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pediatrics.json
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Age-related assessment findings, and developmental stage-related assessment and treatment modifications for pediatric-specific major diseases and/or emergencies
Upper airway obstruction Lower airway reactive disease Respiratory distress/failure/arrest Shock
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Age-related assessment findings, and developmental stage-related assessment and treatment modifications for pediatric-specific major diseases and/or emergencies (cont’d)
Seizures Sudden infant death syndrome Gastrointestinal disease
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Trauma
Applies fundamental knowledge to provide basic emergency care and transportation on assessment findings for an acutely injured patient.
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Special Considerations in Trauma
Recognition and management of trauma in Pediatric patient
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National EMS Education Standard Competencies
Pathophysiology, assessment, and management of trauma in the Pediatric patient
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Introduction
Children differ anatomically, physically, and emotionally from adults. Illnesses and injuries that children sustain, and their responses to them, vary based on age or developmental level. Important to remember that children are not small adults Fear of EMS providers and pain can make the child difficult to assess. Once you learn how to approach children of different ages and what to expect while caring for them, you will find that treating children also offers some very special rewards.
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Communication With the Patient and the Family When caring for a pediatric patient, you must care for parents or caregivers as well.
A calm parent usually results in a calm child. Remain calm, efficient, professional, and sensitive.
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Growth and Development Many physical and emotional changes occur during childhood (birth to age 18).
Stages of thoughts and behaviors: Infancy: first year of life Toddler: 1 to 3 years Preschool-age: 3 to 6 years School-age: 6 to 12 years Adolescent: 12 to 18 years
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The Infant
Infancy is defined as first year of life. First month after birth is neonatal or newborn period. 0 to 2 months Spend most time sleeping and eating Respond mainly to physical stimuli Cannot tell the difference between parents and strangers Crying is one of the main modes of expression. 0 to 2 months (cont’d) An inconsolable infant could be a sign of significant illness. Predisposed to hypothermia 2 to 6 months More active at this stage May follow objects with eyes Persistent crying, irritability, or lack of eye contact can be an indicator of serious illness, depressed mental status, or a delay in development. 6 to 12 months Become mobile, which predisposes them to physical danger Place things in their mouth leading to choking or poisoning May cry if separated from their parents or caregivers Persistent crying or irritability can be a symptom of serious illness. Assessment Observe infant from a distance. Caregiver should hold baby during physical assessment. Provide sensory comfort. Warm hands and end of stethoscope. Do painful procedures at end of assessment.
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The Toddler
After infancy until 3 years of age Experience rapid changes in growth and development 12 to 18 months Explorers by nature and not afraid They lack molars and may not be able to chew food fully increasing the risk of choking. Assessment May have stranger anxiety May resist separation from caregiver May have a hard time describing pain Can be distracted Begin your assessment at the feet. Persistent crying can be a symptom of serious illness or injury. Previous medical experiences may lead to hesitation toward you.
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The Preschool-Age Child
Ages 3 to 6 years Have a rich imagination and can be fearful about pain May believe injury is a result of earlier bad behavior Foreign body aspiration airway obstruction continues to be a high risk. Assessment Can understand directions and be specific in describing painful areas Much history must still be obtained from caregivers. Communicate simply and directly. Appealing to child’s imagination may facilitate examination. Assessment (cont’d) Never lie to the patient. Patient may be easily distracted. Begin assessment at feet, moving to head. Use adhesive bandages to cover the site of an injection or other small wound. Modesty is developing; keep child covered as much as possible.
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School-Age Years
6 to 12 years Beginning to act more like adults Can think in concrete terms Can respond sensibly to questions Can help take care of themselves School is important. Children begin to understand death. Assessment Assessment begins to be more like adults. To help gain trust, talk to the child, not just the caregiver. Start with head and move to the feet. If possible, give the child choices. Ask only the type of questions that let you control the answer. Do not bargain or debate with the patient. Assessment (cont’d) Allow the child to listen to his or her heartbeat through the stethoscope. Can understand the difference between physical and emotional pain Provide simple explanations about what is causing their pain and what will be done. Ask the parent’s or caregiver’s advice about which distraction will work best.
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Adolescents
13 to 18 years Physically similar to adults Puberty begins. Concerned about body image and appearance Strong feelings about privacy Time of experimentation and risk-taking Often feel “indestructible” Struggle with independence, loss of control, body image, sexuality, and peer pressure Assessment Can often understand complex concepts and treatment options Allow them to be involved in their own care. Provide choices, while lending guidance. EMT of same gender should do physical examination, if possible. Assessment (cont’d) Allow them to speak openly and ask questions. Risk-taking behaviors are common. Can ultimately facilitate development and judgment, and shape identity Can also result in trauma, dangerous sexual practices, and teen pregnancy Assessment (cont’d) Female patients may be pregnant. Adolescent may not want parents to know this information. Try to interview without the caregiver/parent present. Have clear understanding of pain Get them talking to distract them.
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Anatomy and Physiology Body is growing and changing very rapidly during childhood.
You must understand the physical differences between children and adults and alter your patient care accordingly.
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The Respiratory System
Anatomy of airway differs from adult’s. Pediatric airway is smaller in diameter and shorter in length. Lungs are smaller. Heart is higher in child’s chest. FIGURE 35-9 The anatomy of a child’s airway differs from that of an adult in several ways. The back of the head is larger in a child. The tongue is proportionately larger and is located more anterior in the mouth. The trachea is smaller in diameter and more flexible. The airway itself is lower and narrower (funnel-shaped). © Jones & Bartlett Learning. Anatomy of airway differs from adult’s. (cont’d) Glottic opening is higher and positioned more anteriorly, and neck appears to be nonexistent. As child develops, the neck becomes proportionally longer as the vocal cords and epiglottis achieve anatomically correct adult position. Anatomy of airway differs from adult’s. (cont’d) Larger, rounder occiput Proportionally larger tongue Long, floppy, U-shaped epiglottis Less-developed rings of cartilage in the trachea Narrowing, funnel-shaped upper airway Anatomy of airway differs from adult’s. (cont’d) Diameter of trachea in infants is about the same as a drinking straw. Airway is easily obstructed by secretions, blood, or swelling. Infants are nose breathers and may require suctioning and airway maintenance. Respiratory rate of 20 to 60 breaths/min is normal for a newborn. Anatomy of airway differs from adult’s. (cont’d) Children have an oxygen demand twice that of an adult. Increases risk for hypoxia Anatomy of airway differs from adult’s. (cont’d) Muscles of diaphragm dictate the amount of air a child inspires. Pressure on child’s abdomen can cause respiratory compromise. Use caution when applying the straps of a spinal immobilization device. Anatomy of airway differs from adult’s. (cont’d) Gastric distention can interfere with movement of the diaphragm and lead to hypoventilation. Breath sounds are more easily heard in children because of their thinner chest walls. Detection of poor air movement or complete absence of breath sounds may be more difficult.
