ATS - pediatric emergencies

PowerPoint module from Action Training Systems

1. EMERGENCY MEDICAL TECHNICIAN Pediatric Emergencies

2. Section 1 Introduction Slide 2

3. Assessment Goals: Responding to a pediatric emergency can be a very emotional situation Emergencies involving children are challenging because of the developmental, medical and physical differences between children and adults Knowing how to modify your assessment and treatments will help you provide the best care Slide 3

4. Training Objectives: Pediatric Assessment Techniques Respiratory Emergencies Transport Considerations Pediatric Trauma Patients Slide 4

5. Section 2 Pediatric Assessment Techniques Slide 5

6. Consider Age & Abilities: Slide 6 Pediatric patients differ in age and abilities Adapt your assessment and care based on the age of the patient For children too young or shy to speak, obtain history information from either their: Caregivers Family

7. Involve the Caregiver : Some children want a parent to hold or comfort them when they are: Sick Injured Involving the parent in your assessment can provide reassurance for both: Parent Child Slide 7

8. Provide Emotional Support: Blood and pain can be very frightening to pediatric patients Some associate their illness or injury as punishment for being bad Providing emotional support is essential to keeping children and their caregivers calm during an emergency Slide 8

9. Be Respectful : Slide 9 Many children: Do not like being touched by strangers May be modest about clothing removal Being friendly and respectful of his or her personal space can help build the child’s trust

10. Older Pediatric Patients: Older children and adolescents often want to be treated as adults Important to recognize when a pediatric patient is old enough to answer questions about his or her illness or injury Slide 10

11. The Pediatric Assessment Triangle: Th e PAT is an assessment method used to visually assess a child before physical contact A quick evaluation includes observing: General appearance Work of breathing Circulation to the skin Slide 11

12. G eneral A ppearance : The child's general appearance is the most important factor when assessing the severity of illness or injury Slide 12

13. Appearance – Use “TICLS”: The mnemonic TICLS “ tickles ” can help you remember the most important points to observe in a child’s appearance   These include: T one I nteractiveness or irritability C onsolability L ook S peech Slide 13

14. T - TICLS: (cont.) T one: Observe patient movement, limpness and listlessness Slide 14

15. I - TICLS: (cont.) I nteractiveness/ I rritability Note if the child is alert, engaged and interested Slide 15

16. C - TICLS: (cont.) C onsolability: Note if the child is consolable Slide 16

17. L - TICLS: (cont.) Assess “ L ook” by noting if the child fixes her gaze on a face or has a blank stare Slide 17

18. S - TICLS: (cont.) Observe “ S peech,” notice talking or crying loudly or if his voice is weak, muffled or hoarse Slide 18

19. TICLS : (cont.) The use of the “TICLES” mnemonic to assess for “ appearance” will allow you to better detect subtle abnormalities in the patient Remember that appearance alone is not conclusive You must also assess the other sides of the triangle Slide 19

20. Work of Breathing: The work of breathing is a quick indicator of the effort that the child is making to compensate for any difficulties in oxygenation and ventilation Slide 20

21. Work of Breathing: Observe for obvious signs of breathing distress: Tripod position Retraction of the chest muscles “See-saw” breathing Nasal flaring Listen for abnormal sounds: Grunting Wheezing Stridor Slide 21

22. Respiratory Rates: Be aware that respiratory rates are higher in children and infants The smaller the child, the higher the rate Slide 22

23. Circulation to the Skin: The third side of the Pediatric Assessment Triangle focuses on circulation to the skin Slide 23

24. Circulation to the Skin: (cont.) This assessment can help to determine the adequacy of cardiac output and perfusion of vital organs Notice whether the patient’s skin is pale, mottled or cyanotic Slide 24

25. Responsive Patients: If the child is responsive and is not critically ill or injured, try to gain her trust so she will cooperate with your assessment Approach slowly and offer a toy to show you are friendly Slide 25

26. Approach: Sit at the child’s level, smile and make eye contact Talk to the child directly Slide 26

27. Approach: (cont.) Explain what you are going to do one step at a time before you do it Be honest if your assessment may cause pain Slide 27

