BLS Management of the Peds Patient By

Daniel B. Green II, NREMT-P, CCP

Objectives

Review developmental milestones of children

Use the pediatric assessment triangle to assess pediatric patients

Discuss modifications to patient assessment based on age

Review common pediatric illnessess and treatments

Pediatric Development

Pediatric Development

Age and Weight

Important to be able to estimate ages and weights for pediatric patients

Affects treatment decisions, particularly for AED and CPR

Age and Weight

Age and Weight

Developmental Characteristics

Children have different behaviors at different ages

Tailor your assessment

Newborns and InfantsBirth to 1 Year

Do not like cold Do not like separation from

primary caregivers Let parent or caregiver

hold child during assessment

Ask caregiver to expose areas for examination

Warm stethoscope bell before placing on child

Newborns and InfantsBirth to 1 Year

Ask caregiver to comfort crying child Try distraction: pen or toy Check fontanels

Bulging indicates possible increased intracranial pressure

Sunken may indicate dehydration

Toddlers 1–3 Years

Sense of independence but unable to communicate complex ideas

Do not like strangers or separation from parents

Require assuranceMay consider illness or separation from family

as punishment

Toddlers 1–3 Years

Place bell of stethoscope under shirt, rather than taking off clothing

Consider demonstrating procedure such as chest auscultation on stuffed toy before using on child

May not tolerate oxygen mask Use blow-by oxygen

Preschoolers 3–6 Years

More developed concrete thinking skills Ask for their version of events and feelings Frightened of potential pain, blood, injury Reassure, provide simple explanations Allow parent or caregiver to remain Protect modesty

School Aged Children6–12 Years

Have basic idea of body and its functions

Very literal Aware of and afraid of

dying, pain, deformity, permanent injury

Use reassurance and include them in discussions of care

Adolescents 12–18 Years

More thorough understanding of A&P

Able to process and express complex ideas

Good risk takers, poor judges of consequence

Sense of immortality Speak respectfully Protect privacy

The Pediatric Airway

HeadProportionally larger and heavier than body

TongueLarger in proportion to lower jawFalls back, occluding airway

TracheaThinner, more elasticMay close off with hyperextension

Breathing

Infants breath primarily through noseNose may be blocked with secretions

Infant and child have higher respiratory rate Abdominal breathers

Tire quickly when stressed

Pediatric Assessment Triangle

Pediatric Assessment

Elements of the pediatric assessment triangleAppearance and environmentWork of breathingCirculation

Appearance and Environment

Key questions Is scene safe? Is there an obvious

mechanism of injury? Is environment safe for

a child? Is child active and

attentive? Can child make eye

contact, respond to parent’s voice?

Work of Breathing

Look for symmetrical chest movement Note respiratory rate Primary causes of cardiac arrest in children

are respiratory disorders

Abnormal Findings

Stridor Harsh, high pitched sound during inhalation or

exhalation Indicates partial upper airway obstruction

Retraction of chest wall muscles Muscles pulling in between ribs, above sternum with

inspiration Nasal flaring

Extended opening or flaring of nostrils Wheezing

High pitched sounds created by air moving through narrowed air passages in lungs

Assessing Circulation

Central perfusion Supply of oxygen to

and removal of wastes from central circulation

Asses with brachial and femoral pulse checks

Check capillary refill Assess skin

temperature, color, and moisture

Assessing Circulation

BP difficult to obtain below 3 years of age Rely on mental status,

quality of pulses, and capillary refill

Children 3 Ensure right size BP

cuff Be aware of variation of

vital signs with age

Compensating/Decompensating

Children will compensate for poor respirations and circulation

However, decompensation may develop quickly

Respiratory Emergencies in Infants and Children

Respiratory distress Respiratory failure Respiratory arrest Airway management Airway adjuncts Oxygen therapy Assisted artificial ventilations Shock

Respiratory Distress

Most common cause in pediatric patients is asthma

Also includesChronic lung diseaseAirway obstructionCongenital heart diseaseForeign body aspirationChest wall trauma

Definitions

Respiratory distressAbnormal physiologic process that prevents

adequate gas exchange Respiratory failure

Inability of respirations to maintain adequate oxygenation and ventilation

Respiratory arrestAbsence of breathing

Upper Airway Obstruction

Partial obstructionStridor on inspiration

Complete obstructionNo crying, no speaking, no coughingCyanosis

Lower Airway Obstruction

Wheezing Prolonged, labored exhalations Rapid respiratory rate No stridor

Signs of Respiratory Distress in Children

Altered mental status Flared nostrils Pale or cyanotic lips or

mouth Noisy respirations

(stridor, grunting, gasping, wheezing)

Respiratory rate greater than 60

Retractions Use of abdominal

muscles for breathing (see-saw breathing)

Poor peripheral perfusion

Decreased heart rate

Signs of Respiratory Failure

Decreased mental status

Poor eye contact No response to verbal

stimuli

Pale, cyanotic skin Delayed capillary refill,

weak pulses Fatigue, floppy, head

bobbing

Continuing Respiratory Failure

Without immediate intervention, child will continue to deteriorate

Respiratory rate 10/min Unresponsive, limp Decreasing heart rate Eventual respiratory and cardiac arrest