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The Circulatory System
Important to know normal pulse ranges Infants heart can beat 160 beats/min or more. Children are able to compensate for decreased perfusion by constricting the vessels in the skin. Signs of vasoconstriction include pallor (early sign), weak distal pulses in the extremities, delayed capillary refill, and cool hands or feet.
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The Nervous System
Pediatric nervous system is immature, underdeveloped, and not well protected. Head-to-body ratio is larger. Occipital region of head is larger. Subarachnoid space is relatively smaller, leaving less cushioning for brain. Brain tissue and cerebral vasculature are fragile and prone to bleeding from shearing forces. Pediatric brain requires higher cerebral blood flow, oxygen, and glucose. At risk for secondary brain damage from hypotension and hypoxic events Spinal cord injuries are less common. If injured, it is more likely to be an injury to the ligaments because of a fall. For suspected neck injury, perform manual in-line stabilization or follow local protocols.
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The Gastrointestinal System Abdominal muscles are less developed.
Less protection from trauma Liver, spleen, and kidneys are proportionally larger and situated more anteriorly and close to one another. Prone to bleeding and injury There is a higher risk for multiple organ injury.
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The Musculoskeletal System
Open growth plates allow bones to grow. As a result of growth plates, children’s bones are softer and more flexible, making them prone to stress fracture. Bone length discrepancies can occur if injury to growth plate occurs. Immobilize all strains and sprains. Bones of an infant’s head are flexible and soft. Soft spots are located at front and back of head. Referred to as fontanelles Will close at particular stages of development Fontanelles of an infant can be a useful assessment tool. Thoracic cage is highly elastic and pliable. Composed of cartilaginous connective tissue Ribs and vital organs are less protected.
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The Integumentary System Pediatric system differs in a few ways:
Thinner skin and less subcutaneous fat Composition of skin is thinner and tends to burn more deeply and easily with less exposure. Higher ratio of body surface area to body mass leads to larger fluid and heat losses.
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Scene Size-up
Assessment begins at time of dispatch. Prepare mentally for approaching and treating an infant or child. Plan for pediatric size-up, equipment, and age-appropriate physical assessment. Collect age and gender of child, location of scene, NOI or MOI and chief complaint from dispatch. Scene safety Ensure proper safety precautions and standard precautions. Note position in which patient is found. Look for possible safety threats. Patient may be safety threat if he or she has infectious disease. Do an environmental assessment.
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Form a general impression.
Use pediatric assessment triangle (PAT). Does not require you to touch the patient Can be performed in less than 30 seconds FIGURE 35-10 The three components of the pediatric assessment triangle (PAT) include appearance, work of breathing, and circulation to the skin. Used with permission of American Academy of Pediatrics, Pediatric Education for Prehospital Professionals, © American Academy of Pediatrics, 2000. PAT Does not require equipment Three elements Appearance Work of breathing Circulation Appearance Note LOC, interactiveness, and muscle tone. Use the AVPU scale, modified as necessary for the pediatric patient’s age. Normal level of consciousness: act appropriately for age, exhibit good muscle tone, and maintain good eye contact TICLS mnemonic helps determine if patient is sick or not sick: Tone, Interactiveness, Consolability, Look or gaze, Speech or cry Work of breathing Increases as the body attempts to compensate for abnormalities in oxygenation and ventilation May manifest as abnormal airway noise, accessory muscle use, retractions, head bobbing, nasal flaring, tachypnea, and tripod position. Circulation to the skin When cardiac output fails, the body shunts blood from areas of lesser need to areas of greater need. Pallor of skin and mucous membranes may be seen in compensated shock. Mottling is sign of poor perfusion. Cyanosis reflects decreased level of oxygen. From PAT findings, you will decide if the patient is stable or requires urgent care. If unstable, assess XABCs, treat life threats, and transport immediately. If stable, continue with the remainder of the assessment process. Hands-on XABCs Assess and treat any life threats as you identify them by following the XABCDE format Exsanguination Airway Breathing Circulation Disability Exposure Airway If airway is open and will remain open, assess respiratory adequacy. If patient is unresponsive or has difficulty keeping airway open, ensure it is properly positioned and clear of mucus, vomitus, blood, and foreign bodies. Airway (cont’d) Always position airway in neutral sniffing position. Keeps trachea from kinking Maintains proper alignment Establish whether patient can maintain his or her own airway. Breathing Use the look, listen, feel technique. Place both hands on patient’s chest to feel for rise and fall of chest wall. Belly breathing in infants is considered adequate. Bradypnea is an ominous sign and indicates impending respiratory arrest. Circulation Determine if patient has a pulse, is bleeding, or is in shock. In infants, palpate brachial or femoral pulse. In children older than 1 year, palpate carotid pulse. Strong central pulses usually indicate that the child is not hypotensive. Circulation (cont’d) Weak or absent peripheral pulses indicate decreased perfusion. Tachycardia may be early sign of hypoxia. Interpret pulse within the context of overall history, the PAT, and primary assessment. Evaluate trend of increasing or decreasing pulse rate. Feel skin for temperature and moisture. Estimate the capillary refill time. Disability Use AVPU scale or pediatric GCS. Check pupil response. Look for symmetric movement of extremities. Pain is present with most types of injuries. Assessment of pain must consider developmental age of patient. Exposure Hands-on ABCs require that the caregiver remove some of patient’s clothing for observation. Avoid heat loss by covering the patient as soon as possible. More prone to hypothermic events Should be kept warm during transport Transport decision Determine whether rapid transport to the hospital is indicated. Rapid transport indicated if: Significant MOI History compatible with serious illness Physical abnormality noted Potentially serious anatomic abnormality Significant pain Abnormal level of consciousness Transport decision (cont’d) Also consider: Type of clinical problem Benefits or ALS treatment in field Local EMS protocol Your comfort level Transport time to hospital If patient’s condition is urgent, initiate immediate transport to the closest appropriate facility. Transport decision (cont’d) Less than 40 lb, transport in car seat. Mount a car seat to a stretcher. Follow manufacturer’s instructions to secure car seat in captain’s chair. Patients who require spinal immobilization: immobilize on long backboard or other suitable spinal immobilization device. Transport decision (cont’d) Patients in cardiopulmonary arrest: use a device that can be secured to the stretcher. Do not use the pediatric patient’s own car seat. The goal is to secure and protect the pediatric patient for transport in the ambulance.
