assessment and general approach
|
Providing the appropriate level of medical care is the first priority when responding to any illness or injury. This priority does not change when responding to children who are victims of maltreatment. BLS and ALS measures should be implemented as indicated after provider safety is assured. Scene assessment and investigation, although very important in understanding mechanisms of injury and the relationship to real or potential maltreatment, should not impede the delivery of expedient and appropriate medical care. Pediatric ABCs and the primary survey are discussed elsewhere and will not be specifically addressed in this chapter.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Secondary survey: signs and symptoms suggestive of abuse or neglect
|
The secondary survey should involve a careful examination of the child, especially the skin surfaces. The most common manifestations of child abuse are cutaneous injuries; therefore, a detailed physical examination is essential in identifying suspicious findings. Bruising, burns, and bite marks are often observed in children who have sustained physical abuse. However, children may have no obvious cutaneous findings and still be victims of physical abuse. For example, the presence of bruising with inflicted rib and extremity fractures has been shown to be uncommon.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Bruising
|
The age and developmental level of the child should be considered when understanding mechanisms and resulting injuries. Bruising is rare in infants before they begin to walk or crawl. When bruising is identified in this age group and a credible history is not obtained from the caregiver, abuse should be considered and the child should receive an appropriate medical evaluation. For mobile children, accidental bruising is more common to certain areas of the body. Skin overlying bony prominences is more likely to bruise from accidental causes such as play activities or falls. Areas over the knees, anterior tibial area, forehead, hips, lower arms, and spine commonly demonstrate bruising from accidental causes. However, this does not guarantee that bruising over these areas cannot result from inflicted trauma. Bruising over more protected areas such as the upper arms, medial and posterior thighs, hands, torso, cheeks, ears, neck, genitalia, and buttocks is more frequently associated with inflicted trauma. The observation of bruising over these areas should raise suspicions for maltreatment. However, bruising over these areas can also occur accidentally; therefore, obtaining a careful history regarding the injuries that may have led to the bruising becomes important in assessing whether or not the injuries are compatible with the caregiver's account and the child’s developmental abilities. Observations that increase concerns for inflicted trauma include multiple sites of bruising and bruising that demonstrates a pattern. Research has shown that dating of bruises (e.g. by the progression of colors) is unreliable. A finding of multiple bruises over the body of a child should increase concerns for inflicted trauma.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Burns
|
Burns are common injuries in children and may occur from both accidental and inflicted causes. Abusive burns represent about 10% of pediatric burns. Most common abusive burns will be scald burns such as immersion burns. Abusive burns may also occur from contact with hot thermal sources, chemicals, electricity, and even microwaves. Obtaining information concerning the history of the burn, to include the mechanism and timing, is important in understanding if an abusive or neglectful injury may have occurred. The history should be correlated not only with the physical presentation of the injury but also with the developmental level of the child if the caregiver is reporting an action on the behalf of the child that led to the burn. Any mismatch with respect to the reported history, a changing history, mechanism, appearance and developmental level of the child should be documented. Delays in seeking care for burns may also represent abuse and neglect, and therefore documenting the reported timing of the burn is important.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Fractures
|
It is estimated that 11–55% of pediatric fractures are the result of physical abuse. Younger children are particularly at risk for sustaining abusive fractures: 55–70% of all abusive fractures occur in infants less than 1 year of age. With respect to orthopedic injuries, a careful history and secondary survey are vital when assessing the young child. EMS providers do not have the advantage of radiography in determining if a child has a fracture. Some children may not exhibit signs such as guarding, deformity, swelling, or pain, thus creating difficulty in making safe and accurate assessments.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Transport decisions
|
Before determining that a child does not require EMS transport, careful consideration should be given to the age of the child, the ability to adequately determine if a fracture or other injury exists, and the history given by the caregivers. Any child with a suspicious or concerning history surrounding the injury should be transported to medical care.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Scene survey
|
Emergency medical services providers are in an excellent position to provide valuable information about the scene and circumstances of the call. In many instances, they will be able to observe and confirm or refute the details provided by the caregiver and communicate these to the medical providers. This type of information becomes very important when determining the credibility of the history and the injuries sustained by the child.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Obtaining the history
|
Obtaining a concise and detailed history will obviously depend on the acuity of the child’s condition. The ability of the child to respond to questions is contingent on age and developmental level as well as the degree of injury. A verbal child may be able to answer simple questions such as “what happened?” but he or she may not be able to answer questions relating to how, where, or when. The following questions should be asked of the caregiver. • How did the injury occur? • Where did the injury occur? • When did it happen? • Who witnessed the event? • What is the child’s medical history? • Who is the child’s regular medical provider? The provider should think about the responses to the questions in terms of a credible explanation for the observed injuries. • Is the explanation credible? Does the injury pattern fit the manner in which the caretaker describes the incident? • Does the scene assessment support the alleged mechanism of injury? • Was there a long delay before seeking medical attention? • If there are histories from more than one source, are they consistent? • Was there adequate supervision of the child? • Does the child have preexisting medical, psychological, or developmental problems? • Does the child have a current health care provider? When was the last time the child saw a health care provider? Has this child been seen by EMS for a previous concern?
