Download Paramedic Care: Principles & Practice Volume 5 Special

Paramedic Care:
Principles & Practice
Volume 5
Special Considerations/
Operations
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chapter 2
Pediatrics
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
Role of Paramedics in Pediatric Care
General Approach to Pediatric Emergencies
General Approach to Pediatric Assessment
General Management of Pediatric Patients
Specific Medical Emergencies
Trauma Emergencies
Sudden Infant Death Syndrome
Child Abuse and Neglect
Infants and Children with Special Needs
Multiple Casualty Incidents Involving
Children
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction
Current research indicates that more than
20,000 pediatric deaths occur each year in
the United States
The leading causes of death are age specific
– They include motor vehicle collisions, burns,
drownings, suicides, and homicides
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Role of Paramedics
in Pediatric Care
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Role of Paramedics
in Pediatric Care
Two key concepts
– Pediatric injuries have become major concerns
– Children are at higher risk of injury than adults
Get involved in identifying and implementing
methods and mechanisms that prevent
injuries
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Continuing Education
and Training
Pediatric centered education
– Pediatric Advanced Life Support (PALS)
– Pediatric Education for Paramedic Professionals
(PEPP)
– Advanced Pediatric Life Support (APLS)
– Prehospital Pediatric Care (PPC)
Center for Pediatric Medicine (CPEM)
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Improved Health Care
and Injury Prevention
Emergency Medical Services for Children
(EMSC)
– Federally funded program
– Goal is to improve the health of pediatric patients
who suffer potentially life-threatening illnesses or
injuries
– Coordinated effort to identify areas of concern
Trauma registries and epidemiological
research rely on the prehospital provider
documentation
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pediatric Health Care
Concerns
Community
education
Data collection
Quality
improvement
Injury prevention
Access
Prehospital care
Emergency care
Definitive care
Finance
Rehabilitation
A systems approach
to pediatric care
Ongoing health care
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Improved Health Care
and Injury Prevention
Take part in, or
offer to organize,
school or
community
programs in
injury prevention
or health care
© Craig Jackson/In the Dark Photography
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Advanced Life Support
Skills in Pediatrics
85% of children treated by EMS personnel
need nothing more than basic life support
skills
It is fairly rare that a paramedic will be called
upon to perform an advanced life support
(ALS) skill
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Approach to
Pediatric Emergencies
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Approach to
Pediatric Emergencies
Varies with the age of the patient and with the
problem being treated
Take into consideration the patient’s
emotional and physiological development
– Involve the family members or caregivers
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Communication and
Psychological Support
Treatment begins with communication and
psychological support
– Interaction with patient and caregivers continues
throughout assessment
Gather information about patient history as
quickly and as accurately as possible
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Responding to Patient Needs
The child’s most common reaction to an
emergency is fear of:
–
–
–
–
–
Separation
Removal from a family place
Being hurt
Being mutilated or disfigured
The unknown
Communicate honestly with the child
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Responding to Parents
or Caregivers
Initial reactions to emergencies vary:
– Shock, grief, denial, anger, guilt, fear, or
complete loss of control
Communication is essential
– Allow one of the parents or caregivers to remain
with the child
Maintain index of suspicion for injuries that
are questionable in nature
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Growth and Development
Newborns
– First hours after birth
– Assessed with APGAR scoring system
– Treatment follows the inverted pyramid
Neonate
– Birth to one month
– Tend to lose 10% of birth weight, but regain in 10
days
– Development centers on reflexes
– Personality begins to form
– Mother, occasionally father, can comfort child
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Neonates
Common illnesses include:
– Jaundice, vomiting, and respiratory distress
Do not develop fever with minor illness
– Fever may be the only sign in meningitis or other
serious illness