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History Taking
Approach to history depends on age of patient. History information for an infant, toddler, or preschool-age child will be obtained from caregiver. Adolescent information is obtained from patient. Questioning the parents or child about the immediate illness or injury should be based on the child’s chief complaint. Questions to ask based on chief complaint NOI or MOI Length of sickness or injury Key events leading up to injury or illness Presence of fever Effects of illness or injury on behavior Patient’s activity level Recent eating, drinking, and urine output Questions to ask (cont’d) Changes in bowel or bladder habits Presence of vomiting, diarrhea, abdominal pain Presence of rashes Obtain name and phone number of caregiver if they are not able to come to the hospital with you. SAMPLE history Same as adult’s Questions based on age and developmental stage Obtaining OPQRST Same for children and adults Questions based on age and developmental stage
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Physical examinations
Secondary assessment of the entire body should be used when patient is unresponsive or has significant MOI. Focused assessments should be performed on patients without life threats. Physical examinations (cont’d) Infants, toddlers, and preschool-age children should be assessed started at the feet and ending at the head. School-aged children and adolescents should be assessed using the head-to-toe approach. Physical examinations (cont’d) Head Look for bruising, swelling, and hematomas. Assess fontanelles in infants. Nose Nasal congestion and mucus can cause respiratory distress. Gentle bulb or catheter suction may bring relief. Physical examinations (cont’d) Ears Drainage from ears may indicate skull fracture. Battle sign may indicate skull fracture. Presence of pus may indicate infection. Mouth Look for active bleeding and loose teeth. Note the smell of the breath. Physical examinations (cont’d) Neck Examine tracheal area for swelling or bruising. Note if patient cannot move neck and has high fever. Chest Examine for penetrating trauma, lacerations, bruises, or rashes. Feel clavicles and every rib for tenderness and/or deformity. Physical examinations (cont’d) Back Inspect back for lacerations, penetrating injuries, bruises, or rashes. Abdomen Inspect for distention. Gently palpate and watch for guarding or tensing of muscles. Note tenderness or masses. Look for seat belt abrasions or bruising. Physical examinations (cont’d) Extremities Assess for symmetry. Compare both sides for color, warmth, size of joints, swelling, and tenderness. Put each joint through a full range of motion while watching the patient’s eyes for signs of pain. Vital signs Some guidelines/equipment used to assess adult circulatory status have limitations in pediatric patients. Normal heart rates vary with age in pediatric patients. Blood pressure is usually not assessed in patients younger than 3 years. Vital signs (cont’d) Assessment of skin is a better indication of pediatric patient’s circulatory status. Use appropriately sized equipment. Use a cuff that covers two thirds of the pediatric patient’s upper arm. Vital signs (cont’d) Formula to determine blood pressure for children ages 1–10 years: 70 + (2 × child’s age in years) = systolic blood pressure Count respirations for at least 30 seconds and double that number. In infants and those younger than 3 years, evaluate respirations by assessing the rise and fall of the abdomen. Vital signs (cont’d) Assess pulse rate by counting at least 1 minute, noting quality and regularity. Normal pediatric vital signs vary with age. Evaluate pupils using a small pen light. Pulse oximeter is a valuable tool for patients with respiratory issues.
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Reassessment
Reassess the pediatric patient’s condition as necessary. Obtain vitals every 15 minutes if stable. Obtain vitals every 5 minutes if unstable. Continually monitor respiratory effort, skin color and condition, and level of consciousness or interactiveness. Interventions Parents or caregivers may be able to assist you by calming and reassuring the child. Communication and documentation Communicate and document all relevant information to ED personnel.
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Respiratory Emergencies and Management
Respiratory problems are the leading cause of cardiopulmonary arrest in the pediatric population. In the early stages, you may note changes in behavior, such as combativeness, restlessness, and anxiety. Signs and symptoms of increased work of breathing: Nasal flaring Abnormal breath sounds Accessory muscle use Tripod position As the pediatric patient progresses to possible respiratory failure: Efforts to breathe decrease. Chest rises less with inspiration. Body has used up all available energy stores and cannot continue to support extra work of breathing. As the patient progresses to possible respiratory failure: (cont’d) Changes in behavior and eventually, altered level of consciousness Patient may experience periods of apnea. Heart muscle becomes hypoxic, and the heart rate slows. As the patient progresses to possible respiratory failure: (cont’d) Respiratory failure does not always indicate airway obstruction. Condition can progress from respiratory distress to failure at any time; reassess frequently. A child or infant needs supplemental oxygen. Assist ventilation with a bag-mask device and 100% oxygen. Allow patient to remain in a comfortable position.
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Children can obstruct airway with any object they can fit into their mouth.
