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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