Allow patient to remain in caregiver’s lap
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Infants (1-5 months)
Double their birth weight by 5 to 6 months of
age
Muscle control develops in a cephalocaudal
progression
Focus on the parents or caregivers for
information
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Infants (6 to 12 months)
May stand or walk without assistance
Risk of foreign body airway obstruction
(FBAO) becomes a serious concern
Express themselves more readily
Common illnesses and injuries
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Infants (6 to 12 months)
Examine while
sitting in the lap
of the parent or
caregiver
Toe-to-head
progression of
exam
© Jeff Forster
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Toddlers
(Ages 1 to 3 Years)
Great strides in motor development
May stray from parents more frequently
– Parents remain the only ones who can comfort
them
Language development begins
Accidents are leading cause of injury
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Toddlers
(Ages 1 to 3 Years)
Examine from head to toe
Avoid asking “yes” or “no” questions
Allow child to hold a favorite blanket or item
Tell child if something will hurt
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Preschoolers
(Ages 3 to 5 Years)
Increase in fine and gross motor skills
Know how to talk
Fear mutilation
– Avoid frightening or misleading comments
Seek comfort and support from within home
Distorted sense of time
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Common Preschooler Illnesses
and Injuries
Croup
Asthma
Poisoning
Auto accidents
Burns
Child abuse
Ingestion of foreign
bodies
Drowning
Epiglottitis
Febrile seizures
Meningitis
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Preschoolers
(Ages 3 to 5 Years)
Treatment of preschoolers requires tact
– Avoid baby talk
– Do not trick or lie to the patient
Allow the child to hold a piece of equipment,
such as a stethoscope
Start the examination with the chest and
evaluate the head last
Always explain what you are going to do
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
School-Age Children
(Ages 6 to 12 Years)
Active and
carefree age group
Growth spurts are
common
Give responsibility
of providing history
Respect modesty
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Common Illness and Injuries in
School-Age Children
Drowning
Auto accidents
Bicycle accidents
Falls
Fractures
Sports injuries
Child abuse
Burns
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Adolescents
(Ages 13 to 18)
Are very “body conscious”
May consider themselves “grown up”
Desire to be liked and included by peers
Are generally good historians
Relationships with parents may be strained
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Common Adolescent Illnesses
and Injuries
Mononucleosis
Asthma
Auto accidents
Sports injuries
Drug and alcohol
problems
Suicidal gestures
Sexual abuse
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
Children are not simply small adults
They have healthier organs, a greater ability
to compensate for most illnesses, and softer,
more flexible tissues
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Head
Large head, small face
– Difficult to maintain seal on BVM
Fontanelles
Heavy head relative to body size
– Increases risk of trauma
Airway positioning techniques
– Patient < 3
Pad between shoulders
– Patient > 3
Pad under occiput
Sniffing position
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Airway
Pediatric patients have narrower airways
– Easily blocked by secretions
Infants are obligate nose breathers
Large, disproportionate tongue
Trachea is softer and more flexible in a child
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Airway
A child’s larynx is higher (C-3–C-4)
In young children, the cricoid ring is the
narrowest part of the airway
Infants have an omega-shaped, floppier
epiglottis
Management principles:
– Keep the nares clear in infants less than 6 months
– Do not overextend the neck
– Utilize basic maneuvers for airway maintenance
May be effective without adjuncts
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chest and Lungs
Infants and children are diaphragmatic
breathers
Pediatric patients are prone to gastric
distention
Rib fractures occur less frequently
Because the chest is more compliable,
energy is transmitted to organs beneath
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chest and Lungs
Lungs are more prone than an adult’s to
pneumothorax following barotrauma
The mediastinum will shift more with tension
pneumothorax than in an adult
Breath sounds are more easily transmitted
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Abdomen
The liver and spleen, both very vascular
organs, are proportionately larger
Abdominal organs are closer together
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Extremities