|
pediatrics.json
|
knowledge
|
pediatrics
|
Communicating with the child and caregivers
|
Method and style of communication are very important when dealing with situations surrounding possible child maltreatment. Judgmental and accusatory questioning may only serve to threaten the caregiver and incite defensiveness or aggression. Maintaining objectivity is very important in managing interactions with the child and caregiver. The provider should avoid challenging the child or caregiver on the proposed history and mechanisms for observed injuries.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Documentation
|
Accurate, detailed, and concise documentation of the scene, a complete physical examination of the child, and history from the caregiver and child are vitally important. Responses and statements made by the child and the caregiver should be placed in quotes. Conflicting histories should be noted. The objective findings documented by the prehospital provider frequently become very important in the investigation of suspected child maltreatment. Concerns should be carefully communicated to the hospital personnel taking over care of the patient from the EMS providers.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Medical conditions that may be confused with child abuse
|
Numerous medical conditions may present with signs and symptoms that may be confused with child maltreatment. Some of these conditions may have already been identified in the child's history. For example, a child with a blood clotting disorder such as hemophilia is more prone to bruising; however, this should not be interpreted to mean that these children have not been abused. Young children may have skin markings that have the appearance of purplish bruising but are congenital melanosis. These markings are usually found on the lower back and buttocks but can also be on other parts of the body. The caregivers are usually able to give a history of these markings as being present since birth.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Sexual abuse
|
Sexual abuse represents the third most common form of child maltreatment. Research and statistics describing EMS response to child sexual abuse calls are minimal; therefore, it is unknown how frequently these types of calls are encountered in the pre-hospital environment and under what conditions. Because it is rare for an acute case of child sexual abuse to present to medical care, it is reasonable to expect that EMS response will also be relatively rare. EMS providers may respond to a call only to find that there is no medical emergency. A caregiver may call EMS not knowing what other action to take or may simply have no transportation options to access medical care for the child. It is important to understand the dynamics of how child sexual abuse is often disclosed in order to respond appropriately. Children frequently do not disclose abuse when it happens. It may be weeks, months, or even years before a child is able to disclose being sexually abused. Smith et al. found that almost half of all women they interviewed who had sustained rape as a child did not disclose the rape within 5 years of the assault and 28% had never disclosed to anyone until surveyed in their study. Children who are verbal often do not disclose sexual abuse due to threats or other manipulation by the abuser, who is often a trusted relative or friend. One of the more common concerns a caregiver may mention is that the child's genital area appears red or irritated. Other concerns may involve a caregiver or other family member observing suspicious contact or inappropriate touching of the child. Once there is an EMS response to a child sexual abuse call, it becomes vital that the medical, psychosocial, and safety needs of the child and family are addressed. This is a very complex process and requires a multidisciplinary and specialized approach. It is impossible for the EMS responder to address the many issues surrounding this type of event. Some communities have established protocols to address this type of response. When there is no local medical protocol, the best course of action is to transport these children to medical care. Acute medical and forensic interventions are seldom indicated due to the rarity of immediate disclosure or discovery of child sexual abuse. Locales and communities may also have differing time-frames for defining acute for the purposes of immediately evaluating child sexual abuse (72–96 hours is more common but some may consider acute up to 120 hours). However, the presence of any of the following within the established acute time-frame warrants having the child medically evaluated: • discovery or disclosure of suspected sexual abuse occurring within the specified acute time-frame • anogenital pain, bleeding, discharge • contact with the suspected perpetrator within the specified acute time-frame • other extragenital findings concerning for trauma such as bruises, abrasions, etc. • a distressed child and/or caregiver. The greatest responsibilities for the EMS provider are identification of concerns, crisis intervention, and careful documentation. If at all possible, the history from the caregiver should not be taken in front of the child if the child is verbal and capable of understanding. If possible, it is preferable to talk with the child alone. Many issues concerning the credibility of the child's history and disclosure of sexual abuse will arise as the child moves through the medical, social, and legal systems. A limited interview of the child should be conducted to ascertain areas of discomfort or pain. Probing questioning of the disclosure and details surrounding the abuse are better left to professionals who are skilled in the area of child interviewing for the purposes of documenting and diagnosing sexual abuse. If a child spontaneously begins to give the history, allow him or her to do so, and document the history as carefully as possible. Use quotes to differentiate the child’s verbatim words from other documentation because the response and the record may become a vital document in legal proceedings. With acute events, preservation of any evidence on the child’s body should be attempted by carefully handling the child and any clothing the child is wearing. Articles such as diapers, clothing, and the child’s bedding and blankets may yield the best source of recoverable evidence and should be protected and preserved. If law enforcement is at the scene, officers should take possession of these items. If law enforcement is not present then the EMS provider should place each item in a separate brown paper bag, labeling each bag with the patient’s name, date, time of recovery, and provider’s signature. The items may then be turned over to the appropriate medical or hospital staff on arrival to medical care. The EMS provider should document the evidence recovered and to whom it was turned over.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Responding to intimate partner violence calls
|
It is not unusual for EMS to respond to calls involving intimate partner violence (IPV). Concerns for child maltreatment should always be considered when responding to calls where IPV is occurring and children are part of the family unit. Children who reside in homes in which IPV is present are at increased risk of being maltreated and neglected, as well as suffering significant emotional and psychological harm from witnessing the abuse. Appropriate measures should be undertaken to address safety concerns for these children and should involve collaboration with law enforcement, child welfare services, and medical oversight.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Medicolegal duties
|