28. Priority Patients: Slide 28 Make a priority determination as soon as possible regarding transport  A priority patient is any patient that is at risk for: Shock Has uncontrolled bleeding Is in any type of respiratory distress

29. Patient Management: Slide 29 Monitor and observe for a decline in blood pressure and perfusion Pediatric patients can compensate for injuries or illness for a long time This can suppress obvious signs and symptoms of shock

30. Shock: O nce the compensation mechanism fails, the child’s condition will deteriorate rapidly: This is referred to as hypotensive, or compensated shock Anticipate shock in a child that is dehydrated from vomiting or diarrhea Slide 30

31. SAMPLE History: Obtain a patient history using the “SAMPLE” mnemonic prior to or during your physical exam if the nature of the call involves illness Slide 31

32. Physical Assessment: Conduct your physical exam based on the nature of illness or mechanism of injury, just as you would for an adult patient Slide 32

33. Precautions: Be cautious when assessing the head of infants and children under 18 months old F ontanels , commonly known as “soft spots” Slide 33

34. Precautions: If the child shows fear or anxiety, perform the exam from toe to head to help him adjust to you Slide 34

35. Assessment Tips: Only lift or remove clothing if it is necessary for your exam and replace it when you are finished with the area When obtaining vital signs, keep in mind that pulse rates are higher in children Slide 35

36. Assessment Tips: (cont.) Slide 36 The pulse should be strong and regular The skin should be warm and dry to the touch

37. Using Pulse Oximetry: Slide 37 The use of pulse oximetry is recommended with pediatric patients but should only be used to note trends in the patient’s condition Consider the entire patient presentation when performing the assessment and providing care

38. Severity: Check the capillary refill by pressing gently on the: Hand Foot Forearm L ower leg The capillaries should refill within two seconds Slide 38

39. Blood Pressure Taking: Blood pressure readings can be challenging to obtain on young children If you don’t have a pediatric-size cuff use: What you have W here it fits The blood pressure can be taken on the: U pper arm L ower arm Thigh Slide 39

40. Decision Making: Blood pressures will vary with age Low blood pressure indicates hypotension, however a normal blood pressure is often found in children with compensated shock Slide 40

41. Estimating Blood Pressures: To estimate the upper median of a normal systolic blood pressure of a child that is between 1 and 10 years of age: T ake a median of 70 M ultiply the child’s age times 2 and add the numbers together Slide 41

42. Precautions: Slide 42 Keep in mind that blood pressures in children under the age of 3 are often misleading or inaccurate In these patients you will: R ely on the quality and rate of the pulse O bserve the skin signs capillary refill Observe mental status to help assess cardiovascular status

43. Section 3 Respiratory Emergencies Slide 43

44. Anatomical Factors: Infants and children are prone to respiratory emergencies because of several anatomical factors   During normal respirations: You will observe more respiratory action in the abdomen than the chest Infants and children tend to breathe from the diaphragm Slide 44

45. Anatomical Factors : (cont.) Infants and children differ from adults: Airways are narrower and softer Tongues take up more space in the mouth, contributing to airway obstructions Slide 45

46. Anatomical Factors: (cont.) Infants and children can have difficulty clearing airway obstructions because they do not have fully developed: Lungs Chest walls Muscles in the neck Slide 46

47. Anatomical Factors : (cont.) When the child is in respiratory distress: Chest movement and the use of the accessory muscles will become more obvious Slide 47

48. Causes of Respiratory Distress : Asthma: Airway spasms or constricts Can be life threatening Colds Respiratory infections such as: Croup Epiglottitis Slide 48

49. Early Signs of Respiratory Distress: Noisy Breathing Exhaling With Abnormal Effort Fast / Slow Breathing Accessory Muscles Use Head Bobbing “See-Saw” Respirations Tripod Position Drooling Nasal Flaring Slide 49

50. Late Respiratory Distress : Cyanosis Slow capillary refill Slow heart rate Altered mental status Decreased respiratory rate Slide 50

