32: Pediatric Assessment and Management
Cognitive Objectives
(1 of 3)
6-1.4 Indicate various causes of respiratory
emergencies.
6-1.5 Differentiate between respiratory distress and
respiratory failure.
6-1.6 List steps in the management of foreign body
airway obstruction.
Cognitive Objectives
(2 of 3)
6-1.7
Summarize EMS care strategies for
respiratory distress and respiratory failure.
6-1.8
Identify the signs and symptoms of shock
(hypoperfusion) in the infant and child patient.
6-1.9
Describe the methods of determining end
organ perfusion in the infant and child patient.
6-1.10 State the usual cause of cardiac arrest in
infants and children versus adults.
Cognitive Objectives (3 of 3)
6-1.12 Describe the management of seizures in the
infant and child patient.
6-1.14 Discuss the field management of the infant
and child trauma patient.
•
There are no affective objectives for this chapter.
Psychomotor Objectives (1 of 2)
6-1.21 Demonstrate the techniques of foreign body
airway obstruction removal in the infant.
6-1.22 Demonstrate the techniques of foreign body
airway obstruction removal in the child.
6-1.23 Demonstrate the assessment of the infant
and child.
Psychomotor Objectives (2 of 2)
6-1.24 Demonstrate bag-valve-mask artificial
ventilations for the infant.
6-1.25 Demonstrate bag-valve-mask artificial
ventilations for the child.
6-1.26 Demonstrate oxygen delivery for the infant
and child.
Additional Objectives*
Cognitive
1. Describe the steps in positioning an infant and/or child
to maintain an open airway.
2. Summarize neonatal resuscitation procedures.
Affective
None
Psychomotor
3. Demonstrate the techniques necessary in neonatal
resuscitation.
*These are noncurriculum objectives.
Pediatric Assessment
and Management
• Caring for sick and injured children presents
special challenges.
• EMT-Bs may find themselves anxious when
dealing with critically ill or injured children.
• Treatment is the same as that for adults in most
emergency situations.
Scene Size-up
• Take note of your surroundings.
• Scene assessment will supplement additional
findings.
• Observe:
– Position of the patient
– Condition of the home
– Clues to child abuse
Initial Assessment
• Begins before you touch the
patient
• Form a general impression.
• Determine a chief complaint.
• The Pediatric Assessment
Triangle can help.
Pediatric Assessment Triangle
• Appearance
– Awake
– Aware
– Upright
• Work of breathing
– Retractions
– Noises
• Skin circulation
Assessing the ABCs
• Ensure airway is open and
position patient.
• Breathing assessment
– Effort
– Obstructions
– Rate
• Circulation assessment
– Rate
– Skin color, temperature,
and capillary refill
Transport Decision
• Children under 40 lb should be transported in a
child safety seat, if the situation allows.
• Seat should be secured to the cot or captain’s
chair.
• Cannot be secured to bench seat
• Child may have to be transported without a seat,
depending on condition.
Focused History and Physical Exam
• Should be completed on scene unless severity
requires rapid transport
• Young children should be examined toe to head.
• Focused exam on noncritical patients
• Rapid exam on potentially critical patients
Vital Signs by Age
Age
Respirations
(breaths/min)
Pulse
(beats/min)
Systolic Blood
Pressure
(mm Hg)
Newborn: 0 to 1 mo
30 to 60
90 to 180
50 to 70
Infant: 1 mo to 1 yr
25 to 50
100 to 160
70 to 95
Toddler: 1 to 3 yr
20 to 30
90 to 150
80 to 100
Preschool age: 3 to 6 yr
20 to 25
80 to 140
80 to 100
School age: 6 to 12 yr
15 to 20
70 to 120
80 to 110
Adolescent: 12 to 18 yr
12 to 16
60 to 100
90 to 110
Older than 18 yr
12 to 20
60 to 100
90 to 140
Respirations
• Abnormal respirations are a
common sign of illness or injury.
• Count respirations for 30
seconds.
• In children less than 3 years,
count the rise and fall of the
abdomen.
• Note effort of breathing.
• Listen for noises.
Pulse
•
•
•
•
In infants, feel over the brachial or femoral area.
In older children, use the carotid artery.
Count for at least 1 minute.
Note strength of the pulse.
Blood Pressure
• Use a cuff that covers two thirds of the
upper arm.
• If scene conditions make it difficult to
measure blood pressure accurately,
do not waste time trying.
Skin Signs
• Feel for
temperature and
moisture.
• Estimate capillary
refill.
Detailed Physical Exam
and Ongoing Assessment
•
•
•
•
Status changes frequently in children.
The PAT can help with reassessment.
Repeat vital signs frequently.
If child deteriorates, repeat the initial assessment.
Care of the Pediatric Airway (1 of 2)
• Position the airway.
• Position the airway in a neutral sniffing position.
• If spinal injury is suspected, use jaw-thrust
maneuver to open the airway.
Care of the Pediatric Airway (2 of 2)
• Positioning the airway:
– Place the patient on a
firm surface.
– Fold a small towel
under the patient’s
shoulders and back.
– Place tape across
patient’s forehead to
limit head rolling.
Oropharyngeal Airways
• Determine the appropriately
sized airway.
• Place the airway next to the
face to confirm correct size.
• Position the airway.
• Open the mouth.
• Insert the airway until flange
rests against lips.
• Reassess airway.
Nasopharyngeal Airways (1 of 2)
• Determine the appropriately
sized airway.
