INFANTS AND
CHILDREN
Objectives
• Understand the anatomic and
physiologic characteristics of infants
and children
• Adapt history-taking and assessment
techniques
• Pediatric
Patients who have not yet reached the
age of puberty
Puberty
• Female
• Male
breast development
hair on face, chest or
underarm
Dealing with pediatric patients
Requires
• Specific knowledge
• Creativity
• Patience
• Be careful of sarcasm and joking
The adolescent
• 12 to 18 yrs
• Sensitive to their dignity
• Sensitive to being patronized
• When injured scared or anxious may
act immature or act out
• May be embarrassed or intimidated
by the attention
• Sensitive to their peers and what
they think
• May be intimidated by those of
authority
• Be discrete
• The young adolescent may be
embarrassed by the changes to his /
her body.
• A simple explanation of an exam
before hand will ease the patient
• Inform and explain the exam to both
parent and patient before performing
• Whenever possible an EMT of the
same sex should be present when an
exam is performed
Supporting the parents or other care
providers
• A calming influence can make a
difference in how a parent responds.
Reaction of parents to sudden lifethreatening injury or illness
• Denial or shock
• Cry, scream, become angry
• Self-guilt, blame
be calm, reassuring and supportive
If parents interfere:
• Try to persuade to assist in care
• If necessary, have friend or relative
remove from scene
• Child may not live in traditional 2-parent
home
use tact
Gain confidence and calm all involved
Don’t distract from care of child
Assessing
• The condition of a sick/injured child
can change rapidly
• Signs or symptoms can be subtle
Pediatric Assessment Triangle
• Appearance
from the doorway
Mental Status
Body position
sniffing position
tripod
refusal to lie down
muscle tone
Breathing
Include the airway
• Visible movement with breathing
• Effort
retractions
nasal flaring
noisy
Circulation
• Skin color
• Pulse
• Subtle cyanosis
• Capillary refill
“Treat as you go care”
SCENE SIZE-UP & SAFETY
• Enter Slowly
• Observe for safety and mechanism
of injury
INITIAL ASSESSMENT
General Impression
• Well or sick
• Mental status
drowsy
sleepy
inattentive
• Effort of breathing
• Skin color
pale
cyanotic
flushed
• Quality of speech
strong cry
speak only in short sentences
grunts
• Interaction with the environment or
others
silence
listlessness
unconscious
• Emotional state
withdrawn
emotionally flat
• Response to you
inattention to strangers
• Tone and body position
limpness
poor muscle tone
position to indicate respiratory
distress
• Mental status
AVPU
never shake
Airway
depressed mental status
secretions
blood
vomitus
trauma
infections
Do not hyperextend neck
Breathing
• Chest expansion
• Effort of breathing
• Sounds of breathing
• Breathing rate
• Color
Circulation
• Skin color
• Pulse
radial in child
brachial or capillary refill for
infants or child <5
PRIORITY PATIENTS
• Poor General Impression
• Unresponsive or listless
• Does recognize parents or primary
care
givers
• Not comforted when held by parent
but becomes calm and quiet when set
down
• Compromised airway
• Respiratory arrest or inadequate
breathing
• Possibility of shock
• Uncontrollable bleeding
FOCUSED HISTORY AND PHYSICAL
EXAM
• Get at eye level
• Ask simple questions
• Always explain what you are doing to
a child
• Never lie
• Base-line vital signs
low b/p may indicate imminent
cardiac arrest
DETAILED PE
• Toe-to-head exam with infants and
small children
• Unless injury/illness won’t permit,
allow parent to hold child in lap
• Must be secured during transport
• Shelter from stares and onlookers
• Children loose heat quickly so recover
quickly after exposing for exam
Specific considerations
• Head
don’t apply pressure to fontanels
in
infants
• Nose and ears
if you observe blood or clear fluid,
suspect skull fracture
• Neck
be conscious of stiffness,
soreness or swelling in medical
emergencies
• Airway
