Chapter 30
Infants and Children
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 1
Case History
You respond to a child in respiratory distress. On
arrival, you observe a 3-year-old boy experiencing
difficulty breathing with a “barking” cough, stridor, and
active accessory muscle use. Your initial assessment
reveals hot and dry skin, cyanosis, “seesaw”
breathing, and retractions between the ribs. The
mother advises you that the child awoke from sleep
30 minutes ago. The symptoms have become
progressively worse.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 2
Spiral of Pediatric Arrest
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 3
Newborns and Infants –
Birth to 1 Year of Age

Minimal stranger anxiety

Do not like to be separated from parents

Do not want to be suffocated by an oxygen mask

Need to be kept warm

Make sure hands and stethoscope are warmed before touching
child.

Breathing rate best obtained at a distance

Examine heart and lungs first, head last.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 4
Toddlers – 1 to 3 Years

Do not like to be touched

Do not like being separated from parents

Do not like having clothing removed


Remove, examine, replace
May feel suffocated by an oxygen mask
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 5
Toddlers – 1 to 3 Years

Children think their illness/injury is punishment


Reassure child that he or she was not bad.
Afraid of needles and fear of pain

Provide encouragement but be honest.
 If possible, keep child close to parent.

Head-to-toe approach
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 6
Preschoolers – 3 to 6 Years

Do not like to be touched

Do not like being separated from parents

Do not like having clothing removed


Remove, examine, replace
Do not want to be suffocated by an oxygen mask
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 7
Preschoolers – 3 to 6 Years

Children think that the illness/injury is a punishment

Reassure child that he or she was not bad.

Afraid of blood and fear of pain

Fear of permanent injury

Modest
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 8
School Age – 6 to 12 Years

Afraid of blood

Fear of pain and permanent injury

Fear of disfigurement/permanent injury

Modest

Should be treated as adults.

May desire to be assessed privately, away from parents or
guardians
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 9
Adolescents – 12 to 18 Years

Fear of disfigurement/permanent injury

Modest

Should be treated as adults.

May desire to be assessed privately, away from parents or
guardians
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10
Anatomic and Physiologic Concerns –
Airway

Small airways throughout the respiratory system

Easily blocked by secretions and airway swelling

Tongue is large relative to small mandible.


Positioning


Can block airway in an unconscious infant or child
Do not hyperextend the neck
Infants are obligate nose breathers.

Suctioning nasopharynx can improve breathing.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11
Comparison of Airway Anatomy
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Suctioning

Vacuum



Child – 300 mm Hg
Newborn – 100 mm Hg
Technique


Child – large-bore, rigid catheter
Newborn and infant – soft catheter or bulb syringe
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13
Oral Airways

Used for patients who do not have a gag reflex

Insert directly using tongue blade.

Take care to avoid injury to soft tissues.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14
Sizing

Multiple sizes

Sizing technique

Corner of the lips to
bottom of earlobe
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Breathing

Respiratory rate higher than
adults

Interventions

Humidified oxygen
 Keep patient warm
 If PPV necessary, do not
overinflate; watch for gastric
inflation.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16
Compensatory Ability

Children can compensate well for short periods of
time.



Increased breathing rate
Increased effort of breathing
Compensation is followed rapidly by
decompensation.


Rapid respiratory muscle fatigue
General fatigue of the infant
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17
Circulation – Pulse Rate
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Circulation – Blood Pressure

Blood pressure increases with age.

Use appropriate size BP cuff.

Use formula to determine lower limit for systolic BP


70 + (2 x Age in years)
Systolic BP <70 mm Hg with tachycardia and cool skin are
indicators of shock.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19
Circulation – Bleeding and Shock

Hypovolemic – most common shock found in children


Bleeding
Dehydration
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20
Dehydration in Children
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21
Blood or Fluid Loss


Average blood volume – 80 ml/kg
Children can maintain BP until almost 40% of fluid
volume is lost.

