Silver Cross EMS System
nd
July 2011 2 Trimester CME
PEDIATRICS
“Things to know, appreciate and think about when
caring for kids”
Presenter: Leslie Livett RN MS
Provena Saint Joseph Medical Center
Objectives
• Differentiate anatomic and physiologic
differences in children vs. adults
• Describe how to systematically access a
pediatric patient
• Identify general treatment techniques specific
to pediatric patients and their families
• Describe the assessment and emergency
management of specific illnesses and injuries
Illness and Injury Prevention
• Pediatric chain of survival
– To assess, support, restore
effective ventilation and
circulation to child in respiratory
arrest
•
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Prevention of illness/injury
Early CPR
Early EMS activation
Early, effective advanced life support
APPROACH TO PEDIATRIC
ASSESSMENT
• Prioritize!
• Find and treat the life threats
• Initiate interventions for non life
threatening conditions
• Management depends on
appropriate triage and assessment
Anatomic and Physiological
Considerations
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Trachea
Chest wall
Intercostal muscles
Decreased oxygen reserves
Increased risk of head injury
Higher incidence of multiple organ failure
Breath sounds
Prone to temperature extremes
Larger body surface area
Pliabilty of bones
Less protection of abdominal organs
Circulating blood volume
Developmental Challenges
• Understanding the differences and
developmental stages leads to
better triage/treatment decisions
Less than 1 year
• Homicide leading cause of all
injury deaths (intentional and
unintentional)
• For unintentional injuries causing
death, suffocation leads the list
• Most common age for child abuse
• Toddlers and Preschoolers (1-4 years)
– I’ll Do it myself
• School Age (5-9years)
– Injury and death due to motor
vehicle/occupant, motor vehicle/pedestrian,
fires and burns ,drowning and homicides
• Middle School Age/Preadolescent (1014 years)
– Risk takers/invincibility
– Injury and death due to motor
vehicle/occupant, motor vehicle/pedestrian,
homicide, drowning, motorcycle/moped, bike,
unintentional firearms.
• Adolescents
– Invincibility, hormonal changes
– Deaths due to motor vehicle/occupant,
homicide, suicide, drowning pedestrian,
motorcycle or moped, ATV, followed by
unintentional firearm injuries
Assessment of the
Ill/Injured Child
• Initial assessment
– First impression
• Younger children need different approach
than older children
Pediatric assessment triangle (PAT)
Assessment of the
Ill/Injured Child
Pediatric Assessment Triangle
Assessment of the
Ill/Injured Child
• Physical examination
– Urgent problems, provide initial care
for life-threatening conditions, rapid
transport
– ABC’s----- The Pediatric Way
»Assessment and
resuscitation are the same
as with adults!
PRIMARY SURVEY
• Airway
– Inspection
– Position
– Signs/ Symptoms partial airway
obstruction
– Management
– Non invasive access options
– Intubation
BREATHING
• Assess ventilations
• Listen to breath sounds
• Causes and treatment
– Hypoventilation
• Management
CIRCULATION
• CV assessment
– Heart rate
– Pulses Capillary refill/ peripheral pulses
– Blood pressure
– IV/IO
• Indirect CV assessment
– End organ perfusion
• Hemorrhage
• Management
DISABILITY
• Unique considerations
– Fontanelles/cranial sutures
– Response to the environment
• Assessment
– AVPU
– GCS
– Consistency is key
EXPOSURE
• Management
SECONDARY SURVEY
• History
– Purpose
– Historians
– SAMPLE
• Vital Signs
– Pulse
– Blood pressure
Assessment of the
Ill/Injured Child
• Reassessment
– Continually monitor
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Respiratory effort
Color
Mental status
Pulse oximetry
Vital signs
Specific Pathophysiology,
Assessment, and Management
– Croup
• Description and definition
– Viral respiratory infection, affects upper
respiratory tract
– Below glottis most common
– Swollen, inflamed mucosa
– Hoarseness, inspiratory stridor, barking cough
Specific Pathophysiology,
Assessment, and Management
Croup
• Epidemiology and demographics
– Most common cause of upper airway
obstruction in pediatrics
– Affects children 6 months to 6 years, peaks at
age 2
– Parainfluenza viruses most often in fall, RSV in
midwinter, spring
– Person-to-person spread
– 2- to 4-day incubation period