In cases of trauma, teeth may have been dislodged into the airway. FIGURE 35-22 Any number of objects can obstruct a child’s airway, including batteries, coins, toys, buttons, and candy. © Jones & Bartlett Learning. Photographed by Kimberly Potvin. Blood, vomitus, or other secretions can cause severe airway obstruction. Infections can cause obstruction. Infection should be considered if patient has congestion, fever, drooling, and cold symptoms. Croup is an infection in the airway below the level of the vocal cords. Epiglottitis is an infection of the soft tissue above the level of the vocal cords. FIGURE 35-23 Epiglottitis is an infection that can cause airway obstruction in pediatric patients. © Jones & Bartlett Learning. Obstruction by foreign object may involve upper or lower airway. May be partial or complete Signs and symptoms associated with partial upper airway obstruction include decreased breath sounds and stridor. Signs and symptoms of lower airway obstruction include wheezing and/or crackles. Best way to auscultate breath sounds in pediatric patient is to listen to both sides of the chest at armpit level. Immediately begin treatment of airway obstruction. Encourage coughing to clear airway when patient is conscious and forcibly coughing. If this does not remove the object, do not intervene except to provide oxygen. Allow patient to remain in whatever position is most comfortable. If you see signs of a severe airway obstruction, attempt to clear the airway immediately. Ineffective cough (no sound) Inability to speak or cry Increasing respiratory difficulty, with stridor Cyanosis Loss of consciousness If an infant is conscious with a complete airway obstruction, perform up to five back blows followed by chest thrusts. If a child is conscious with a complete airway obstruction, perform abdominal thrusts (Heimlich maneuver). Use head tilt–chin lift and finger sweep to remove a visible foreign body in an unconscious pediatric patient. Use chest compressions to relieve a severe airway obstruction in an unconscious pediatric patient.
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A condition in which the bronchioles become inflamed, swell, and produce excessive mucus, leading to difficulty breathing
A true emergency if not promptly identified and treated Common causes for asthma attack include upper respiratory infection, exercise, exposure to cold air or smoke, and emotional stress. Signs and symptoms Wheezing as patient exhales In some cases, airway is completely blocked, and no air movement is heard. Cyanosis and respiratory arrest may quickly develop. Tripod position allows for easier breathing. Treatment Allow patient to assume a position of comfort. Administer supplemental oxygen. Bronchodilator via metered-dose inhaler with a spacer mask device (if protocol allows) If assisting ventilations, use slow, gentle breaths. Contact ALS.
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Leading cause of death in children
Pneumonia is a general term that refers to an infection to the lungs. Often a secondary infection Can also occur from chemical ingestion Diseases causing immunodeficiency in children increase risk. Incidence is greatest during fall and winter months. Presentation in pediatric patient Unusual rapid breathing Sometimes with grunting or wheezing sounds Nasal flaring Tachypnea Hypothermia or fever Unilateral diminished breath sounds or crackles over the infected lung segments Pediatric patient treatment Primary treatment will be supportive. Monitor airway and breathing status. Administer supplemental oxygen if required. If the child is wheezing, administer a bronchodilator, if permitted. Diagnosis of pneumonia must be confirmed in the hospital.
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An infection of the airway below the level of the vocal cords, usually caused by a virus
Typically seen in children between ages 6 months and 3 years Easily passed between children Starts with a cold, cough, and a low-grade fever that develops over 2 days Hallmark signs are stridor and a seal-bark cough. Treatment Croup often responds well to the administration of humidified oxygen. Bronchodilators are not indicated for croup and can make the child worse.
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Epiglottitis Bacterial infection of the soft tissue in the area above the vocal cords
Incidence decreased since development of vaccine. Epiglottis can swell to two to three times normal size. Children look ill, report a very sore throat, and have a high fever. Tripod position and drooling
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Bronchiolitis
Specific viral illness of newborns and toddlers, often caused by RSV Causes inflammation of the bronchioles RSV is highly contagious and spread through coughing or sneezing. Virus can survive on surfaces. Virus tends to spread rapidly through schools and in childcare centers. More common in premature infants and results in copious secretion Occurs during first 2 years of life; more common in males Most widespread in winter and early spring Bronchioles become inflamed, swell, and fill with mucus. Airways can easily become blocked. Look for signs of dehydration, shortness of breath, and fever. Treatment Use calm demeanor when approaching. Allow patient to remain in position of comfort. Treat airway and breathing problems. Humidified oxygen is helpful. Consider ALS backup.
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Caused by a bacterium spread via respiratory droplets
Less common in the United States Signs and symptoms: coughing, sneezing, and a runny nose Coughing becomes more severe with distinctive whoop sound during inspiration. Infants may develop pneumonia or respiratory failure. To treat pediatric patients, keep the airway patent (open) and transport. Pertussis is contagious, so follow standard precautions, including wearing a mask and eye protection.
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Devices that help to maintain the airway or assist in providing artificial ventilation, including:
Oropharyngeal and nasopharyngeal airways Bite blocks Bag-mask devices
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Oropharyngeal airway
Keeps tongue from blocking airway and makes suctioning easier Should be used for pediatric patients who are unconscious and in respiratory failure Should not be used in conscious patients or those who have a gag reflex or who may have ingested a caustic or petroleum-based product
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Nasopharyngeal airway
Usually well tolerated Used for responsive pediatric patients Used in association with possible respiratory failure Rarely used in infants younger than 1 year Should not be used if there is nasal obstruction or head trauma
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Airway Adjuncts
Nasopharyngeal airway potential problems May become obstructed by mucus, blood, vomitus, or the soft tissues of the pharynx May stimulate the vagus nerve and slow the heart rate, or enter the esophagus, causing gastric distention May cause a spasm of the larynx and result in vomiting if inserted into responsive patient Should not be used when pediatric patients have facial trauma because the airway may tear soft tissues and cause bleeding into the airway.