Softer and more porous bones
– Treat “sprains” and “strains” as fractures
Injuries to growth plate
– Keep in mind when inserting an intraosseous
needle
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Skin and Body Surface Area
Three distinguishing features
– Skin is thinner
– Less subcutaneous fat
– Increased BSA to weight ratio
Children risk greater injury from extremes in
temperature or thermal exposure
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Respiratory System
Tidal volume proportionately similar to that of
adolescents and adults
– However, metabolic needs demand double the
oxygen
– Proportionately smaller oxygen reserves
Infants at high risk for hypoxia
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiovascular System
Cardiac output is rate dependent
Possess vigorous, but limited, cardiovascular
reserves
– Absolute blood volume is smaller
They can maintain blood pressure longer than
an adult but still be at risk of shock
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Nervous System
Develops continually throughout childhood
– Remains very fragile
Bony structures offer less protection of the
brain and spinal cord
– Greater force can be transmitted
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Metabolic Differences
Infants and children have a limited store of
glycogen and glucose
Pediatric patients are prone to hypothermia
because of their greater BSA-to-weight ratio
Significant volume loss can result from
vomiting and diarrhea
Newborns and neonates lack the ability to
shiver
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Approach to Pediatric
Assessment
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Basic Considerations
Much of the initial patient assessment can be
done during visual examination of the scene
Involve the caregiver or parent as much as
possible
Allow to stay with child during treatment and
transport
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Scene Size-up
Conduct a quick scene size-up
Look for clues to mechanism of injury or
nature of illness
– Presence of dangerous substances
– Environmental hazards
– Evidence of child abuse
Allow child time to adjust to you before
approaching
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Initial Assessment
Pediatric Assessment Triangle
– A way of quickly evaluating the level of severity
and the need for immediate intervention
Appearance
Breathing
Circulation
Vital Functions
–
–
–
–
Level of Consciousness
Airway
Breathing
Circulation
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pediatric Assessment
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Evidence of
Compromised Breathing
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anticipating
Cardiopulmonary Arrest
Respiratory rate
greater than 60
Heart rate greater
than 180 or less
than 80 (under 5
years)
Heart rate greater
than 180 or less
than 60 (over 5
years)
Respiratory distress
Trauma
Burns
Cyanosis
Altered level of
consciousness
Seizures
Fever with
petechiae
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pediatric BLS Algorithm
Click here to view the Pediatric BLS Algorithm.
Reproduced with permission from “2005 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care,” Circulation 2005, Volume 112, IV-158. © 2005 American
Heart Association.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Transport Priority
Urgent
– Rapid trauma assessment
– Transport immediately
Non-urgent
– Complete the focused history and physical exam
at the scene
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Transitional Phase
Depends on seriousness of patient’s
condition
Intended for the non-acutely ill patient
Phase of care that allows patient to become
familiar with you and your equipment
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Focused History and
Physical Exam
If the patient has a medical illness:
– History will precede the physical exam
If the patient is suffering from trauma:
– Physical exam will take precedence
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
History
Nature of illness/injury
Length of time ill or injured
Presence of fever
Effects of illness/injury on behavior
Bowel/urine habits
Presence of vomiting/diarrhea
Frequency of urination
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
History
Identify chronic illnesses, use of medications,
and allergies
If under a doctor’s care, obtain the name of
the physician
With trauma, reconsider the mechanism of
injury
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Physical Exam
Focused Exam
– For trauma:
Rapid trauma exam
– Use the toe-to-head approach with the younger
child
– If minor illness or injury, perform a physical exam
that is focused on the affected areas and systems
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Physical Exam
Focused exam (cont.)