Low BP is a LATE sign of shock.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 22
Shock – Causes

Rarely a primary cardiac event

Common causes

Diarrhea and dehydration
 Trauma
 Vomiting
 Blood loss
 Infection
 Abdominal injuries
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 23
Shock – Causes

Less common



Allergic reactions
Poisoning
Cardiac
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 24
Signs and Symptoms –
Shock

Rapid respiratory rate

Pale, cool, clammy skin

Weak or absent peripheral pulses

Delayed capillary refill
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 25
Signs and Symptoms –
Shock

Decreased urine output

Ask parents about diaper wetting and look at diaper.

Mental status changes

Absence of tears, even when crying
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 26
Metabolic Considerations

Keep child warm.



Higher baseline metabolic rate
• Growing requires more fuel than adults.
• Rapid respiratory and pulse rates
Need to expend more energy to keep warm.
Infants <6 months do not have ability to shiver.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 27
General Impression

Assessment of mental status

Effort of breathing

Color

Quality of cry/speech
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 28
Interaction with
Environment and Parents

Normal behavior for child of this age

Playing
 Moving around
 Attentive versus nonattentive




Eye contact
Recognizes parents
Responds to parent’s calling
Response to the EMT


Should be appropriately upset
Tone/body position
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 29
Approach to Evaluation

Begin from across the room.

Mechanism of injury

Assessment of surroundings

General impression of well versus sick
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 30
Assess Breath Sounds

Present

Absent

Stridor

Wheezing

Cyanosis
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Detailed Physical Exam

Begin with a trunk-to-head approach.


Situation- and age-dependent
Should help reduce the infant or child’s anxiety
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 32
Common Problems
in Infants and Children









Airway obstructions
Respiratory emergencies
Seizures
Altered mental status
Poisonings
Fever
Shock
Near drowning
SIDS
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Airway Obstruction –
Croup
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Airway Obstruction –
Epiglottitis
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Mild –
Infant or Child Alert and Sitting

Stridor, crowing, or noisy

Retractions on inspiration

Pink

Good peripheral perfusion

Still alert, not unconscious
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 36
Emergency Medical Care

Allow position of comfort.

Assist younger child to sit up.

Do not lay the child down; may sit on parent’s lap.

Offer oxygen and transport.

Do not agitate child, limited examination.

Do not assess blood pressure.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 37
Foreign Body Airway Obstruction
(FBAO)

Determine






LOC
Air exchange
Ability to speak or cry
History of respiratory infections, fever, barking cough
History of choking
Treat all suspected infectious causes of obstruction as if they
are epiglottitis.
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FBAO – The Alert Child

Keep management to a minimum.

Keep parents and child calm.

Allow position of comfort (parent’s arms).

Administer humidified oxygen if child will allow (without
agitation).

Transport without delay.

Do not intervene if child is alert and moving air.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 39
FBAO – Severe

Unconscious



Reopen airway/reattempt ventilation (PPV).
If child has a foreign body obstruction, perform CPR.
When you open the airway look for a FB.
» If you see it, remove it with a finger sweep.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 40
Airway Obstruction Management

Infant



Back blows
Chest thrusts
Child

Abdominal thrusts
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 41
Respiratory Emergencies

Recognize the difference between upper airway
obstruction and lower airway disease.

Upper airway obstruction


Stridor on inspiration
Lower airway disease



Wheezing
Breathing effort on exhalation
Rapid breathing (tachypnea) without stridor
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 42
Early Respiratory Distress

Nasal flaring

Intercostal retraction

Neck muscles, supraclavicular, subcostal retractions

Stridor

Neck and abdominal muscle retractions

Audible wheezing

Grunting
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 43
Severe Respiratory Distress

Early signs, plus








Altered mental status
Rate >60/min
Cyanosis
Decreased muscle tone
Severe use of accessory muscles
Poor peripheral perfusion
Altered mental status
Grunting
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 44
Respiratory Arrest

Breathing rate <10/min

Limp muscle tone

Unconscious

Slower, absent heart rate

Weak or absent distal pulses
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 45
Emergency Medical Care

Provide oxygen for all respiratory distress.

Assist ventilation for severe respiratory distress.