All states and territories in the United States require reporting suspicions of child abuse. Prehospital providers should have a good understanding of how legal requirements guide reporting in their respective states or jurisdictions. Accurate and detailed written documentation is vital in conveying important information to which the prehospital provider may be privileged based on his or her unique position in the continuum of care. A thorough summary of the assessment and suspicions should be relayed to receiving physicians, nurses, and social workers.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Conclusion
|
Emergency medical services providers are in an excellent position to provide valuable information in the recognition, documentation, and ultimate intervention in cases of child maltreatment, but it is likely that prehospital personnel need more training in recognizing and managing child maltreatment than is typically provided. Field personnel frequently have the opportunity to observe the home and/or the scene and note consistencies or inconsistencies that accompany the history provided by caregivers. EMS providers often see or hear things at the scene or en route that are suspicious and need follow-up or further investigation. Accurate documentation of the history and observations made is vital in the comprehensive assessment of child maltreatment.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Key Terms
|
Adult: For the purpose of providing emergency medical care, anyone who appears to be approximately 12 years old or older., Apparent life-threatening event (ALTE): A sudden event in infants under the age of 1 year, during which the infant experiences a combination of symptoms including apnea, change in color, change in muscle tone and coughing or gagging., Child: For the purpose of providing emergency medical care, anyone who appears to be between the ages of about 1 year and about 12 years; when using an automated external defibrillator (AED), different age and weight criteria are used., Child abuse: Action that results in the physical or psychological harm of a child; can be physical, sexual, verbal and/or emotional., Child neglect: The most frequently reported type of abuse in which a parent or guardian fails to provide the necessary, age-appropriate care to a child; insufficient medical or emotional attention or respect given to a child., Croup: A common upper airway virus that affects children under the age of 5., Epidemiology: A branch of medicine that deals with the incidence (rate of occurrence) and prevalence (extent) of disease in populations., Epiglottitis: A serious bacterial infection that causes severe swelling of the epiglottis, which can result in a blocked airway, causing respiratory failure in children; may be fatal., Febrile seizures: Seizure activity brought on by an excessively high fever in a young child or an infant., Fever: An elevated body temperature, beyond normal variation., Infant: For the purpose of providing emergency medical care, anyone who appears to be younger than about 1 year of age., Pediatric Assessment Triangle: A quick initial assessment of a child that involves observation of the child’s appearance, breathing and skin., Respiratory failure: Condition in which the respiratory system fails in oxygenation and/or carbon dioxide elimination; the respiratory system is beginning to shut down; the person may alternate between being agitated and sleepy., Retraction: A visible sinking in of soft tissue between the ribs of a child or an infant., Reye’s syndrome: An illness brought on by high fever that affects the brain and other internal organs; can be caused by the use of aspirin in children and infants., Seizure: A disorder in the brain’s electrical activity, sometimes marked by loss of consciousness and often by uncontrollable muscle movement; also called a convulsion., Shaken baby syndrome: A type of abuse in which a young child has been shaken harshly, causing swelling of the brain and brain damage., Status asthmaticus: A potentially fatal episode of asthma in which the patient does not respond to usual inhaled medications., Sudden infant death syndrome (SIDS): The sudden death of an infant younger than 1 year that remains unexplained after the performance of a complete postmortem investigation, including an autopsy, an examination of the scene of death and a review of the care history., Thready: Used to describe a pulse that is barely perceptible, often rapid and feels like a fine thread.
|
pediatrics.json
|
knowledge
|
pediatrics
|
INTRODUCTION
|
In an emergency, you should be aware of the special healthcare or functional needs and considerations of children and infants. Knowing these needs and considerations will help you better understand the nature of the emergency and provide appropriate care. A young child may be scared or nervous due to the circumstances of the emergency, because they are being assessed by a stranger, a combination of those reasons or some other reason. Being able to communicate with and reassure children and infants can be crucial to your ability to care for these patients effectively.
|
pediatrics.json
|
knowledge
|
pediatrics
|
ANATOMICAL DIFFERENCES
|
It is important to be aware of the anatomical differences among adults, children and infants. The most significant of these differences involve the airway and breathing. Children and infants have proportionately larger tongues than do adults, so it is easier for the tongue to block the airway. Placing pressure under the chin, which can occur during the head-tilt/chin-lift or jaw-thrust (without head extension) maneuvers, can cause the tongue to be pushed back and block the airway. Newborns and infants prefer to breathe through the nose and may not open their mouths when their nose is blocked, so they are more likely to develop respiratory distress if the nose is blocked. Additionally, the epiglottis is much higher in children and infants than it is in adults. A newborn’s trachea is also very narrow, only about 4 or 5 mm wide, so swelling, for example due to inhaling toxic fumes, can become life threatening very quickly. Children and infants younger than age 5 also breathe at a rate two to three times faster than that of adults, and their breathing is shallower, as less volume and pressure are needed to ventilate the lungs.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Determining the Age Group of the Patient for the Purpose of Providing Emergency Medical Care
|
At times, care must be provided according to the age of the patient and it is not always easy to determine exact age. The American Red Cross follows established age categories for emergency care that are based on epidemiological patterns of injury including care needed, while at the same time being easy to recognize based on the patient’s appearance. Always follow local protocols and medical direction when deciding how to care for a child versus an adult. In general, children and infants predominantly suffer respiratory emergencies, which, if untreated, can lead to cardiac emergencies. Adolescents and adults will often suffer primarily cardiac events. Lastly, an individual can generally look at a patient and determine if the patient is an adult, a child or an infant. At times, a small 13 month old may be categorized as an infant, or a small 13 year old as a child. However, the difference between the perceived age category and the actual age would not have any significant impact on care. Additionally, the easy recognition of a perceived age category helps to provide appropriate care quickly, a benefit that far outweighs any age discrepancy. Based on this physiological, epidemiological and recognition approach, the following general age groups have been developed:
Infant—Anyone who appears to be younger than about 1 year of age.
Child—Anyone who appears to be between the ages of about 1 year and about 12 years. For automated external defibrillator (AED) purposes, based on U.S. Food and Drug Administration (FDA) approval of pediatric-specific devices, a patient who is between the ages of 1 and 8 or weighs less than 55 pounds is considered a child. If precise age or weight is not known, the responder should use best judgment and not delay care to determine age.