Specific Pathophysiology,
Assessment, and Management
– Croup
• History
– Upper respiratory infection 2-3 days/spasmodic
– Night
• Physical examination
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Increased respiratory rate, elevated temperature
Loud stridor, hoarse voice, barking cough
Nasal flaring
Retractions
Specific Pathophysiology,
Assessment, and Management
– Croup
• Therapeutic intervention
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Keep warm, comfortable
Assess for FBAO via history only
O2 saturation above 95%
Nebulized saline per medical direction
Respiratory failure, arrest
Specific Pathophysiology,
Assessment, and Management
• Respiratory compromise
– Epiglottis
• Description and definition
– Bacterial infection of upper airway
– Complete airway obstruction, death within
hours
– History, observe from distance
Specific Pathophysiology,
Assessment, and Management
Specific Pathophysiology,
Assessment, and Management
• Respiratory compromise
– Epiglottis
• Epidemiology and demographics
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3-7 years old
Decreased from HiB virus in children
Adolescents, adults increasing
No seasonal preference
Specific Pathophysiology,
Assessment, and Management
– Epiglottis
• Physical examination
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Acutely ill appearance
Prefer sitting up, leaning forward, mouth open
Difficulty swallowing, sore throat, drooling
Muffled voice
Shallow breathing
Stridor late, near-complete airway obstruction
Increased respirations, pulse, temp
Specific Pathophysiology,
Assessment, and Management
– Epiglottis
• Therapeutic intervention
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Close observation, frequent reassessment
Position of comfort
Do not examine oropharynx
Do not administer anything by mouth
Administer high concentration O2
Assist breathing with 100% O2
Total obstruction, ventilate with high pressure
Specific Pathophysiology,
Assessment, and Management
Specific Pathophysiology,
Assessment, and Management
– Asthma and reactive airway disease
• Description and definition
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Reversible obstructive airway disease
Chronic inflammation
Hyperreactive airways
Bronchospasm episodes
Specific Pathophysiology,
Assessment, and Management
– Asthma and reactive airway disease
• Etiology
– Triggered by allergen, air pollution, exercise,
cold air, infection
– Both larger and smaller airways
– Ineffective ventilation, hypoxemia
– Air trapping, inadequate ventilation,
hypoxemia, hypercapnia, respiratory acidosis
Specific Pathophysiology,
Assessment, and Management
– Asthma and reactive airway disease
• Risk factors
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Personal, family history
Passive cigarette smoke
Male gender
Maternal history
Viral respiratory infection
Smaller airways in early life
Low birth weight
Specific Pathophysiology,
Assessment, and Management
– Asthma and reactive airway disease
• History
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Recurrent respiratory symptoms
Exercise
Viral infections
House dust mites, molds, smoke, pollen
Weather changes
Strong emotional depression
Airborne chemicals
Specific Pathophysiology,
Assessment, and Management
– Asthma and reactive airway disease
• Signs/symptoms
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Wheezing
Dry cough
Chest tightness, shortness of breath
Retractions
Tachypnea
Poor air entry
Prolonged expiratory phase
Specific Pathophysiology,
Assessment, and Management
– Asthma and reactive airway disease
• Therapeutic intervention
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Position of comfort
O2, saturation >95%
Assist with bag-mask at 100% O2
Cardiac monitor
Bronchodilators
Epinephrine
ET intubation
Specific Pathophysiology,
Assessment, and Management
• Shock
– Perfusion
• Circulation of blood through organ, part of
body
• Delivers O2, nutrients to cells
• Removes waste products
• Inadequate circulation of blood through
organ
Specific Pathophysiology,
Assessment, and Management
– Initially subtle signs
• Compensated shock signs/symptoms
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Irritability/anxiety
Tachycardia, tachypnea
Weak peripheral pulses, full central pulses
Delayed capillary refill
Cool, pale extremities