51. Managing Respiratory Distress: Number one priority with pediatric patients is to ensure a patent airway at all times Consider any airway or breathing problems to be life threatening P repare for immediate transport to an appropriate facility Slide 51

52. Managing Respiratory Distress: (cont.) Provide high-concentration oxygen by pediatric nonrebreather mask if permitted by your local protocol If the child feels suffocated by an oxygen mask, use the “blow-by” technique Slide 52

53. Managing Respiratory Distress: (cont.) Hold the mask about 2” (5 cm) away from the child’s face Tell the child to breathe in normally But to blow out forcefully as if they were blowing up a balloon Show the child by breathing in and out with him or her Slide 53

54. Precautions: Slide 54 Be aware that children under the age of 6 have a proportionately larger and heavier head May cause the airway to close when the child is lying on his back Place a folded towel under the child’s shoulders to keep the neck in a neutral position

55. Positive Pressure Ventilation : You must use positive-pressure ventilation if the child is apneic or if the patient has an inadequate respiratory rate or tidal volume Slide 55

56. Oxygen Use - Infant/Young Child: For both infants and young children, use a pediatric bag mask device with a volume not to exceed 450 to 500 milliliters Delivered breaths should just achieve chest rise with each inspiration Slide 56

57. Oxygen Use - Infant/Young Child: (cont.) Attach an oxygen reservoir to the bag and maintain an oxygen flow of: 10-15 lpm into a pediatric bag A t least 15 lpm into an adult-sized bag Slide 57

58. Delivering Oxygen – Older Children: Older children or adolescents may require an adult-sized bag mask device of 1000 milliliters to achieve adequate chest rise Slide 58

59. Delivering Oxygen: Slide 59 For children age 1 until puberty, deliver breaths at a rate of 1 breath every 3 to 5 seconds (12 to 20 bpm) Breaths should be sufficient to make the chest rise visibly

60. Delivering Oxygen : (cont.) If air does not enter freely during ventilation, reposition the head and try again If the airway still will not open, suspect an airway obstruction Slide 60

61. Delivering Oxygen : (cont.) For children who have reached puberty: D eliver breaths at a rate of 1 breath every 5 to 6 seconds (10 to 12 bpm) Chest rise should be visible Monitor the patient to make sure ventilation is adequate Slide 61

62. Clearing an Airway Obstruction—Alert Child Over 1 Year Old: Stand behind the patient Reach around and locate the navel With the other hand make a fist and place it just above the navel Grasp your fist with the other hand Pull in and up with swift, firm thrusts Slide 62

63. Clearing an Airway Obstruction—Alert Child Over 1 Year Old: (cont.) Watch and listen for the child to cough or speak to determine if the object has been cleared Slide 63

64. Clearing an Airway Obstruction—Responsive Infant: Position the infant over the length of your arm face down Support the head with your hand placed around the jaw Keep the head lower than the trunk Support your forearm on your thigh Slide 64

65. Clearing an Airway Obstruction—Responsive Infant : (cont.) Slide 65 Deliver 5 back blows between the infant’s shoulder blades using the heel of your other hand Turn the infant over between your arms and deliver 5 chest thrusts Continue back blows and chest thrusts if the infant is responsive and the airway is still obstructed

66. Clearing an Airway Obstruction— Un conscious Infant/Child: If the infant or child loses consciousness, immediately begin CPR After 30 compressions, assess the airway for an obstruction Perform a finger sweep by using your little finger to remove any airway obstructions you can see Slide 66

67. Clearing an Airway Obstruction— Un conscious Infant/Child: (cont.) Try ventilating again Begin CPR appropriate to the size of the child if there is no sign of an airway obstruction and no pulse Slide 67

68. Respiratory Arrest: Respiratory arrest is the most common precursor to cardiac arrest in pediatric patients You must act immediately to prevent a respiratory emergency from becoming a cardiorespiratory emergency Slide 68