Adult—Anyone approximately 12 years old or older.
|
pediatrics.json
|
knowledge
|
pediatrics
|
CRITICAL FACTS
|
It is important to be aware of the anatomical differences among adults, children and infants. The most significant of these differences involve the airway. In general, children and infants predominantly suffer respiratory emergencies, which, if untreated, can lead to cardiac emergencies. Anyone who appears younger than 1 year of age should be considered an infant, 1 to 12 years a child, and 12 and older an adult. Based on this physiological, epidemiological and recognition approach, the following general age groups have been developed: Infant —Anyone who appears to be younger than about 1 year of age. Child —Anyone who appears to be between the ages of about 1 year and about 12 years. For automated external defibrillator (AED) purposes, based on U.S. Food and Drug Administration (FDA) approval of pediatric-specific devices, a patient who is between the ages of 1 and 8 or weighs less than 55 pounds is considered a child. If precise age or weight is not known, the responder should use best judgment and not delay care to determine age. Adult —Anyone approximately 12 years old or older.
|
pediatrics.json
|
knowledge
|
pediatrics
|
CHILD DEVELOPMENT - Infants (Birth to 1 Year)
|
Infants’ inability to do anything for themselves and their inability to communicate where there may be pain or discomfort makes them among the most vulnerable of children and patients. After the first few weeks of birth, an infant can usually recognize a parent’s or caregiver’s voice. After a few months, facial recognition becomes possible. The quality of crying usually differs according to the cause, but the subtleties of the differences may only be recognized by the parent or caregiver. Crying could be triggered by hunger, the need for diapers to be changed, pain, fear or for unknown reasons.
|
pediatrics.json
|
knowledge
|
pediatrics
|
CHILD DEVELOPMENT - Toddlers (1 to 3 Years)
|
Toddlers can readily recognize familiar faces and may be fearful of strangers. They may not be cooperative when dealing with an unknown person, even if the parent or caregiver is in the room. Toddlers may also fear being separated from the people they know. Crying makes it difficult for them to communicate. Some toddlers relate well to stuffed animals, to help them calm down and demonstrate what the problem may be. When dealing with an unknown emergency with a toddler, keep in mind that toddlers’ curiosity about the world around them makes poison ingestion a common injury.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Preschoolers (3 to 5 Years)
|
Preschoolers communicate their ideas more effectively than toddlers, but they may have difficulty with certain concepts. They may have difficulty understanding complex sentences that contain more than one idea, so speak in simple terms. Children at this stage often feel that bad things are caused by their thoughts and behaviors. Their fears may seem out of proportion to the events. The sight of blood may be disturbing, but often a dressing or bandage can help calm the situation.
|
pediatrics.json
|
knowledge
|
pediatrics
|
School-Age Children (6 to 12 Years)
|
Children of school age have been exposed to more unfamiliar faces and are more likely to cooperate with strangers. With reassurance from familiar faces (parents, caregivers, guardians, teachers), they are likely to understand the situation once it has been explained, and are able to cooperate with emergency responders. This age group is often fascinated with the topic of death and may have strong fantasies or imaginary ideas. Children of school age need continual reassurance.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Adolescents/Teens (13 to 18 Years)
|
The characteristics of adolescents and teens vary quite a bit from the beginning of the age group (age 13) to the end (age 18). Thirteen year olds are just leaving the school-age group, and 18 year olds are on the cusp of adulthood and already may have had to take on adult responsibilities. Generally, adolescents are more able to provide accurate information and cooperate with emergency responders. However, they may be apt to fall into mass hysteria, in which multiple adolescents feel they are all experiencing the same problems or symptoms. This requires understanding and tolerance on behalf of the emergency responder. Generally, this group is quite modest and will require privacy. They are also aware of the potential for fatality or permanent disability and often fear they will experience this.
|
pediatrics.json
|
knowledge
|
pediatrics
|
ASSESSING PEDIATRICS - General Considerations
|
Assessing an injured or sick child is similar to assessing an adult, with a few differences. Primary assessments on a conscious child should be done unobtrusively, so the child has time to get used to you and feel less threatened. Try to carry out as many of the components of the initial evaluation by careful observation, without touching the child or infant. Approach the parent or caregiver, if possible, as the child will see you communicating with them and subsequently may feel more comfortable with your exam and treatment. If appropriate, a parent or caregiver may hold the child during assessment and treatment. Observe the young patient to assess for breathing, the presence of blood, movement and general appearance. If the child is showing signs or symptoms of a serious injury or illness, start the assessment using the head-to-toe approach. If the child is agitated or upset and there are no signs or symptoms of a serious injury or illness, the assessment can be done toe to head, which allows the patient to get used to you rather than have you in their face from the start. When treating children, remember that you are also treating their parent or caregiver as they, too, are likely to be scared or stressed. Reassess continuously as you wait for more advanced medical support to arrive. Document and report all your findings to more advanced medical personnel when they arrive.
|
pediatrics.json
|
knowledge
|
pediatrics
|
ASSESSING PEDIATRICS - Scene Size-Up
|
Begin observing the scene from the moment you arrive. The big picture will allow you to assess the situation and may give clues to other issues, such as child abuse. As usual, also assess the scene for personal safety. Be alert for any signs that may indicate poisoning (empty bottles, for example) and look for signs of child abuse. Are the adults responding in an appropriate manner? Are they appropriately concerned, or are they angry or indifferent? Does the child seem frightened of them and/or their reactions? Does the parent or caregiver answer your questions directly? Is the environment safe for a child? While noting how the patient was found (position and location), keep in mind that the child may have been moved by well-meaning adults. Be sure to ask as part of your patient history. If you have confirmation that the patient has been moved, ask the adults where the child was and how the child was found.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Pediatric Assessment Triangle
|
The Pediatric Assessment Triangle is a quick initial assessment of a child that takes between 15 and 30 seconds and provides a picture of the severity of the child’s or infant’s injury or illness. This is done during the scene size-up as part of forming your general impression and before beginning the primary assessment. It does not require touching the patient, just looking and listening. You should observe three components in the child—appearance, work of breathing and skin: Appearance: Does the child appear to have normal muscle tone? Is the child crying, talking or moving about? Is the child able to interact with you or other adults in the area? Is the child able to make eye contact or be consoled?