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Oxygen Delivery Devices
Several options for pediatric patient Blow-by technique at 6 L/min provides more than 21% oxygen concentration. Nasal cannula at 1 to 6 L/min provides 24% to 44% oxygen concentration. Nonrebreathing mask at 10 to 15 L/min provides up to 95% oxygen concentration. Bag-mask device at 10 to 15 L/min provides nearly 100% oxygen concentration. Nonrebreathing mask, nasal cannula, or simple face mask is indicated for pediatric patients who have adequate respirations and/or tidal volumes. Bag-mask device is used for those with respirations less than 12 breaths/min or more than 60 breaths/min, an altered LOC, or inadequate tidal volume. Blow-by method Less effective than face mask or nasal cannula for oxygen delivery Does not provide high oxygen concentration Administration Place tubing through hole in bottom of cup. Connect tube to oxygen source at 6 L/min. Hold cup 1 to 2 inches away from nose and mouth. Nasal cannula Some patients prefer the nasal cannula; some find it uncomfortable. Applying a nasal cannula Choose appropriately sized nasal cannula. Connect tubing to an oxygen source at 1 to 6 L/min. FIGURE 35-28 The blow-by technique may be less frightening to a child than an oxygen mask. Make a small hole in an 8-oz (237-mL) cup, or use a funnel inserted into the end of the oxygen tubing. Connect tubing to an oxygen source, and hold the cup approximately 1 to 2 inches (2 to 5 cm) from the child’s face. © Jones & Bartlett Learning. FIGURE 35-29 The prongs of a pediatric nasal cannula should not fill the nares entirely. © Jones & Bartlett Learning. Nonrebreathing mask Delivers up to 90% oxygen Allows patient to exhale all carbon dioxide without rebreathing it Applying a nonrebreathing mask Select appropriately sized mask. Connect tubing to oxygen source at 10 to 15 L/min. Adjust oxygen flow as needed. Bag-mask device Indicated in patients with too fast or too slow respirations, who are unresponsive, or who do not respond to painful stimuli Assisting ventilations with bag-mask device Select appropriately sized equipment. Maintain a good seal with the mask on the face. Ventilate at the appropriate rate and volume, using a slow, gentle squeeze. FIGURE 35-30 A pediatric nonrebreathing mask delivers up to 95% oxygen and allows the patient to exhale carbon dioxide without rebreathing it. © Jones & Bartlett Learning. FIGURE 35-31 Proper mask size for bag-mask ventilation is critical. The mask should extend from the bridge of the nose to the cleft of the chin, avoiding compression of the eyes. © Jones & Bartlett Learning. Courtesy of MIEMSS. Two-person bag-mask ventilation Similar to one-person bag-mask ventilation except one rescuer holds the mask to the face and maintains the head position Usually more effective in maintaining a tight seal
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Cardiopulmonary Arrest Cardiac arrest in pediatric patients is associated with respiratory failure and arrest.
Children are affected differently by decreasing oxygen concentration. Children become hypoxic and their hearts slow down, becoming more bradycardic.
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Develops when the circulatory system is unable to deliver a sufficient amount of blood to the organs
Results in organ failure and eventually cardiopulmonary arrest Compensated shock is the early stage of shock. Decompensated shock is the later stage of shock. Common causes include: Trauma injury with blood loss Dehydration from diarrhea or vomiting Severe infection Neurologic injury Common causes include: (cont’d) Severe allergic reaction/anaphylaxis to an allergen Diseases of the heart Tension pneumothorax Blood or fluid around the heart Cardiac tamponade Pericarditis Pediatric patients respond differently than adults to fluid loss. May respond by increasing heart rate, increasing respirations, and showing signs of pale or blue skin Signs of shock in children Tachycardia Poor capillary refill time (> 2 seconds) Mental status changes Treat shock by assessing XABCs. The order becomes CAB if there is obvious life-threatening external hemorrhage or if cardiac arrest is suspected. Blood pressure does not fall until shock is severe. Treatment Limit your management to simple interventions. Do not waste time performing field procedures. Ensure airway is open; prepare for artificial ventilation. Control bleeding. Treatment (cont’d) Give supplemental oxygen by mask or blow-by. Continue to monitor airway and breathing. Position the patient in a position of comfort. Keep warm with blankets and heat. Provide immediate transport. Contact ALS backup as needed. Anaphylaxis A life-threatening allergic reaction that involves generalized, multisystem response Characterized by airway swelling and dilation of blood vessels Common causes are insect sting, medications, or food allergy. Anaphylaxis (cont’d) Signs and symptoms Hypoperfusion Stridor and/or wheezing Increased work of breathing Restlessness, agitation, and sometimes a sense of impending doom Hives Anaphylaxis (cont’d) Treatment Maintain airway and administer oxygen. Allow caregiver to assist in positioning the patient, oxygen delivery, and maintaining calm. Assist with epinephrine auto-injector based on protocol. Provide rapid transport.
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Bleeding Disorders Hemophilia is a congenital condition in which patients lack normal clotting factors.
Most forms are hereditary and severe. Predominantly found in male population Bleeding may occur spontaneously. All injuries become serious because blood does not clot.
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Altered Mental Status
Abnormal neurologic state Understanding developmental changes and listening to caregiver’s opinion are key. AEIOU-TIPPS reflects major causes of AMS. Signs and symptoms vary from simple confusion to coma. Management focuses on ABCs and transport.
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Result of disorganized electrical activity in the brain
Manifests in a variety of ways Subtle in infants, with an abnormal gaze, sucking, and/or “bicycling” motions More obvious in older children with repetitive muscle contractions and unresponsiveness Once seizure stops and muscles relax, it is referred to as postical state. The longer and more intense the seizures are, the longer it will take for this imbalance to correct itself. Postictal state is over once normal level of consciousness is regained. Status epilepticus Seizures that continue every few minutes without regaining consciousness in between or last longer than 30 minutes Recurring or prolonged seizures should be considered life threatening. If patient does not regain consciousness or continues to seize, protect him or her from harming self and call for ALS backup. Management Securing and protecting airway are priority. Position head to open airway. Clear mouth with suction. Use recovery position if patient is vomiting. Provide 100% oxygen by nonrebreathing mask or blow-by method. Begin bag-mask ventilations if no signs of improvement. Management (cont’d) Some caregivers will have given the child a rectal dose of diazepam (Diastat) prior to your arrival; monitor breathing and level of consciousness carefully. Transport to the appropriate facility.