neutral position in infants
sniffing or neutral-plus position in
children
ON-GOING ASSESSMENT
• DON’T TAKE YOUR EYES OFF
YOUR PEDIATRIC PAITENT FOR A
MINUTE
Oxygen Administration
• Consider blow-by method
CARING FOR SHOCK (hypoperfusion)
• Common causes
diarrhea and/or vomiting with
resulting dehydration
infection
trauma
especially abdominal injuries
Blood loss
Body
9 lb
newborn
60 lb child
125 lb adult
blood volume
12 oz coke can
2 liter bottle
2 2-liter
bottles
Less common causes
• Allergic reaction
• Poisoning
• Cardiac event
• Compensation
Signs and Symptoms
• Rapid respiratory rate
• Pale, cool, clammy skin
• Weak or absent peripheral pulses
• Delayed capillary refill
• Decreased urinary output
• Mental status change
• Absence of tears even when crying
Care
• Airway
Oxygen
always be prepared to deliver
artificial ventilations
• Manage bleeding
• Elevate legs if no trauma
• Keep warm
especially top of head
• Transport immediately
Hypothermia
• Larger proportional body surface
this increases risk
• If active rewarming is necessary,
consult medical control
• Avoid rough handling
PEDIATRIC MEDICAL EMERGENCIES
Respiratory Disorders
differentiate upper airway obstruction from
lower airway disorders
Respiratory Distress
• Nasal flaring
• Retraction
• Stridor (high-pitched, harsh sound)
• Wheezing
• Grunting
• Respiratory rate >60
Other signs of early respiratory
distress
• Cyanosis
• Decreased muscle tone
• Capillary refill >2 seconds
• Altered mental status
• Decreased blood pressure (late sign)
Care
• O2
• If necessary ventilate
RESPIRATORY COMPRIMISE IS
THE PRIMARY CAUSE of CARDIAC
ARREST IN CHILDREN
RESPIRATORY DISEASES
Croup
• Viral
• 6 months to 4 yrs
• Inflammation of larynx, trachea and
bronchi
• During the day mild fever and hoarseness
• At night “seal bark” cough, difficulty
breathing, restlessness, and paleness with
cyanosis
Care
• High concentration O2
• Position of comfort
• Rapid transport
Epiglottitis
• Bacterial
• Swelling of epiglottis and partial
airway obstruction
• Can be life threatening
Signs
• Sudden onset of high fever
• Painful swallowing
• Tripod position
• Sitting still but muscles working hard
to breathe
• Appears more ill than child with
croup
Care
• Immediate transport with child on
parents lap if possible
• High concentration of humidified
oxygen
• Monitor airway; always be prepared
for ventilations
DO NOT PLACE ANYTHING IN THE
MOUTH
Fever
• Never blow off a fever as
unimportant
• There are many causes of fever
• Fever with rash is a potentially
serious condition
• Febrile seizures
Care
• Remove clothing (be cautious of
hypothermia)
• If heat exposure, cover with towels
soaked in tepid water (protocol)
• Monitor for shivering and
hypothermia
• Give fluids by mouth or ice chips
(protocol)
• A mild fever can quickly spike
may be an indication of a serious or
life-threatening problem
• Rapid transport if a child has had a seizure
protect against extreme temperatures
• Do not submerge in cold water or cover
with towels soaked in ice water
• Do not use rubbing alcohol as a means to
cool
Meningitis
• Viral or bacterial
• Infection of brain lining and spinal cord
Signs/symptoms
• High fever
• Lethargy
• Irritability
• Headache
• Stiff neck
• Sensitivity to light
• Fontanelles may be bulging
• Movement is painful, child does not want to be touched
• Sudden excitement may cause seizures
• rash
Care
• Monitor ABCs and vital signs
• Be alert for seizures
• Care for fever
• Immediate transport
Some forms of meningitis may be
highly infectious
Diarrhea and Vomiting
• ABCs
oxygen
suction
• Monitor for shock
• Save samples of vomitus or rectal
discharge
Seizures
consider to be life-threatening
Fever is most common cause
Other causes
• Epilepsy
• Infections
• Poisons
• Hypoglycemia
• Trauma
• Decreased levels of oxygen
Assessment
• Prior seizures
if yes:
was this a normal seizure
pattern?
How long did it last?
What part of the body
was seizing?