Systolic BP within normal limits
Decreased urinary output
Specific Pathophysiology,
Assessment, and Management
• Decompensated shock signs/symptoms
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Lethargy, altered mental status
Marked tachycardia/bradycardia
Absent peripheral pulses, weak central pulses
Markedly delayed capillary refill
Cool, pale, dusky, mottled extremities
Hypotension
Markedly decreased urinary output
Cardiac arrest imminent
Specific Pathophysiology,
Assessment, and Management
– Shock severity
• Hypotension
– Differentiates compensated from
decompensated
– Late sign of cardiac compromise
Specific Pathophysiology,
Assessment, and Management
• Shock
– Hypovolemic shock
• Small blood volume, hemodynamic
compromise
• Loss of blood, plasma, fluids, electrolytes,
endocrine disorders
• Major blood loss causes
Specific Pathophysiology,
Assessment, and Management
• Shock
– Hypovolemic shock
• Signs/symptoms
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Compensated, decompensated shock
Internal, external bleeding
Poor skin turgor
Decreased saliva/tears
Sunken fontanelle
Specific Pathophysiology,
Assessment, and Management
• Shock
– Hypovolemic shock
• Therapeutic interventions
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Trauma suspected, cervical spine stabilization
Open airway with jaw thrust without head tilt
O2
Effective oxygenation, breathing
Pulse oximeter
O2 saturation >95%
Specific Pathophysiology,
Assessment, and Management
– Hypovolemic shock
• Therapeutic interventions
Absent pulse/circulation, chest compressions
Cardiac monitor
IV access/IO access
Isotonic crystalloid bolus, 20 mL/kg per
medical direction
– Check glucose level
– Maintain normal body temperature
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Specific Pathophysiology,
Assessment, and Management
– Hypovolemic shock
• Anaphylactic shock
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Substance exposure previously sensitized
Histamine released
Signs/symptoms
Causes
O2, effective ventilation, oxygenation
Pulse oximeter
Saturation >95%
Absent pulse, heart rate <60 beats/min
Specific Pathophysiology,
Assessment, and Management
– Hypovolemic shock
• Anaphylactic shock
– Cardiac monitor
– Epinephrine intramuscularly/subcutaneously
per medical direction
– Bronchodilator, antihistamine, steroid
– Vascular access
– Monitor for work of breathing, crackles
– Glucose level
Specific Pathophysiology,
Assessment, and Management
• Hypovolemic shock
• Neurogenic shock
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Cardiac monitor
IV, IO needle if necessary
20-mL/kg fluid per medical direction
Monitor work of breathing, crackles
Maintain normal body temperature
Hypothermia
Glucose level
Specific Pathophysiology,
Assessment, and Management
• Seizures
– Altered mental status
• Causes
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Hypoxia
Head trauma
Seizures
infection
Hypoglycemia
Drug/alcohol ingestion
Specific Pathophysiology,
Assessment, and Management
• Seizures
– Temporary change in
behavior/consciousness, abnormal
electrical activity
– Partial seizures
• Simple
• Complex
• Generalized
Specific Pathophysiology,
Assessment, and Management
• Seizures
– Status epilepticus
• Repeated seizures without full recovery of
responsiveness between seizures
• Life threatening
• Febrile seizure
Specific Pathophysiology,
Assessment, and Management
• Seizures
– Causes
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Head trauma
Toxins
Hypoxia
Fever
Hypoglycemia
Infection
• Metabolic
disorders
• Brain
tumor/abscess
• Vascular disorders
• Cardiac
dysrhythmias
• Genetic,
hereditary factors
Specific Pathophysiology,
Assessment, and Management
• Hypoglycemia
– Description and definition
• Metabolically stressed
• Prolonged, irreversible brain damage
• Alcohol intoxication
– Etiology
• Too much insulin, not eaten,
overexercised, physical/emotional stress
Specific Pathophysiology,
Assessment, and Management
• Hypoglycemia
• Signs/symptoms
– Normal/decreased responsiveness, pale,
diaphoretic
– Normal/increased breath rate
– Tachycardia, normal/delayed capillary refill,
cool/pale/clammy skin
– Rapid onset, headache
– Normal breath odor, tremors, staring, inability
to concentrate, uncoordination, irritability
Specific Pathophysiology,