Respiratory distress and altered mental status
Presence of cyanosis with oxygen
Respiratory distress with poor muscle tone
Respiratory failure
Provide oxygen and ventilate with bag-valve-mask for
respiratory arrest.
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Submersion Incident/
Near Drowning

Artificial ventilation is top priority.

Consider possibility of trauma.

Consider possibility of hypothermia.

Consider possible ingestion, especially alcohol.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 47
Submersion Incident/
Near Drowning

Protect airway, suction if necessary.

Secondary drowning syndrome


Deterioration after breathing is normal from minutes to hours
after event.
All near submersion incident victims should be transported to
the hospital.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 48
Emergency Medical Care






Ensure airway and provide oxygen.
Be prepared to artificially ventilate.
Manage bleeding, if present.
Elevate legs.
Keep warm.
Transport.


Note need for rapid transport of infant and child
Secondary examination is completed en route
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 49
Sudden Infant Death Syndrome
(SIDS)

Sudden death of infants in first year of life

Causes are many and not clearly understood.

Baby is most commonly discovered in the early
morning.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 50
Emergency Medical Care

Try to resuscitate,unless rigor mortis present.

Parents will be in agony from emotional distress,
remorse, and imagined guilt.

Avoid any comments that might suggest blame to the
parents.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 51
Fever

Common reason for infant or child ambulance call

Many causes

Rarely life-threatening
 Severe cause — meningitis

Fever with a rash is a potentially serious consideration.

Emergency medical care

Transport.
 Be alert for seizures.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 52
Seizures

Seizures in children are rarely life threatening.

Seizures may be brief or prolonged.

Assess for presence of injuries.

Causes






Fever and infections
Poisoning
Hypoglycemia
Trauma
Decreased levels of oxygen
Idiopathic in children
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 53
Seizures – History

Has the child had prior seizure(s)?


If yes, is this the child’s normal seizure pattern?
Has the child taken his or her prescribed anti-seizure
medications?
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 54
Emergency Medical Care

Ensure airway position and patency.

Position patient on side, if no possibility of cervical
spine trauma.

Have suction ready.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 55
Emergency Medical Care

Provide oxygen.

Respiratory arrest or severe respiratory distress


Ensure airway position and patency.
Ventilate with bag-valve-mask

Transport

Although brief seizures are not harmful, a more dangerous
underlying condition may exist.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 56
Head Injury and Seizures

Seizures can be caused by head injury.

Inadequate breathing and/or altered mental status
may occur after a seizure.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 57
Altered Mental Status –
Causes

Hypoglycemia

Poisoning

Postseizure

Infection

Head trauma

Decreased oxygen levels

Hypoperfusion (shock)
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 58
Emergency Medical Care

Ensure patency of airway.

Be prepared to artificially ventilate/suction.

Transport.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 59
Poisonings

Poisoning is a common reason for infant and child
EMS calls.

Identify suspected container through adequate
history.

Bring container to receiving facility, if possible.
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Emergency Medical Care –
Responsive Patient

Contact medical control.

Consider need to administer activated charcoal.

Provide oxygen.

Transport.

Continue to monitor patient.

May become unresponsive
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 61
Emergency Medical Care –
Unresponsive Patient

Ensure patency of airway.

Be prepared to artificially ventilate.

Provide oxygen, if indicated.

Call medical direction.

Transport.

Rule out trauma.

Trauma can cause altered mental status.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 62
Trauma








Motor vehicle passengers
Struck while riding bicycle
Pedestrian struck by vehicle
Falls from height
Diving into shallow water
Burns
Sports injuries of head and neck
Child abuse
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Head Injury

Open airway

Modified jaw thrust

Head injury with internal injuries is likely in children.

Signs and symptoms of shock with head injury
 Suspicion of other possible injuries

Respiratory arrest

Common secondary to head injuries
 May occur during transport
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 64
Head Injury

Common signs and symptoms are nausea and
vomiting.

Most common cause of hypoxia is tongue obstructing
the airway.