• Recent fevers
• Has the child taken/been given any
anti-seizure medication or any other
meds
• Assess for illness and injury
Care
• ABCs
oxygen
do not insert op or bite stick
• Watch for vomiting
suction
• Transport
• Be aware of postictal state
Altered Mental Status
Causes
• Hypoglycemia
• Poisoning
• Infection
• Head injury
• Decreased oxygen levels
• Shock
• Postictal state
Assessment
• Mechanism of injury
• Shock
• Evidence of poisoning
• Obtain history
seizure disorder
diabetes
• Transport
Poisoning
Can depress the respiratory,
circulatory and
nervous systems
Assessment
Aspirin
• Hyperventilation, vomiting, sweating
• Skin may feel hot
• In severe cases: seizures, coma or
shock
Acetaminophen (Tylenol)
• Restless (early sign) or drowsy
• Nausea, vomiting, heavy perspiration
• Loss of consciousness is possible
Lead
• Nausea with abd pain or vomiting
• Muscle cramps/weakness, headache,
irritability
Iron
• Within 30 minutes or several hours
nausea, bloody vomiting, often
with
diarrhea
• May develop shock
up to 24 hrs
child will appear to be getting
better
Petroleum product poisoning
• Vomiting with coughing or choking
• Distinctive odor of a petroleum
distillate
Care
• Contact medical direction or the poison control
center
• Activated charcoal
• Oxygen
• Transport
If unresponsive
• Airway
• Oxygen
• Contact medical direction or the poison control
center
• Rule out trauma as a cause for altered mental
status
Drowning
• Water temperature may affect
outcome
Assessment
• CPR
if trauma related, CPR with
considerations and precautions
• Consider alcohol as a contributing
factor
Secondary drowning syndrome
• Deterioration after normal breathing
resumes
• Minutes to hours after the event
Care
• CPR
• Suction
• Safe-guard against hypothermia
remove wet clothing
dry the skin
cover with a blanket
• Treat any trauma
• Transport even if they seem to have
recovered
SIDS
No cause has yet been identified
do not diagnose
• CPR
local protocol for obvious signs of death
i.e. rigor mortis
• Make sure parent receive emotional support
do not speak with suspicious tone or ask
inappropriate questions
Maintain composure and professionalism
you can fall apart afterwards
PEDIATRIC TRAUMA EMERGENCIES
Injuries are the number one cause of death
in infants and children
MVA
• Unrestrained
head and neck injuries
• Restrained
Abdominal and lower spine injuries
Struck by vehicle
• Triad of injuries
Head injury
ABD injury with possible internal
bleeding
Lower extremity injury
Features of head, neck, chest, ABD, and
extremity trauma………
Head
• Proportionately larger and heavier
leads to injury when propelled
forward
• Respiratory arrest is a common
secondary effect of head injury
• Signs of head injury
altered mental status
nausea and vomiting
Chest
• Less developed/immature respiratory
muscles
• more elastic ribs make the chest
more easily deformed
• tire easily therefore cannot maintain
a rapid respiratory rate for long
• Injuries to structures beneath the
ribs are common as elastic ribs rarely
fracture
• If MOI is significant, suspect
internal injuries even if there are no
signs of chest trauma
Abdomen
• Infants and children are abdominal
breathers
observe to evaluate respiratory
status
• ABD muscles offer less protection to
organs
• Can be site of hidden injuries
Extremities
• Bones are more flexible
• Injuries are manages the same as
adults
Burns
• Rule of nines
• Cover the burn with nonadherent dressing
sterile sheets may be used
• Use precaution with moist dressings
body surface proportionally larger to body
mass, making them prone to heat
loss
burned patients who become hypothermic have a
higher death rate
Keep covered to prevent drop in body temperature
Trauma Care
• ABCs
jaw thrust to open airway
suction if necessary
• Oxygen administration
high concentration
• Spinal immobilization
• Transport immediately
• On-going assessment
• Assess and treat other injuries en route if time
permits
CHILD ABUSE AND NEGLECT
No race, creed, ethnicity, or economic
background is exempt
May include
• Psychological abuse
• Nelgect
• Physical
• Sexual
Physical and sexual abuse
• “battered children”
children are beaten with anything
that can be used as a weapon
children are intentionally burned