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Inflammation of tissue that covers the spinal cord and brain
Caused by infection by bacteria, viruses, fungi, or parasites Left untreated, can lead to brain damage or death Being able to recognize a pediatric patient with meningitis is important. Individuals at greater risk Males Newborn infants Compromised immune system by AIDS or cancer History of brain, spinal cord, back surgery Children who have had head trauma Children with shunts, pins, or other foreign bodies in their brain or spinal cord Signs and symptoms vary with age. Fever and altered level of consciousness Child may experience seizure. Infants younger than 2 to 3 months can have apnea, cyanosis, fever, distinct high-pitched cry, or hypothermia. Signs and symptoms (cont’d) “Meningeal irritation” or “meningeal signs” are terms to describe pain that accompanies movement. Often results in characteristic stiff neck In an infant, increasing irritability and a bulging fontanelle without crying Neisseria meningitidis is a bacterium that causes rapid onset of meningitis symptoms. Often leads to shock and death Children present with small, pinpoint, cherry-red spots or a larger purple/black rash. FIGURE 35-33 Children infected with Neisseria meningitidis typically have small, pinpoint, cherry-red spots or a larger purple or black rash. © Mediscan/Alamy Stock Photo. Patients with suspected meningitis should be considered contagious. Use standard precautions. Follow up to learn the patient’s diagnosis. Treatment Provide supplemental oxygen and assist with ventilations, if needed. Reassess vital signs frequently.
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Gastrointestinal Emergencies and Management
Never take a complaint of abdominal pain lightly. Complaints of gastrointestinal origin are common in pediatric patients. Ingestion of certain foods or unknown substance In most cases, patient will be experiencing abdominal discomfort with nausea, vomiting, and diarrhea. Appendicitis is also common. If untreated, can lead to peritonitis or shock Will typically present with fever and pain upon palpation of right lower quadrant Rebound tenderness is a common sign. If you suspect appendicitis, promptly transport to the hospital for evaluation. Obtain a thorough history from the primary caregiver. How many wet diapers today? Is the child tolerating liquids and keeping them down? How many times has the child had diarrhea and for how long? Are tears present during crying?
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Poisoning Emergencies and Management
Common among children Can occur by ingesting, inhaling, injecting, or absorbing toxic substances Common sources Alcohol Aspirin and acetaminophen Cosmetics Household cleaning products Houseplants Common sources (cont’d) Iron Prescription medications of family members Illicit (street) drugs Vitamins Signs and symptoms vary, depending on substance, age, and weight. Be alert for signs of abuse. After primary assessment, ask caregiver the following: What is the substance involved? Approximately how much was ingested? What time did the incident occur? Any changes in behavior or level of consciousness? Any choking or coughing after the exposure? Contact Poison Control for assistance. Treatment Perform external decontamination. Assess and maintain ABCs and monitor breathing. If shock is present, treat and transport. Give activated charcoal according to medical control or local protocol.
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Dehydration Emergencies and Management
Occurs when fluid loss is greater than fluid intake Vomiting and diarrhea are common causes. Infants and children are at greater risk. Can be mild, moderate, or severe Mild dehydration signs Dry lips and gums, decreased saliva and wet diapers Moderate dehydration signs Sunken eyes, sleepiness, irritability, loose skin, sunken fontanelles Severe dehydration signs Mottled, cool, clammy skin; delayed CRT; increased respiration Treatment Assess ABCs and obtain baseline vital signs. If severe, ALS backup may be necessary for IV access. Transport to ED. FIGURE 35-35 An infant with dehydration may exhibit “tenting” or poor skin turgor. Courtesy of Ronald Dieckmann, MD.
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Fever Emergencies and Management
An increase in body temperature 100.4°F (38°C) or higher is abnormal. Rarely life threatening Causes Infection Status epilepticus Cancer Drug ingestion (aspirin) Causes (cont’d) Arthritis Systemic lupus erythematosus (rash on nose) High environmental temperature Result of internal body mechanism in which heat generation is increased and heat loss is decreased Accurate body temperature is important for pediatric patients. Rectal temperature is most accurate for infants and toddlers. Under tongue or arm will work for older children. Patient may present with signs of respiratory distress, shock, a stiff neck, a rash, hot skin, flushed cheeks, and, in infants, bulging fontanelles. Transport and manage ABCs.
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Common between 6 months and 6 years
Caused by fever alone Typically occur on first day of febrile illness Characterized by tonic-clonic activity Last less than 15 minutes with little or no postictal state May be sign of more serious problem Assess ABCs, provide cooling measures with tepid water, and provide prompt transport. All patients with febrile seizures need to be seen in the hospital setting.
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Drowning Emergencies and Management
Second-most-common cause of unintentional death among children Principal condition is lack of oxygen. Hypothermia from submersion in icy water Diving increases risk of neck and spinal cord injuries. Signs and symptoms Coughing and choking Airway obstruction and difficulty breathing AMS and seizure activity Unresponsiveness Fast, slow, or no pulse Pale, cyanotic skin Abdominal distention Management Assess and manage ABCs. Contact ALS crew to intervene if needed. Administer 100% oxygen. Apply cervical collar if trauma is suspected. Perform CPR in unresponsive patient in cardiopulmonary arrest.
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Pediatric Trauma Emergencies and Management Number one killer of children in the US
Quality of care can impact recovery. The muscles and bones of children continue to grow well into adolescence. Fracture of the femur is rare. Older children and adolescents are prone to long bone fractures.
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Physical Differences Children are smaller than adults.
Locations of injuries may be different. Children’s bones and soft tissues are less well developed than an adult’s. Force of injury affects structures differently.
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Psychological Differences Psychological differences
Often injured because of underdeveloped judgment and lack of experience Always assume the child has serious head and neck injuries.
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Vehicle collisions
Exact area struck depends on the child’s height and the final position of the bumper at impact. Typically sustain high-energy injuries to the head, spine, abdomen, pelvis, or legs.
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Sport injuries
Children are often injured in organized sports activities. Head and neck injuries can occur in contact sports. Remember to immobilize cervical spine.