• Place the airway next to the
face to make certain length
is correct.
• Position the airway.
• Lubricate the airway.
Nasopharyngeal Airways (2 of 2)
• Insert the tip into the
right naris.
• Carefully move the tip
forward until the
flange rests against
the outside of the
nostril.
• Reassess the airway.
Assessing Ventilation
• Observe chest rise in older children.
• Observe abdominal rise and fall in younger
children or infants.
• Skin color indicates amount of oxygen getting
to organs.
Oxygen Delivery Devices
• Nonrebreathing mask at 10 to
15 L/min provides 90% oxygen
concentration.
• 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.
BVM Devices
• Equipment must be the right size.
• BVM device at 10 to 15 L/min provides 90%
oxygen concentration.
• Ventilate at the proper rate and volume.
• May be used by one or two rescuers
One-rescuer BVM Ventilation
A
B
C
D
Airway Obstruction
• Croup
– A viral infection of the airway below the level of
the vocal cords
• Epiglottitis
– Infection of the soft tissue in the area above the
vocal cords
• Foreign body airway obstructions
Signs and Symptoms
• Decreased or absent breath
sounds
• Stridor
• Retractions
• Difficulty speaking
Signs of Severe
Airway Obstruction
• Signs and symptoms
– Ineffective cough (no sound)
– Inability to cry
– Increasing respiratory difficulty, with stridor
– Cyanosis
– Loss of consciousness
Removing a Foreign Body Airway
Obstruction (1 of 5)
• In an unconscious child:
– Place the child on a firm, flat surface.
• Open airway using head tilt-chin lift maneuver.
– Inspect the upper airway and remove any
visible object.
– Attempt rescue breathing.
• If unsuccessful, reposition head and try again.
– If ventilation is still unsuccessful begin CPR.
Removing a Foreign Body Airway
Obstruction (2 of 5)
• Place heel of one hand on lower half of sternum
between the nipples.
• Administer 30 chest compressions at a depth of
1/3 to 1/2 the depth of the chest.
Removing a Foreign Body Airway
Obstruction (3 of 5)
• Open airway using head tilt-chin lift maneuver.
If you see the object, remove it.
• Repeat process.
Removing a Foreign Body Airway
Obstruction (4 of 5)
• In a conscious child:
– Kneel behind the
child.
– Give the child five
abdominal thrusts.
– Repeat the technique
until object comes out.
Removing a Foreign Body Airway
Obstruction (5 of 5)
• If the child becomes
unconscious, inspect the
airway.
• Attempt rescue
breathing.
• If airway remains
obstructed, begin CPR.
Management of Airway
Obstruction in Infants
•
•
•
•
•
•
Hold the infant facedown.
Deliver five back slaps.
Bring infant upright on the thigh.
Give five quick chest thrusts.
Check airway.
Repeat cycle as often as
necessary.
Neonatal Resuscitation
• Resuscitation measures include:
– Positioning airway
– Drying
– Warming
– Suctioning
– Tactile stimulation
Neonatal Equipment
Additional Efforts
• Deliver chest compressions
at 120 per minute.
• Coordinate chest
compressions with
ventilations at a ratio of 3:1.
• If meconium is present,
suction infant vigorously.
BLS Review
• Cardiac arrest in children is commonly due to
respiratory arrest.
• Many causes of respiratory arrest
• For purposes of pediatric BLS:
– Infancy ends at 1 year of age.
– Childhood extends from 1 year of age to
onset of puberty (12 to 14 years of age).
Determine Responsiveness
• Gently tap on shoulder and speak loudly.
• If responsive, place in position of comfort.
• If you find an unresponsive child when you are not
on duty:
– Provide BLS for about 2 minutes.
– Then call EMS system.
Airway
• Airway may be obstructed by tongue.
• Use head tilt-chin lift technique or jaw-thrust
maneuver to open the airway.
• Jaw-thrust maneuver is safer if possibility of
neck injury exists.
Breathing
• Look, listen, and feel.
• Provide rescue
breathing if needed.
• Perform Sellick
maneuver to prevent
gastric distention.
Circulation
• Assess circulation after airway is open and two
rescue breaths have been given.
• Check for pulses.
• Evaluate for other signs of circulation.
• Take at least 5 seconds but not more than 10
seconds trying to find a pulse.
• If infant or child is not breathing, the pulse is often
too slow or absent. CPR will be required.
Infant CPR (1 of 2)
• Place infant on firm
surface and maintain
airway.
• Place two fingers in the
middle of the sternum.
• Use two fingers to
compress the chest 1/3 to
1/2 the depth of the chest
at a rate of 100/min.
Infant CPR (2 of 2)
• Allow sternum to return briefly to its normal
position between compressions.
• Coordinate rapid compressions and
ventilations in a 30:2 ratio.
• Reassess the infant for return of breathing and
pulse after every 2 minutes of CPR.
Child CPR (1 of 2)
• Place child on firm surface
and maintain airway with
one hand.
• Place heel of other hand
over lower half of the
sternum.
– Avoid the xiphoid
process.
• Compress chest 1/3 to 1/2
the depth of the chest at a
rate of 100/min.
Child CPR (2 of 2)
• Coordinate compressions with ventilations in a 30:2
ratio for one rescuer, 15:2 for two rescuers, pausing for
ventilations.
• Reassess for breathing and pulse after every 2 minutes
of CPR.
• If the child resumes effective breathing, place child in
recovery position.