may be severely shaken, thrown,
pushed down steps, to the extreme
of being thrown from a car
shot, stabbed, electrocuted, or
suffocated
• Sexual abuse ranges from adults
exposing themselves, to sexual
torture
Assessment
You may see
• Slap marks
• Bruises
• Abrasions
• Lacerations
• Incisions
• Broken bones
in various stages of healing
• Head injuries
shaken baby syndrome
• Abdominal injuries
ruptured spleens, livers and lungs that
have been lacerated by broken ribs
• Internal bleeding
blunt trauma
punching
lacerated and avulsed genitalia
• Bite marks
• “Glove” and “stocking” burn marks
dipping in hot water
• Demarcation burns
in the shape of utensils used
• Bulging fontanelle
ICP from shaking
Be on the alert for
• Repeated responses to the same
child or
children
• Indications of past injuries
• Poorly healing wounds or improperly
healed fractures
• Past burns or fresh bilateral burns
• Many different types of injuries
bilaterally or anterior/posterior
• Responses such as “he/she falls a lot”
• Child seems to expect no comfort
from parents
• No apparent reaction to pain
• Parent or care-giver does not want
you to be alone with the child
• Conflicting or changing stories or
overwhelms with explanations
Pay attention to the adult as you treat the
child
• Inappropriately unconcerned
• Feeling there could be an emotional
explosion at any moment
• Deep state of depression
• Indications of alcohol/drug abuse
• Voicing suicide or seeking mercy for the
unhappiness of the child/children
• Refuses to have child transported to the
nearest hospital or where the child has
been seen
before
BE THE CHILD’S ADVOCATE BUT
DO NOT ACUSE THE PARENT
Assessment-Sexual abuse
• Rearrange or remove clothing only as
necessary to determine and treat
injuries. helps to preserve
evidence
• Examine genitalia only if there is
obvious
injury or the child tells
you of a recent injury.
• Be as calm and reassuring as possible
Signs include
• Obvious sexual assault
• Unexplained genitalia injury
bruising
lacerations
bloody discharge from genitalia
orifices
• Try to talk to the child separately
• Control emotions and hold back
accusations
• Report (protocol)
obligated
Maintain patient and family
confidentiality
• Only share information with agencies
involved
• Use terms such as “suspicion” and
“possible”
• Remember the suspected abuser
needs help
• Your suspicions may turn out to be
unfounded
SUSPICIONS SHOULD BE AROUSED
NOT BY INDIVIDUAL INJURIES
BUT BY PATTERNS OF INJURIES
AND BEHAVIORS
Infants and Children with Special
Needs
Emergency Information Form
• Form kept with patient that contains
up-to-date information
medical condition
history
precautions needed
specific management plans
If available, bring form with you
Special Needs include:
• Premature babies with lung disease
• Babies and children with heart
disease
• Infants and children with neurological
disease
• Children with chronic disease or altered
function from birth
Often cared for by parents at home,
technologically dependent
Tracheostomy tube
• Complications
Obstruction
Bleeding from or around the tube
air leak
dislodged tube
Care:
• Maintain an open airway
• Suction
• Position of comfort
• Transport
Ventilators
Parents well trained but will call if
complications
Care:
• Maintain an open airway
• Pocket mask or BVM with O2
• Transport
Central Lines
Complications:
• Infection
• Bleeding
• Clotting
• Cracked line
GI Tubes and Gastric Bleeding
• Tubes placed through the abdominal
wall directly into the stomach
• Used when Pt. can’t feed orally
• Most dangerous potential problem
Respiratory Distress
Care:
• Be alert for AMS in diabetic patients
• Protect/maintain the airway
• Suction
• Transport
sitting
right side with head elevated
Shunts
• Drainage device that runs from the
brain to the ABD to drain CSF
Complications:
ICP resulting in AMS
Infection resulting in AMS
Care:
• Patients are prone to respiratory
arrest
• Maintain/protect airway
• Ventilate if needed
• Transport
• Stress
Blood Pressure
• Not taken in children <3
• Systolic
80 + 2(age)
• Diastolic
2/3 systolic
• Or tables, charts you may have
access to
Examples:
• 5 yr. old
• 11 yr. old
80 + 2(age)
2/3 systolic
90
60
80 + 2(age)
2/3 systolic
102
68