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Injuries to Specific Body Systems
Head injuries Common in children because the size of the head in relation to the body Infant has softer, thinner skull. May result in brain injury Scalp and facial vessels may cause great deal of blood loss if not controlled. Head injuries (cont’d) Nausea and vomiting are common signs and symptoms of a head injury in children. Easy to mistake for abdominal injury or illness Suspect a serious head injury in any child who experiences nausea and vomiting after a traumatic event. Immobilization Necessary for all children with possible head or spinal injuries after a traumatic event Can be difficult because of the child’s body proportions Younger children require padding under the torso to maintain a neutral position. May be necessary to immobilize child in a car seat Chest injuries Usually the result of blunt trauma Chest wall flexibility in children can produce a flail chest. May be injuries within the chest even though there may be no sign of external injury Pediatric patients are managed in the same way as adults. Abdominal injuries Common in children Children can compensate for blood loss better than adults. Children can have a serious injury without early external evidence of a problem. Monitor all children for signs of shock. If signs of shock are evident, prevent hypothermia with blankets. FIGURE 35-37 All children with abdominal injuries should be monitored closely for signs of shock. Although children may compensate for significant blood loss better than adults, shock develops in children after proportionally smaller blood losses. © Jones & Bartlett Learning. Burns Considered more serious than burns to adults Have more surface area to relative total body mass, which means greater fluid and heat loss Do not tolerate burns as well as adults More likely to go into shock, develop hypothermia, and experience airway problems Burns (cont’d) Common ways that children are burned Exposure to hot substances Hot items on a stove Exposure to caustic substances Infection is a common problem. Burned skin cannot resist infection as effectively. Sterile techniques should be used when handling skin. Burns (cont’d) Consider child abuse in any burn situation. Report any information about suspicions. Severity Minor Moderate Critical Burns (cont’d) Pediatric patients are managed in the same manner as adults. Prevent hypothermia if shock is suspected. If patient shows bradycardia, ventilate. Monitor the patient during transport. Injuries to the extremities Children have immature bones with active growth centers. Growth of long bones occurs from the ends at specialized growth plates. Potential weak spots Incomplete or greenstick fractures can occur. Injuries to the extremities (cont’d) Generally, extremity injuries in children are managed in the same manner as adults. Painful deformed limbs with evidence of broken bones should be splinted. Pain management Look for visual clues and use the Wong-Baker FACES pain scale. Interventions are limited to positioning, ice packs, and extremity elevation. ALS interventions may be needed. Another important tool is kindness and providing emotional support.
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JumpSTART triage system
Intended for patients younger than age 8 years and weighing less than 100 lb Four triage categories Green Yellow Red Black
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JumpSTART triage system (cont’d)
Green: minor; not in need of immediate treatment Able to walk (except in infants) Yellow: delayed treatment Presence of spontaneous breathing, with peripheral pulse, responsive to painful stimuli JumpSTART triage system (cont’d) Red: immediate response Apnea responsive to positioning or rescue breathing; respiratory failure; breathing but without a pulse; or inappropriate painful response Black: deceased or expectant deceased Apneic without pulse, or apneic and unresponsive to rescue breathing
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Disaster Management
FIGURE 35-39 The JumpSTART triage system © Lou Romig, MD, 2002.
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Child Abuse and Neglect Any improper or excessive action that injures or otherwise harms a child
Includes physical abuse, sexual abuse, neglect, and emotional abuse Over half a million children are victims of child abuse annually. Many children suffer life-threatening injuries.
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Signs of Abuse
Child abuse occurs in every socioeconomic status. Be aware of patient’s surroundings. Document findings objectively. Ask yourself the following: Injury typical for age of child? MOI reported consistent with the injury? Caregiver behaving appropriately? Evidence of drinking or drug use at scene? Delay in seeking care for the child? Good relationship between child and caregiver or parent? Ask yourself the following: (cont’d) Are there multiple injuries at different stages of healing? Any unusual marks or bruises that may have been caused by cigarettes, heating grates, or branding injuries? Are there several types of injuries? Any burns on hands or feet that involve a glove distribution? Ask yourself the following: (cont’d) Is there unexplained decreased level of consciousness? Is the child clean and an appropriate weight for his or her age? Is there any rectal or vaginal bleeding? What does the home look like? Clean or dirty? Warm or cold? Is there food? CHILD ABUSE mnemonic may help. Bruises Observe color and location. New bruises are pink or red. Over time turn blue, then green, then yellow-brown and faded Bruises to the back, buttocks, or face are suspicious and are usually inflicted by a person. Burns Burns to the penis, testicles, vagina, or buttocks are usually inflicted by someone else. Burns that look like a glove are usually inflicted by someone else. Suspect child abuse if the child has cigarettes burns or grid pattern burns. Fractures Fractures of the humerus or femur do not normally occur without major trauma. Falls from bed are not usually associated with fractures. Maintain an index of suspicion if an infant or young child sustains a femur fracture or a complete fracture of any bone. Shaken baby syndrome Infants may sustain life-threatening head trauma by being shaken or struck. Bleeding within the head and damage to the cervical spine Infant will be found unconscious, often without evidence of external trauma. Neglect Refusal or failure to provide life necessities Examples are water, clothing, shelter, personal hygiene, medicine, comfort, personal safety
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Symptoms and Other Indicators of Abuse
Abused children may appear withdrawn, fearful, or hostile. Be concerned if child does not want to discuss how an injury occurred. Parent may reveal a history of “accidents.” Be alert for conflicting stories or lack of concern. Abuser may be a parent, caregiver, relative, or friend of the family. EMTs in all states must report suspected abuse. Most states have special forms to do so. Supervisors are generally forbidden to interfere with the reporting. Law enforcement and child protection services will determine whether there is abuse.
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Children of any age and gender can be victims of sexual abuse.
Maintain an index of suspicion. Often long-standing abuse by relatives Assessment Limited to determining type of dressing required Treat bruises and fractures as well. Do not examine genitalia unless there is evidence of bleeding or other injury. Assessment (cont’d) Do not allow child to wash, urinate, or defecate until a physician completes examination. Ensure an EMT or police officer of the same gender remains with the child. Maintain professional composure. Assume a caring, concerned approach. Shield the child from onlookers. Assessment (cont’d) Obtain as much information as possible from the child and any witnesses. Transport all children who are victims of sexual assault. Sexual abuse is a crime. Cooperate with law enforcement officials in their investigations.
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Sudden Unexpected Infant Death
Sudden unexplained death (SUID) refers to a sudden unexpected death where the cause is not known until and investigation is conducted. One of the causes of SUID is sudden infant death syndrome (SIDS), which results in death that cannot be explained by any other means.
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Sudden Unexpected Infant Death Syndrome
About 3,500 infants die of SIDS annually. Baby should be placed on his or her back on a firm mattress, in a crib free of bumpers, blankets, and toys. Baby should sleep in the same room, but not the same bed, chair, or sofa as an adult. Breastfeeding and use of a pacifier may lower the risk.