– Pupils
– Capillary refill
Valuable in pediatric patient < 6
– Hydration
Skin turgor, presence of tears and saliva, and the
condition of the fontanelles
– Pulse oximetry
Information regarding peripheral oxygen saturation
Shock and hypothermia can effect reasons
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Glasgow Coma Scale
Scoring
determines
severity:
– GCS 13–15 =
Mild
– GCS 9–12 =
Moderate
– GCS < 8 =
Severe
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Vital Signs
Pulse
Respirations
Blood pressure
(children over 3
years of age)
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Obtaining the Pediatric Pulse
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Non-Invasive Monitoring
Includes
– Pulse oximeter
– Automated blood
pressure devices
– Self-registering
thermometers
– ECGs
© Ken Kerr
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Ongoing Assessment
Reassess the patient since conditions can
change rapidly
– Every 15 minutes in stable patients
– Every 5 minutes in unstable patients
Monitor the patient’s respiratory effort, skin
color, mental status, temperature, and pulse
oximetry
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Management of
Pediatric Patients
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Management of
Pediatric Patients
Your top priorities in treating an infant or
child are airway, breathing, and circulation
Maintain skills through practice
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
BLS Maneuvers:
Infants and Children
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Foreign Body Airway
Obstruction
Responsive Child
– Perform a series of
abdominal thrusts
Responsive Infant
– Five back blows
followed by five chest
thrusts
– Visually inspect
Unresponsive
Child/Infant
– Never use blind finger
sweeps
– Attempt ventilation and
chest compressions
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Suctioning
Decrease suction
pressure to less
than 100 mm/Hg
in infants
Avoid excessive
suctioning time
Avoid stimulation
of the vagus nerve
Check the pulse
frequently
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygenation
Adequate
oxygenation is the
hallmark of pediatric
patient management
Methods of oxygen
delivery
– Masks
– “Blow-by”
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Airway Adjuncts
Airway adjuncts may create greater
complications in children than in adults
– Soft-tissue damage, vomiting, and stimulation of
the vagus nerve
– Use if prolonged ventilations necessary
– Infants and children often improve quickly through
the administration of 100% oxygen
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Airway Adjuncts
Oropharyngeal
– Utilize a tongue
blade for insertion
– Inserted with the tip
pointing toward the
tongue and pharynx
Nasopharyngeal
– Do not use them on
any child with
midface or head
trauma
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilation
Avoid excessive bag pressure and volume
Obtain chest rise and fall
Allow time for exhalation
Flow-restricted, oxygen-powered devices
are contraindicated
Do not use BVMs with pop-off valves
Avoid hyperextension of the neck
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilation
Use a properly sized
mask to ensure a
good fit
Apply cricoid
pressure through
application of the
Sellick maneuver
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Advanced Airway and
Ventilatory Management
Success of these techniques requires
knowledge of the procedures that set
pediatric skills apart from the ALS skills used
on adults
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Foreign Body Airway
Obstruction
If a child’s airway cannot be cleared by basic
airway procedures, visualize the airway with
the laryngoscope
– Once visualized, use the Magill forceps to remove
it
– If unable to remove, intubate around object
Needle Cricothyrotomy
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal Intubation
Allows direct visualization of the lower airway
through the trachea
The most effective method of controlling a
patient’s airway
Mistakenly sized or misplaced tube can
quickly lead to hypoxia and death
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomical and
Physiological Concerns
A straight blade is preferred for greater
displacement of the tongue
Proper sizing of the endotracheal tubes is
crucial
– Use a resuscitation tape
– Estimate the correct tube size by using the
diameter of the patient’s little finger
– (Patient’s age in years + 16) ÷ 4 = Tube size
Depth of insertion
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Depth of Insertion
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomical and
Physiological Concerns
Cuffed or uncuffed endotracheal tubes can be
used in children (but not in neonates)
Infants and small children may have greater
vagal response than adults
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Indications
Need for prolonged artificial ventilation
Inadequate ventilatory support with a BVM
Cardiac or respiratory arrest
Control of an airway in a patient without a
cough or gag reflex
Providing a route for drug administration
Access to the airway for suctioning
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilate the Child
© Scott Metcalfe
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Prepare the equipment
© Scott Metcalfe
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Insert the
laryngoscope
© Scott Metcalfe
Visualize
the larynx
and insert
the tube
© Scott Metcalfe
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilate and