Assessment, and Management
• Hypoglycemia
– Therapeutic intervention
• ABCs
• IV access
• Dextrose, glucagon per medical
direction
• Recheck vital signs often
• Recheck blood glucose level 10 minutes
after therapy
Specific Pathophysiology,
Assessment, and Management
• Hyperglycemia
– Description and definition
• Excess glucose in blood
• Dehydration, ketoacidosis
– Etiology
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Blood glucose level too high
Not enough insulin
Eaten too much
Emotional stress
Specific Pathophysiology,
Assessment, and Management
• Hyperglycemia
– Epidemiology and demographics
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Excessive food intake containing sugar
Insufficient insulin dosage
Infection, surgery, emotional stress
Polydipsia, polyuria, polyphagia
Specific Pathophysiology,
Assessment, and Management
• Hyperglycemia
– Physical examination
• Slight respiratory rate increase
• Kussmaul respirations
• Tachycardia
• BP decrease
• Poor skin turgor, dry mucous
membrane, sunken fontanelle
• Abdominal tenderness, distention
Specific Pathophysiology,
Assessment, and Management
• Hyperglycemia
Therapeutic intervention
• Open airway, suction, O2
• Cardiac monitor, pulse oximeter
• Check glucose level
• Dehydration, IV access, 20-mL/kg bolus
normal saline per medical direction
Specific Pathophysiology,
Assessment, and Management
• Meningitis
– Description and definition
• Inflammation of meninges
• Infection spread quickly
• Brain becomes swollen, covered with
pus
• Newborns
• Older children
Specific Pathophysiology,
Assessment, and Management
• Meningitis
– History
• Sudden or gradual onset
• Recent ear/upper respiratory infection,
fever
• Apnea, respiratory distress in neonates
• Vomiting, headache, poor feeding,
photophobia
• AMS, lethargy, irritability
Meningitis Signs/Symptoms
– Fever, chills
– Tachycardia,
tachypnea
– Cough, sore throat
– Nasal congestion
– Malaise
– Cool/clammy skin
– Petechiae
– Respiratory distress
– Poor feeding
– Vomiting, diarrhea
– Dehydration
– Shock
– Purpura
– Seizures
– Severe headaches
– Irritability
– Stiff neck
– Bulging fontanelle
Meningitis-Therapeutic
Invervention
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PPE
ABCs, Supportive care
Seizure monitoring
IV, O2, monitor
Pulse oximeter
IV fluid bolus
Reassess
Specific Pathophysiology,
Assessment, and Management
• Meningitis
– Physical
examination
– Differential
diagnosis
– Therapeutic
interventions
– Patient and family
education
Let’s take 5
• Audrey will find a film for your
viewing pleasure.
• Remember the audio will come from
your computer, not the phone
• Grab a pop and see you in a few
minutes.
Pediatric Trauma!
EPIDEMIOLOGY FOR
TRAUMA
• Injury every 4 seconds, death every
6 minutes
• Mortality rates higher here than
any other country
• One million hospitalizations/year
• 25 million ED visits
Incidence
• 250,000 children suffer head
injuries each year
• 50% of injury related deaths are
head injury
• Falls < 2 years and child abuse < 1
year
Key Concepts to
Remember
•
•
•
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Brain Sensitivity
Brain Perfusion
CPP
3 Components of the box
Categories of Injury
• Coup
• Contrecoup
Causes of Brain Injury
• Primary
– Direct insult at the time of the injury
– Results in dysfunction to skull, scalp,
neurons, axons and blood vessels
• Secondary or Tertiary (indirect)
injury
– Results of metabolic events
precipitated by the trauma
Glasgow Coma Scale
• Standard for reliability. Influences
treatment, transport and transfer
decisions
– GCS 3-7 severe injury
– GCS 8-12 moderate injury
– GCS 13-15 mild injury
• In the child look for headache, stiff neck,
photophobia, cranial nerve involvement,
posturing or Cushing’s triad Bradycardia:
•
Systolic hypertension
Bradycardia
• Irregular breathing pattern
This is a late finding.
Assessment
• History is important
• Must recognize brain injury
• Must recognize signs and symptoms
of increasing ICP
General Management of
Head/Brain Injuries
• Maintain airway and ventilation
– The brain does not tolerate hypoxia
– Tube if you need to
– Make sure suction is available!!!!
•
•
•
•
Elevate head of bed 30 degrees
Prevent hypotension
Avoid Glucose
Treat seizures
– Use the GCS for serial comparisons!
– A GCS that falls 2 points suggests
significant deterioration!