Breathing: Does the child appear to be breathing? Does breathing require great effort (flaring nostrils, indrawn area just below the throat or use of abdominal muscles)? Is the child leaning forward in an attempt to breathe? Is any noise coming from the child, such as wheezing or any other abnormal sound?Skin (Circulation): When looking at the child, is the skin pale, mottled or cyanotic (bluish)? Are any signs of trauma or bleeding present?
|
pediatrics.json
|
knowledge
|
pediatrics
|
CRITICAL FACTS 1
|
Assessing an injured or sick child is similar to assessing an adult, with a few differences. Primary assessments on a conscious child should be done unobtrusively, so the child has time to get used to you and feel less threatened. Try to carry out as many of the components of the initial evaluation by careful observation, without touching the child or infant. Observe the young patient to assess for breathing, the presence of blood, movement and general appearance. Unless the child is agitated or upset, start the assessment using the head-to-toe approach. The Pediatric Assessment Triangle is a quick initial assessment of a child that takes between 15 and 30 seconds and provides a picture of the severity of the child’s or infant’s injury or illness. This is done during the scene size-up and before beginning the primary assessment. It does not require touching the patient, just looking and listening.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Equipment for Assessing and Caring for Children and Infants
|
As children come in all different sizes, so does the equipment used to assess them. A wide range of sizes should be available for assessing children, to provide optimal care. Essential equipment and supplies include: Bag-valve-mask (BVM) resuscitators with oxygen reservoirs. Oxygen masks. Non-rebreather masks. Airway adjuncts. Bulb syringe. Portable suction unit with regulator. Suction catheters. Cervical immobilization devices. Backboard and other extrication devices. Extremity splints. Stethoscope for pediatrics. Blood pressure cuffs. Thermal blankets. Water-soluble lubricant. A new, clean stuffed animal and references for the Glasgow Coma Scale and Pediatric Trauma Score are also recommended.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Airway
|
An airway that is open, even if only partially open, will allow the child to cough, cry or breathe. Even with an open airway, the child should be observed closely for any change in status. A child whose airway becomes compromised or shows signs or symptoms of inadequate breathing or a lack of oxygen will need immediate care. A child’s airway can be blocked by anatomical or mechanical obstructions. For example, illness can cause constriction of the bronchi and upper airway as in status asthmaticus (asthma) or anaphylaxis (anatomical). Infection and trauma can also cause swelling and block the airway. Children are prone to airway obstruction caused by small objects as well as food (mechanical). Choking hazards among children include small objects such as coins, buttons, small toys and parts of toys and balloons, as well as certain food items. While hazardous for all children, these objects generally pose a larger threat to children under age 4. If a solid object is blocking the child’s upper airway, oxygen may not enter the lungs. This situation requires immediate care for a conscious choking child or infant; a combination of skills may be needed to clear the airway including abdominal thrusts and back blows for a child, or back blows and chest thrusts for an infant. If secretions are blocking the airway, suctioning will help remove them. The suction may need to be repeated frequently to maintain an open airway, so the child should be monitored at all times.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Ventilation/Oxygenation
|
A child who is in respiratory distress may be agitated or drowsy. Agitation results from trying to get air; drowsiness is the result of insufficient oxygenation. The breathing effort increases in many cases, but as respiratory failure sets in, the breathing effort may decline considerably as the child weakens. Additionally, a combination can occur; the child may breathe with great effort for periods, followed by declining efforts as the child tires. If the child is not breathing adequately or is not breathing at all, ventilation and/or oxygenation will be required. Signs of the need for this assistance would be agitation or drowsiness, limp muscles, inability to respond and a pale or cyanotic appearance.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Circulation
|
Circulation in a child is similar to that of an adult, though the average child’s pulse is more rapid than an adult’s. Observe the child for signs and symptoms of shock, which include restlessness; cold, clammy, pale or ashen skin; rapid or irregular breathing; falling blood pressure; altered mental status; rapid, weak or thready pulse; delayed capillary refill; and an absence of tears if the child or infant is crying. Place the child in the supine position (flat on their back). A child who is in shock or is at risk of going into shock must be kept from getting chilled or overheated. Place a blanket over the child to help maintain the body temperature. Monitor the child closely for any changes in status.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Determining the Level of Consciousness
|
Using the AVPU scale, you can start to determine the child’s level of consciousness (LOC). The AVPU scale is a mnemonic that describes stages of awareness: Alert (the patient can respond to questions and is aware of the surroundings), Voice (the patient responds to verbal stimuli), Pain (the patient only responds to painful stimuli) and Unresponsive (the patient does not respond to any stimuli). The AVPU scale is covered more thoroughly in Chapter 7. Another way to determine the LOC is pupil assessment, which involves checking to see if the pupils react to light. Shine a flashlight or penlight quickly into and then out of the child’s eye. In a normal reaction, the pupil constricts in response to the light and then dilates again after the light is removed. Movement is another good indication of LOC. Observe the child. A fully alert child will have spontaneous movements and as LOC diminishes, so will the movement.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Exposure
|
Despite the need to keep the child covered if you are concerned about shock, you must be able to assess the child properly and thoroughly, barring any life-threatening situation. Check the child for any other injuries or signs of trauma. You do not need to uncover the child completely. You may remove the top part of the blanket to examine the upper body, cover the child and then remove the lower part of the blanket to examine the lower body. Be swift and cover the child as quickly as possible. Because a large proportion of body heat is lost through the head and neck, cover the child’s head to minimize the loss of body heat.