auscultate
© Scott Metcalfe
Confirm tube
placement
© Scott Metcalfe
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Secure the tube
© Scott Metcalfe
Reconfirm
proper tube
placement
© Scott Metcalfe
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Confirmation of Tube
Placement
Visualization
– Tube passing through the vocal cords
– Equal rise and fall of the chest
– Condensation inside the tube
Auscultation
– Lung sounds in the axilla
– Absence of sounds over the epigastrium
– Lack of phonation (inability to speak)
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Adjuncts to ETT Confirmation
Esophageal
detection devices
– May be inaccurate
in pediatrics
Pulse oximetry
– Useful in trending
the patient’s
oxygenation
Capnography
– Preferred method of
continuous tube
confirmation
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal Intubation
Be extremely vigilant about repeatedly or
continuously monitoring proper endoctracheal
tube placement
DOPE
–
–
–
–
Displacement
Obstruction
Pneumothorax
Equipment failure
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Rapid Sequence Intubation
Indicated in pediatric patients when intubation
is difficult due to combativeness or clenched
teeth
Neuromuscular compliance is gained by the
use of a paralytic
– Succinylcholine (Anectine)
1–2 mg/kg IV push
Sedative administration
– Includes midazolam (Versed), diazepam (Valium),
thiopental, and fentanyl
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Rescue Airways
Laryngeal Mask
Airway (LMA) is now
routinely used in
several EMS
systems
© Ray Kemp/911 Imaging
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Nasogastric Intubation
Indications:
– Inability to achieve adequate tidal volume during
ventilation due to gastric distention
– Presence of gastric distention in an unresponsive
patient
Measure the tube from the tip of the nose,
over the ear, to the tip of the xiphoid process
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygenate and continue to ventilate,
if possible
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Measure the NG tube from the tip of
the nose, over the ear, to the tip of the
xiphoid process.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Lubricate the end of the tube. Then
pass it gently downward along the
nasal floor to the stomach.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Auscultate over the epigastrium to
confirm correct placement. Listen for
bubbling while injecting 10–20 cc of
air into the tube.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Use suction to aspirate
stomach contents.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Secure the tube in place.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Circulation
Two problems lead to cardiopulmonary arrest
in children:
– Shock
– Respiratory failure
End-organ changes indicate the effectiveness
of respiratory and cardiovascular function
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Vascular Access
Neck veins
Scalp veins
Arms
Hands
Feet
Intraosseous infusion
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Intraosseous Infusion
Large volumes of
fluid may be
administered
Drugs can be
administered
intraosseously
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Intraosseous Infusion
Indications
Primary indications for intraosseous access
– Existence of shock or cardiac arrest
– An unresponsive patient
– Unsuccessful attempts at peripheral IV insertion
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Intraosseous Infusion
Contraindications
The primary contraindications for IO infusion
include:
– Presence of a fracture in the bone chosen for
infusion
– Fracture of the pelvis or extremity fracture in the
bone proximal to the chosen site
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Drugs Administered by
IO Route
Epinephrine
Atropine
Dopamine
Lidocaine
Sodium bicarbonate
Dobutamine
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Intraosseous Infusion
Placement of
the needle into
the marrow
cavity can be
determined by
noting a lack of
resistance
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Intraosseous Infusion
Click here to view a video on intraosseous infusion.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Fluid Administration
The accurate dosing of fluids in children is
crucial
Initial dosage of 20 mL/kg of an isotonic
solution
– Reassess and repeat as necessary
Minidrip administration sets, flow limiters, or
infusion pumps should be routinely used in
pediatric cases
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Medications
The major aim in
pediatric
resuscitation is
airway
management and
ventilation
Medications may
need to be
administered
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Electrical Therapy
Initial dose of 4 joules per kilogram of body
weight
If still unsuccessful, focus on correcting
hypoxia and acidosis
Transport to a pediatric critical care unit, if
possible
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
C-Spine Immobilization
Because of a child’s disproportionately larger
and heavier head, the cervical spine (Cspine) is vulnerable to injury
Use the appropriate-sized pediatric
immobilization equipment
Use appropriate amounts of padding
Minimize the emotional stress
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Transport Guidelines
Consider three
factors:
– Time of transport
– Specialized facilities
– Specialized
personnel
Reassure the child
© Ken Kerr
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