Airway Management

Airway is primary concern for children

Modify head tilt/chin lift to maintain neutral position

Avoid hyperextension or flexion

Consider placing towel under body to maintain neutral airway position

Suctioning Secretions and Vomit

Use bulb-type suction device for suctioning nose and mouth of infant

For larger children, use thin flexible plastic catheter

Use rigid catheter for removing thick secretions and vomit

Principles of Suctioning

Administer oxygen prior to suctioning

Suction for maximum of 5 seconds at a time

Do not touch the back of the throat May slow heart rate

and cause soft-tissue damage

Partial Airway Obstruction

Alert Noisy respirations Increased work of

breathing Retractions around

ribs and sternum Pink mucous

membranes Good peripheral

pulses

Managing Partial Airway Obstruction

Place child in position of comfort

Likely sitting up Calm child Allow child to sit with

parent or caregiver Provide oxygen by

mask or blow-by technique

Let child or caregiver hold oxygen device

Management of Airway Obstruction

Intervene if following signs are notedAbsence of speaking or crying Ineffective coughAltered mental statusRespiratory arrest

Children Under 1 Year of Age

If ventilation is ineffective or impossible, clear airway 5 back blows 5 chest thrusts If object is visible,

remove Continue until effective

Children Over 1 Year of Age

If ventilation is ineffective or impossible, clear airwayPerform chest compressionsDo not perform blind finger sweeps

Shock

Causes in childrenVomitingDiarrhea InfectionTraumaBlood loss

Less commonAllergic reactionsPoisoning

Cardiac Causes of Shock

Very rare in children Occasionally may have child with

congenital or chronic heart disease

Signs and Symptoms of Shock

Rapid heart rate Rapid respiratory rate Cool extremities Pale skin, dry mucous

membranes Delayed capillary fill

time

Weak central pulse Weak or absent distal

pulse Decreased response

to environment “Floppy” muscle tone

Questions to Ask Caregiver

Has child been vomiting or had diarrhea? How many wet diapers in the past

24 hours?

Management of Shock in Children

Child showing signs of shock is very sick Children tend to compensate well, then

decompensate quickly

Emergency Care for Shock

BSI and scene safety Ensure adequate ABCs Control obvious bleeding Administer high flow

oxygen Keep patient warm Elevate legs, if possible Expedite transport/call for

ALS backup

Trauma in Children

Leading cause of death in infants and children Head injuriesChest injuriesAbdominal injuries Injuries to the extremitiesBurn injuries

Common Mechanisms of Injury

Motor vehicle crash Motor vehicle versus bicycle Pedestrian versus motor vehicle Fall from height Diving into shallow water Others

Burns, sports injuries, child abuse

Motor Vehicle Crashes

Most common cause of blunt trauma Unrestrained child

Injuries to head and neck Restrained child

Abdominal and lower spine injuries

Motor Vehicle versus Bicycle

Injuries to Head Spine Abdominal injuries

Pedestrian versus Motor Vehicle

Bumper hits abdomen or upper legs Child thrown and lands on head With toddlers, bump will impact head and

neck Often associated with abdominal, head,

upper leg, pelvic injuries

Head Injuries

Use modified jaw-thrust Tongue obstruction in supine patient most

common cause of hypoxiaDeveloping respiratory failure and arrest

Watch forNausea, vomitingSecondary injuries

Chest Injuries

Children's ribs are more pliableWill bend further before breaking

May be significant internal bleeding without obvious external signs of injury

Abdominal Injuries

More common in children than adults Abdominal muscles are weaker than in

adults Internal organs are less securely anchored Suspect abdominal injury in child who is

deteriorating without outward signs of injury Be aware of gastric distension when

providing assisted ventilations

Injuries to the Extremities

Isolated limb injuries more frequent in pediatric population

Rarely life-threatening Use of PASG prohibited in children Ensure you know local protocols

Burn Injuries

Impaired skin integrity and exposure increase risk of hypothermia

Know Rule of 9s for infants and children

Heads are larger relative to body

Cover with sterile nonstick gauze

Transport to burn center

Emergency Medical Care

BSI, scene survey Maintain cervical

stabilization Use modified jaw-thrust Suction if necessary Provide oxygen Assist respirations as

required Secure to backboard Transport to appropriate

facility

Seizures

Causes Infection Poisoning Hypoglycemia Hypoxia Head trauma

Febrile Seizures

Most common cause of seizures in infants and children

Usually associated with viral illness

Assessment of Seizure Patient

Ask caregiverHow many seizures child has hadHow long seizures lastedWhat part of the body was convulsingRecent history of fever or chronic seizure

disorderWhat medications child takes

Emergency Care for Seizures

Protect cervical spine as necessary

Ensure patent airway Provide oxygen Suction, assist

respirations, if required

Transport to appropriate facility

Poisoning

Common cause is accidental ingestion

Look for substance and container at scene

Emergency Care for Poisoning

If responsiveContact medical directionAdminister oxygen and transport

If unresponsiveMaintain patent airwaySuction and assist ventilations as necessaryContact medical directionAdminister oxygen and transport

Fever

Seldom life-threatening on its own Causes usually infectious

e.g., meningitis Transport and be alert for seizures

The Last Word

Keys are airway, breathing, and oxygenation

Cardiac events in children are almost always preceded by an obstructed airway or inadequate respirations

EMS providers often intimidated by pediatric calls

Practice your skills when working with children

Remain calm and supportive