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Sudden Infant Death Syndrome
Risk factors Mother younger than age 20 years Mother smoked during pregnancy Mother used alcohol or illicit drugs during pregnancy or after birth Low birth weight Can occur at any time of day You are faced with three tasks Assessment of the scene Assessment and management of patient Communication and support of the family
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Patient Assessment and Management
Victim of SIDS will be pale or blue, not breathing, and unresponsive. Other causes include: Overwhelming infection Child abuse Airway obstruction Meningitis Other causes include: (cont’d) Accidental or intentional poisoning Hypoglycemia Congenital metabolic defects Begin with XABC assessment. Provide necessary interventions. Depending on how much time has passed, the child may show postmortem changes. If you see these signs, call medical control. If no signs of postmortem changes, begin CPR immediately. Pay special attention to any marks or bruises on the child before performing any procedures. Note any interventions that were performed before your arrival.
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Scene Assessment Carefully inspect environment, noting condition of scene and where infant was found.
Assessment should concentrate on: Signs of illness General condition of the house Signs of poor hygiene Family interaction Site where the infant was discovered
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Communication and Support of the Family Sudden death of an infant is devastating for a family.
Tends to evoke strong emotional responses among health care providers Allow the family to express their grief.
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Provide the family with empathy and understanding.
The family may want you to initiate resuscitation efforts, which may or may not conflict with your EMS protocols. Introduce yourself to the child’s parents or caregivers and ask about the child’s date of birth and medical history. Do not speculate on the cause of the child’s death. The family should be asked whether they want to hold the child and say good-bye. The following interventions are helpful. Use the child’s name. Speak to family members at eye level. Use “died” and “dead” instead of “passed away” or “gone.” Helpful interventions (cont’d): Acknowledge family’s feelings, but never say, “I know how you feel.” Offer to call other family members or clergy. Keep any instructions short, simple, and basic. Ask family members if they want to hold the child. Wrap the child in a blanket and stay with the family while they hold the child. Do not to remove equipment that was used in attempted resuscitation. Everyone expresses grief in a different way. Some will require intervention. Many caregivers feel directly responsible for the death of a child. Some EMS systems arrange for home visits after a child’s death for closure. You need training for these visits. Child’s death can be very stressful. Take time before going back to the job. Talk with other EMS colleagues. Be alert for signs of posttraumatic stress in yourself and others. Consider the need for help if signs occur.
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Infants who are not breathing, cyanotic, and unresponsive sometimes resume breathing and color with stimulation.
Apparent life-threatening event (ALTE) Classic ALTE is characterized by: Distinct change in muscle tone Choking or gagging After ALTE, child may appear healthy and show no signs of illness or distress. Complete careful assessment and provide rapid transport to the ED. Pay strict attention to airway management. Assess infant’s history and environment. Allow caregivers to ride in the back of the ambulance.
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Brief Unresolved Unexplained Event Signs and symptoms
Brief changes in color such as pale skin or cyanosis Choking Absent, slow, or irregular breathing Decreased level of consciousness No abnormality found on assessment Transport required for evaluation
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neonate
a baby that is less than 1 month old.
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ductus arteriosa
a duct from the pulmonary arteries to the aorta that bypasses the non-function pulmonary system of a fetus.
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apgar score
appearance. pulse. grimace. activity. respirations.
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normal apgar score
a score between 7-10 is normal for neonates.
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apgar score of 4-6
mild distress. stimulation and oxygenation indicated.
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apgar score < 4
severe distress. immediate resuscitation required: ppv and/or chest compressions. do not delay resuscitative efforts to acquire apgar in the event of apnea or other obvious sign of distress.
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at a heart rate of 60 bpm, what intervention is indicated for a neonate?
chest compressions and positive pressure ventilations.
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at a heart rate of 100 bpm, what intervention is indicated for a neonate?
positive pressure ventilations
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unless resuscitation is require, at what time are apgar scores indicated?
at 1 min and then at 5 min after birth. continue updating scores at 5-10 min intervals.
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how many veins are in the umbilical cord and what color are they?
there are 1 vein and it is red.
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how many arteries are in the umbilical cord and what color are they?
there is two arteries in the umbilical cord and it is blue.
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premature neonate
a neonate born prior to 37 weeks gestation.
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what is the most common cause of respiratory distress and cyanosis in a newborn/neonate?
prematurity of the neonate. (underdeveloped respiratory system)
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pediatric assessment triangle
appearance. work of breathing. circulation of skin.
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appearance section (peds. assessment triangle) and ticls
tone. interactiveness. consolability. look/gaze. speech/cry. these categories help assess a pediatric level of alertness and their verbal response to stimuli.
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work of breathing section (peds. assessment triangle)
abnormal sounds, abnormal position (i.e. sniffing position or tripod position), abnormal effort (i.e. accessory muscle use, see-saw breathing)
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circulation to skin (peds. assessment triangle)
pallor, mottling, cyanosis. skin temperature, check pulse, capillary refill (< 5 years old).
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respiratory rates for a neonate-infant (< 1 y/o).
30-60 breaths/min.
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respiratory rate for toddler (1-3 y/o)
24-40 breaths/min
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respiratory rate for preschooler (3-5 y/o)
24-40 breaths/min
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respiratory rate school age (6-10 y/o)
18-30 breaths/min
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respiratory rate early adolescence (11-14 y/o)
12-26 breaths/min
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retraction (respiration)
skin and soft tissues of the chest visibly depress around ribs and above the collar bone. sign of respiratory distress or increased work of breathing.
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nasal flaring
the stretching of the nostrils, increasing diameter. normally seen on respiration. sign of respiratory distress or increased work of breathing.
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head bobbing
the lifting and tilting of the head backwards during inspiration and forward on inspiration. normally seen in young children in respiratory distress with increased work of breathing.
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grunting (respiration)
a sound made by infants in respiratory distress who are attempting to maintain his/her alveoli by creating back pressure.
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pulse rate newborn (< 1 month)
100-180 bpm
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pulse rate infant (1-12 months)
100-160 bpm