|
pediatrics.json
|
knowledge
|
pediatrics
|
SAMPLE History
|
When taking a child’s SAMPLE (signs and symptoms, allergies, medications, pertinent medical history, last oral intake and events leading up to the incident) history, you will need the parent’s or caregiver’s cooperation. Encourage this cooperation by remaining respectful and polite during the conversation, even if the adult is difficult or if you suspect child abuse or child neglect. Ask questions that require detailed answers, not yes-or-no questions. If the child is young but wants to participate, welcome this. An older child, particularly an adolescent, may want to speak with you privately. Keep this in mind if you must ask sensitive questions about topics such as sexual activity or drug use. If you are not sure that the answers you receive are accurate or contain enough information, try asking the question in another manner, using different phrasing. Use feedback, repeating the answers as you make note of them, to be sure you heard correctly.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Symptoms and Duration
|
Ask the parent, caregiver, or child, if appropriate, about the symptoms, any changes (worsening or easing) and how long they have been present. While obtaining a patient history, inquire about: Fever. Unusual activity level. History of eating, drinking and urine output. History of vomiting, diarrhea and abdominal pain.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Allergies
|
Ask the parent, caregiver or child, if appropriate, if they have any allergies. While obtaining a patient history, inquire about allergies to: Medications. Food. Environmental elements, such as dust, pollen or bees.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Medications
|
Ask the parent or caregiver about medications the child might take. Does the child take any prescription medications or has the parent or caregiver given any over-the-counter medications recently? Does the child have any allergies to medications? Could the child have gotten into someone else’s medications?
|
pediatrics.json
|
knowledge
|
pediatrics
|
CRITICAL FACTS 3
|
You will need the parent’s or caregiver’s cooperation while taking a child’s SAMPLE history. Be respectful and polite, even if you suspect child abuse or neglect. Avoid asking yes-or-no questions. Allow a child to participate; older children may want to talk privately, especially if you must ask sensitive questions concerning sexual activity or drug use.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Pertinent Past Medical Problems or Chronic Illnesses
|
Ask the parent or caregiver if something like this has ever occurred before. If so, what caused it before and what happened in the long run? Does the child have any chronic illnesses, such as asthma or diabetes? Has the child been ill lately with any other type of illness?
|
pediatrics.json
|
knowledge
|
pediatrics
|
Last Oral Intake
|
Ask the parent or caregiver when the child last had something to eat or drink and what it was.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Events Leading Up to the Injury or Illness
|
Ask the parent or caregiver what specifically was going on when the injury or illness was first noticed. What was the environment like (where did it happen)? What was the child doing? What was the child’s reaction?
|
pediatrics.json
|
knowledge
|
pediatrics
|
Physical Exam
|
Conducting a physical exam of a child or an infant requires some special handling. Try to have only one individual deal with the child, to reduce the anxiety of being handled by multiple strangers. If you can, crouch down to the child’s eye level. Speak calmly and softly and maintain eye contact. Be gentle and never lose your temper. Involve people who are familiar to the child, if possible. For preschoolers, save frightening tools like stethoscopes until the child has had a chance to get used to you. When examining a child, the standard procedure is to go from head to toe. For a very agitated child, however, the exam may be more successful if it is performed toe to head. A head-to-toe exam involves the following components: Head: Look for bruising or swelling. Ears: Look for drainage suggestive of trauma or infection. Mouth: Look for loose teeth, identifiable odors or bleeding. Neck: Look for abnormal bruising. Chest and back: Look for bruises, injuries or rashes. Extremities: Look for deformities, swelling or pain on movement.
|
pediatrics.json
|
knowledge
|
pediatrics
|
COMMON PROBLEMS IN PEDIATRIC PATIENTS - Airway Obstructions
|
Some of the most common airway problems you may encounter with small children and infants are airway obstructions. Airway obstructions may be categorized as either partial or complete. Signs of a partial airway obstruction in a child or an infant who is alert and sitting up include: Abnormal high-pitched musical sounds, crowing or noisy respirations. Retraction . Drooling. Frequent coughing. Keep the child or infant in a position of comfort, possibly sitting on a parent’s or caregiver’s lap. The child can stay there while you administer supplemental oxygen based on local protocols. A complete airway obstruction is a life-threatening situation. A partial airway obstruction in a child or an infant who is showing signs of cyanosis should be treated as a complete airway obstruction. Signs of a complete airway obstruction include: Inability to cough, cry or speak. Cyanosis. Loss of consciousness. Altered mental status. Care includes clearing the airway and attempting ventilation using the mouth-to-mask technique. For more information on clearing airway obstructions in children and infants, refer to Chapter 11.
|
pediatrics.json
|
knowledge
|
pediatrics
|
COMMON PROBLEMS IN PEDIATRIC PATIENTS - Breathing Emergencies
|
Respiratory distress is apparent when the child or infant begins to experience difficulty breathing. If uncorrected, respiratory distress can lead to respiratory failure.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Anatomic and Physiological Differences in Children
|
Anatomical differences among adults, children and infants can change their susceptibility to respiratory difficulties and affect how to provide emergency care: In children and infants, the tongue is larger in relation to the space in the mouth than it is in adults. This can increase the risk of the tongue blocking the trachea.