Pediatric Spinal Inury
Pediatric Trauma
• Specific injuries
– Spinal trauma
• Spinal nerve injury without vertebrae injury
• <8 years, C1 and C2 injury
• >8 years, C5-C7 injury
Pediatric Trauma
Spinal trauma
• Signs
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Neck/back pain
Movement pain of neck/back
Posterior neck/midline back pain on palpation
Spinal column deformity
Neck/back muscle guarding/splinting
Priapism
Neurogenic shock signs
Paralysis, paresis, numbness, arm/leg tingling
Diaphragmatic breathing
Pediatric Trauma
Spinal trauma management
• ABCs
• Spinal stabilization indications
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Mechanisms of injury involving blunt trauma
MOI with rapid, forceful head movement
AMS with trauma, drowning history
Neurological deficit in arms/legs
Helmet damage
Tenderness/deformity in cervical, thoracic,
lumbar region
Pediatric Trauma
Spinal trauma management
• Spinal stabilization
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Head, neck in neutral in-line position
Rigid cervical collar
Logroll onto rigid board
Secure around chest, pelvis, legs
Secure head first
Safety seat can be used
Cravat around head
Pad all open areas
Pediatric Trauma
– Chest trauma
• High mortality rate
• Most common
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Pulmonary contusion, laceration
Pneumothorax, hemothorax
Rib/sternal fractures
Cardiac injury
Diaphragm injury
Major blood vessel injury
Pediatric Trauma
Chest trauma
• Rib fracture, significant force
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Left lower, spleen injury
Right lower, liver injury
Multiple, inadequate breathing, pneumonia
Flail chest, life-threatening
Pulmonary contusion easily missed
Tension pneumo, immediate threat to life
Massive hemothorax, rare
Hypovolemia, jugular venous distention absent
Bradycardia, arrest imminent
Pediatric Trauma
Abdominal and pelvic trauma
• Abdominal wall thin, organs closer to
skin
• MVCs most common with blunt trauma
• Spleen most frequent injury
• Liver, lethal hemorrhage
• Kidney injury
Pediatric Trauma
– Abdominal and pelvic trauma
• General management
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ABCs
Palpate one quadrant at a time
Hypovolemia/shock, fluids
Pelvic injury, hemorrhage
Rapid transport
Pediatric Trauma
– Extremity trauma
• Greenstick fracture
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Splinters in pieces, remains connected
Growth plate injury
Bilateral femur fractures
Child abuse
Pediatric Trauma
– Extremity trauma
• General management
ABCs
Control bleeding
Splint
Immobilize joint above and below the injury
Pulses, motor function, sensation before/after
splinting
– Hypovolemia/shock, IV fluids
– Transport
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Pediatric Trauma
• Special considerations
– Airway control
• In-line stabilization in a neutral position
• 100% O2, trauma
• Open airway, suction, jaw thrust without
head/tilt
• Assist ineffective breathing
• Intubation, inadequate airway
• Needle cricothyroidectomy rarely
indicated
Pediatric Trauma
Immobilization
Rigid c-collar
Towel, blanket roll
Child safety seat
Vest-type device,
short wooden
backboard
• Pediatric
immobilization
device
•
•
•
•
• Long
backboard
• Straps,
cravats
• Tape
• Padding
• Do not flex
neck
Pediatric Trauma
– Fluid management
• Large-bore IV in large peripheral vein
• Or IO access
• 20 mL/kg fluid bolus per medical
direction
• Reassess vital signs
• Repeat if there is no improvement
• Rapid transport
Child Abuse
– Maltreatment
• Physical abuse, neglect
• Emotional abuse, neglect
• Sexual abuse
– Neglect
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•
•
•
Failure to provide for basic needs
Physical
Educational
Emotional
Child Abuse
– Physical abuse
• Inflicting of nonaccidental injury
– Emotional abuse
• Conveyance that child is worthless
Child Abuse
• Red Flags
– Burns
– Fractures
– Hair loss
– Suspicious stories
– Bruising
Call DCFS
• We are mandated reporters by law
• We must call DCFS if we suspect
child abuse or neglect.
– 1-800-25-Abuse
• Doesn’t matter if nurse, doctor,
cops or neighbors are calling too.
• The law says if you see it, you call.
– Trauma Prevention
– Learning by example
– Safety should be part of the daily routine
– Remember, Trauma is leading cause of death
and disability in children and adolescents
– Changes in products or environment
» Education
» Products
» Environment
» Legislation
COMMUNICATION TIPS
• Provide reassurance
• Always talk with children of all ages
• Remember the family
And the # 1 Thing To
Remember About “Little People”
is . . . .
AIRWAY
MANAGEMENT!
Just Like Adults
Some Quick System Notes
• Next month is a trimester testing
month, so get those study guides
completed!
• In September, CME will focus on
new SMO’s, which have been
approved and will be released in
2012.
• The new SMO’s have lots of fun
additions for BLS providers!
Thank You for your
Attention
References:
Comprehensive Pediatric emergency Care (Aehlert)
Mosby’s Paramedic Care
Journal of Trauma Nursing, “The Trauma Top 10”, October
2009, Noreen Felich, RN
Please refer any further questions to Audrey at
afinkel@silvercross.org and she will get them answered for you!