Jaw thrust is critically important.
Do not use sandbags.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 65
Chest Injury

Children have very soft, pliable ribs.

Significant injuries may be present without external
signs.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 66
Abdomen and Extremities

More common site of injury in children than adults

Often a source of hidden injury

Always consider abdominal injury in the multiple trauma patient
with no external signs whose condition is deteriorating.

Air in stomach can distend abdomen.


Interferes with artificial ventilation efforts.
Extremities

Injuries are managed in the same manner as adults.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 67
Other Trauma Considerations

Pneumatic antishock garments can be used for children.

Use only if PASG fits child.
 Do not place infant in one leg of trouser

Indications for PASG use

Trauma with signs of severe hypoperfusion and pelvic instability

Do not inflate abdominal compartment.

Criticality of burns

Cover with sterile dressing (nonstick).
 Identify candidates for burn centers.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 68
Emergency Medical Care

Ensure airway position and patency.

Use jaw thrust.

Suction as necessary.

Provide oxygen.

Assist ventilations as needed.

Provide spinal immobilization.

Transport immediately.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 69
Child Abuse and Neglect

Definition of abuse


Definition of neglect


Improper or excessive action so as to injure or cause harm
Giving insufficient attention or respect to someone who has a claim
to that attention
EMT must be aware of condition to be able to recognize the
problem.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 70
Signs and Symptoms –
Abuse

Multiple bruises in various stages of healing

Injury inconsistent with mechanism described.

Repeated calls to the same address.

Fresh burns

Parents are inappropriately unconcerned.

Conflicting stories

Child fearful to discuss how the injury occurred.
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Abuse –
Belt Marks
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Abuse –
Bruises on Four Surfaces
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Abuse –
Immersion Scald
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Appearance of Bruises in Various
States of Healing
Age of Bruise
1-3 days
3-7 days
>7 days
>3 weeks
Appearance
Red/blue
Purple
Yellow/brown
Brown to clearing
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 75
Signs and Symptoms –
Neglect

Lack of adult supervision

Malnourished-appearing child

Unsafe living environment

Untreated chronic illness

CNS injuries are the most lethal.

Shaken baby syndrome
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 76
Reporting Abuse

Do not accuse in the field.

Accusation and confrontation delays transportation.

Bring objective information to the receiving facility.

Reporting required by state law and local regulations.

Be objective.

Document what you see and what you hear, NOT what you think.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 77
Infants and Children
with Special Needs

Premature babies with lung disease

Babies and children with heart disease

Infants and children with neurologic disease

Children with chronic disease or altered function from birth

Often these children will be at home, technologically dependent.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 78
Tracheostomy Tubes
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Suction of Tracheostomy
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Gastrostomy Tube
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Central Lines

Intravenous lines (IVs) placed near the heart for long-term use

Complications

Cracked line
 Infection
 Clotting off
 Bleeding

Emergency medical care

If bleeding, apply pressure.
 Transport.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 82
Shunts

Device running from brain to abdomen to drain excess cerebrospinal
fluid

Reservoir on side of skull

Change in mental status

Prone to respiratory arrest

Manage airway.
 Ensure adequate ventilation.

Transport
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 83
Family Response

A child cannot be cared for in isolation from the family.


You have multiple patients.
Strive for calm.

Calm parents = calm child
 Agitated parents = agitated child


Anxiety arises from concern over child’s pain; fear for child’s
well-being.
Anxiety is worsened by sense of helplessness.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 84
Family Response

Parent may respond to EMT with anger or hysteria.

Parents should remain part of the care unless child is not aware
or medical conditions require separation.

Parents should be instructed to calm child; can maintain position
of comfort and/or hold oxygen.

Parents may not have medical training, but they are experts on
what is normal or abnormal for their children and what will have
a calming effect.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 85
Provider Response

Anxiety from lack of experience with seriously injured
children

Fear of failure

Skills can be learned and applied to children.

Identifying patient with his or her own children
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 86
Provider Response

Providers should



Realize that much of what they learned about adults applies
to children
Remember the differences
Infrequent encounters with sick children

Advance preparation is important.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 87