In children, the airway is smaller, resulting in more objects, such as different types of solid foods, being a choking hazard. Their smaller airway can make children more prone to developing infections or amassing liquid secretions. This also affects the choice of ventilation equipment used.
In children, the trachea is not as long as it is in adults, so any attempt to open the airway by tilting the child’s head too far back will result in blocking the airway.
Children breathe using their diaphragm, so ensure nothing is pressing on the abdomen to prevent this. Also, if possible, allow the child to sit up.
Young children and infants do not usually breathe through their mouth; they breathe through their nose. Ensure that the nose is as clear as possible for breathing.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Pathophysiology
|
The process of respiratory emergencies usually follows the pattern of respiratory distress, followed by respiratory failure, which is then followed by respiratory arrest if emergency interventions are not attempted or are not successful.
Respiratory distress occurs when the child is having trouble breathing but is visibly able to breathe. A child in respiratory distress may be mentally alert and/or agitated. The patient’s breathing effort is increased and the skin color may be normal or pale.
Respiratory distress preceding respiratory failure is characterized by:
In infants, a respiratory rate of more than 60 breaths per minute.
In children, a respiratory rate of more than 30 breaths per minute.
Flaring of the nostrils.
Use of neck muscles and muscles between and below the margin of the ribs to aid in breathing.
Abnormal, high-pitched sounds when breathing. Cyanosis.
Altered mental status.
Grunting.
Respiratory failure occurs when the respiratory system is beginning to shut down. The child may be sleepy and lethargic, or may alternate between being agitated and sleepy. Muscle tone is generally limp, breathing is usually visible, and breathing can decrease or alternate between increased and weak effort as the child becomes tired. The skin is usually pale, mottled or cyanotic.
Respiratory arrest occurs when the respiratory system shuts down. The child is unconscious and completely limp. Signs of breathing may be slight, but are most likely absent, and the skin color is cyanotic.
The importance of recognizing early signs of respiratory distress cannot be emphasized enough. Early recognition of respiratory emergencies can make the difference between life and death. More information on the recognition and care of breathing emergencies can be found in Chapters 10 and 11.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Assessing Breathing Emergencies
|
The child’s ability to breathe adequately must be assessed by checking the mental status, muscle tone, breathing movement, breathing effort and skin color. Once you have made your assessment, be sure to frequently perform follow-up assessments to note if there are any changes in the child’s respiratory status.
|
pediatrics.json
|
knowledge
|
pediatrics
|
CRITICAL FACTS 2
|
Certain problems are unique to children, such as specific kinds of injury and illness. Some of the most common airway problems the emergency responder may encounter with small children and infants are airway obstructions.
Anatomical differences among adults, children and infants can change their susceptibility to respiratory difficulties and affect how to provide emergency care.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Common Respiratory Problems in Children
|
Although many types of breathing problems can affect children, some will be seen by emergency responders more often than others, such as croup, epiglottitis, asthma and choking on an obstruction.
Croup is a common upper airway virus that affects children younger than 5. The airway constricts, limiting the passage of air, causing the child to produce an unusual sounding cough that can range from a high-pitched wheeze to a barking cough. Croup occurs most often during the evening and night hours. A child with croup may progress quickly from respiratory distress to respiratory failure. Children with croup may benefit from humidified oxygen. If you are transporting the child to the hospital, you may see an improvement in the child once exposed to cool air outdoors.
Epiglottitis: Epiglottitis is a bacterial infection that causes severe swelling of the epiglottis. While it is extremely rare, the symptoms may be similar to croup; it is a more serious illness and can result in death if the airway is blocked completely. If the child is older, you may see the tripod position, where the child is sitting up and leaning forward, perhaps with the chin thrust outward. Other signs are drooling, difficulty swallowing, voice changes and fever. A child with epiglottitis can move from respiratory distress to respiratory failure very quickly without emergency care. With epiglottitis, keeping the child as calm as possible is vital. Do not examine the throat using a tongue depressor or place anything in the child’s throat, as these can trigger a complete airway blockage. Asthma: Asthma is a common illness and can be triggered in many children by exposure to allergens. Air is drawn into the lungs, but as the bronchioles constrict during an asthma attack, they also may fill with mucus, blocking the air in the lungs from exiting. This blockage results in the characteristic wheeze when the patient exhales. Ask the parent or caregiver if the child is known to have asthma and, if so, if any rescue medications are available. If medications have been administered, find out what has been taken and how often up to the time of your arrival. The status of a child with asthma can change very quickly, so constant monitoring is necessary. The typical signs of asthma include rapid respirations that take effort as respiratory distress develops, but the breathing may seem to become less labored. This does not indicate improvement, but rather deterioration in respiratory status. Choking: Choking is a common emergency in young children, particularly once they become mobile and are able to explore on their own. Your interventions will be based on your assessments as to whether the child has a partial or complete airway obstruction.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Providing Care for Breathing Emergencies
|
Treatment of all respiratory emergencies is generally the same. Use equipment that is properly sized for the child, particularly if using an oxygen mask. The mask should fit the child and should deliver the appropriate amount of oxygen. Monitor the airway and breathing continuously, and arrange for transport as quickly as possible.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Circulatory Failure
|
As with adults, undetected and uncorrected circulatory failure in children and infants can cause cardiac arrest. Signs and symptoms of circulatory failure include: Increased heart rate (but can also be decreased). Unequal pulses (femoral compared with radial). Delayed capillary refill. Changes in mental status. Unlike adults, children seldom initially suffer a cardiac emergency. Instead, they suffer a respiratory emergency that develops into a cardiac emergency. Motor-vehicle collisions, drowning, smoke inhalation, poisoning, airway obstruction and falls are all common causes of respiratory emergencies that can develop into a cardiac emergency. A cardiac emergency can also result from an acute respiratory condition, such as a severe asthma attack. Always be prepared for the possibility of circulatory failure when dealing with a respiratory emergency. Care for circulatory failure includes identifying problems through assessment; assisting attempts to breathe by opening the airway, removing obstructions or providing ventilation; and observing for signs of cardiac arrest, performing CPR and using an AED. More information on the identification and care for circulatory failure can be found in Chapter 13.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Seizures
|
A seizure is a disorder in the brain’s electrical activity, sometimes marked by loss of consciousness and often by uncontrollable muscle movement; also called a convulsion. A chronic condition, such as epilepsy, or an acute event may cause seizures. In children, febrile seizures are the most common type of seizure. These seizures occur with a rapidly rising or excessively high fever, higher than 102° F (38.9° C). Febrile seizures may have some or all of the following signs and symptoms: Sudden rise in body temperature Change in LOC Rhythmic jerking of the head and limbs Loss of bladder or bowel control Confusion Drowsiness Crying out Becoming rigid Holding the breath Rolling the eyes upward
|
pediatrics.json
|
knowledge
|
pediatrics
|
Assessing Seizures
|
When obtaining a history from the parent or caregiver, you need to know several things to assess what type of seizure the child may be having and what may have caused it. Ask questions such as: Has the child ever had seizures before? If so, does the child have medications for them? If not, is there a family history of seizures? Does the child have diabetes? If so, what type of insulin/medication is being used and when was the last time it was given? Does the parent or caregiver monitor the blood sugar level? If so, what was the child’s blood sugar level when it was most recently monitored? Has the child begun taking any new medications lately? If the child takes medications, is it possible there may have been an overdose? Could the child have taken someone else’s medication? Did the child have access to anything poisonous? Has the child had an injury, particularly a head trauma, recently? Has the child seemed sick or had a high fever, stiff neck or recent headache? What did the seizure look like? Did it involve the child’s whole body, or only one half of the body? Did it start in one area and progress to the rest? Did the child fall when the seizure began and if so, was it possible the child’s head struck an object or the floor?
|
pediatrics.json
|
knowledge
|
pediatrics
|
Managing Seizures
|
The general principles of managing a seizure are to prevent injury, protect the child’s airway and ensure that the airway is open after the seizure has ended. Call for more advanced medical personnel for a child or an infant who has had a seizure and for a young child or an infant who experienced a febrile seizure brought on by a high fever. Do not put anything in the child’s mouth and do not restrain the child. Ensure that the environment is as safe as possible to prevent injury to the child during the seizure by moving away any furniture or other objects. Place the child in a side-lying recovery position during the seizure, if it is possible and safe to do so. After the seizure, ensure the child’s airway is open and administer supplemental oxygen, based on local protocols. Suctioning the airway may be necessary to remove excessive fluids. Also, after the seizure, assess the patient for any injuries that may have been sustained as a result of the seizure. If you have not already done so, position the child or infant on their side so that fluids (saliva, blood, vomit) can drain from the mouth. Care for a child or an infant who experiences a febrile seizure is much the same as for any other seizure. Most febrile seizures last less than 5 minutes and are not life threatening. However, immediately after a febrile seizure it is important to cool the body if a fever is present. See Chapter 14 for more information on managing seizures.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Fever
|
Fever is defined as an elevated body temperature. It signifies a problem and, in a child or an infant, can indicate specific problems. Often these problems are not life threatening, but some can be. A high fever in a child often indicates some form of infection. In a young child, even a minor infection can result in a rather high fever, which is often defined as a temperature higher than 102° F (38.9° C). If a fever is present, call for more advanced medical help at once. Your initial care for a child with a high fever is to gently cool the child. Never rush cooling down a child. If the fever has caused a febrile seizure, rapid cooling could bring on another seizure. Parents or caregivers often heavily dress children with fevers. Remove the excess clothing or blankets. Do not use an ice water bath or rubbing alcohol to cool down the body. Both of these approaches are dangerous, and parents and caregivers should be discouraged from ever using them. Do not give children or infants aspirin or products that contain aspirin when they show flu-like symptoms including fever, or if they may have a viral illness such as chicken pox, as this may result in an extremely serious medical condition called Reye’s syndrome. Reye’s syndrome is an illness that affects the brain and other internal organs. Ask the parent or caregiver what medications they may have given the child so you can inform more advanced medical personnel.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Poisoning
|
Poisoning can cause many types of emergencies, from seizures to cardiac arrest. Unintentional poisoning is a leading cause of unintentional death in the United States for adolescents, children and infants. Just under half of exposure cases managed by Poison Control Centers involve children younger than 6. Children in this age group often become poisoned by ingesting medications (typically those intended for adults) and household products, such as laundry detergent pods and solid objects, like batteries, particularly the watch-sized batteries found in many children’s toys.
|
pediatrics.json
|
knowledge
|
pediatrics
|
Shock
|
Shock is the body’s reaction to a physical or emotional trauma in both adults and children. Physical trauma could include loss of blood. In small children, the loss of blood may be much more significant than in adolescents or adults. This adds to the increased risk of shock and the speed with which it may develop. Children can go into shock very quickly, regardless of the cause, and may go into cardiac arrest much faster than adults.
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.