69. Respiratory Arrest : (cont.) If the infant or child should experience an unwitnessed or sudden cardiopulmonary arrest, the resuscitation sequence is now “C-A-B” rather than “ A-B-C” Slide 69

70. Section 4 Transport Considerations Slide 70

71. Transporting Pediatric Patients: To safely transport a child that is ill or injured, you will need to take into consideration several factors First: D ecide what the best position and placement of the child will be in the ambulance This will be determined by what treatments or monitoring you anticipate performing while enroute Slide 71

72. Using a Car Seat: If the patient is: Stable Weighs less than 40 lbs (18 kg) N o interventions are anticipated: It may be preferable to transport an infant or child in her own car seat Transporting a child in a familiar car seat can be comforting during a unusual or scary event Slide 72

73. Using a Car Seat: (cont.) Your protocols will direct the situations that are acceptable to transport using the child’s own car seat The NHTSA also makes recommendations for the use of a child's CRS , for transport following a minor vehicle collision Slide 73

74. NHTSA Criteria: The National Highway Traffic Safety Association criteria: The vehicle was able to be driven away from the crash site The vehicle door nearest the child’s seat was undamaged There were no injuries to any vehicle occupants The airbags, if present, did not deploy There is no visible damage to the car seat Slide 74

75. Local Protocols: If your protocols permit the use of a child’s own CRS, inspect it for damage T hen properly secure it to the ambulance Slide 75

76. Securing the Car Seat: Slide 76 Secure the car seat using the existing straps on the cot and belt pathways provided on the CRS If the child is: Less than 40lbs (18kg) In a rear-facing car seat: P lace the CRS against the back of the cot

77. Securing the Car Seat : (cont.) Slide 77 Adjust the car seat harness: To be at or below the shoulders of the patient T hen connect the harness and pull it snug   Place the harness clip at the level of the patient’s armpits

78. Securing the Car Seat: (cont.) If the patient is: O ver 40lbs (18 kg) You may choose to secure the child to the stretcher in a seated position without a car seat   Slide 78

79. Securing the Car Seat: (cont.) You can use: The existing straps on the gurney and adjust and size them properly to secure the child U se a restraint system designed for pediatric patients Slide 79

80. Positioning D uring Transport: Slide 80 It may be recommended to place the child in a supine position If the patient has immediate or anticipated interventions other than oxygen or simple wound care

81. Motor Vehicle Collisions: Pediatric patients can sustain a neck injury in vehicle collisions even when properly secured in a car seat   In some situations, if the car seat is not damaged, it may be recommended to leave the child in the CRS and immobilize the patient in place Slide 81

82. Immobilizing in a CRS: Slide 82 To immobilize a child in a car seat: Immediately provide manual cervical spine stabilization Quickly assess for other injuries Place an appropriately sized cervical collar on the patient Place a small blanket or towel on the patient’s lap Secure the pelvic area to the seat using tape or straps

83. Immobilizing in a CRS : (cont.) Slide 83 Place rolled towels on both sides of the head to fill voids between the head and the seat Secure the head by taping across the forehead Carry the immobilized patient to the ambulance S trap patient to stretcher in an upright position  

84. Using a Backboard: If the child requires a backboard and a pediatric immobilization device is not available, you will need to pad the board to maintain the spine in a neutral in-line position   Slide 84

85. Using a Backboard : (cont.) Place an 1” to 1½” (2-4 cm) of padding beneath shoulders and back Making head level with the occipital region of the head The padding should extend from the shoulders to the pelvis Slide 85

86. Securing to the Backboard: Slide 86 Position the patient so you can appropriately secure to the backboard Then secure the board to the stretcher with 3 horizontal restraints: Across the chest At the waist At the knees

87. P lace vertical restraints over each shoulder You may also consider securing the foot end of the backboard to the stretcher to prevent forward movement Slide 87 Securing to the Backboard: (cont.)

88. Safe Transport Considerations: Immobilizing and treating pediatric patients can be challenging   Infants and children should always be restrained, and never be held in the arms or lap during transport Slide 88

89. Transporting Caregivers: Slide 89 If your protocols permit, it is helpful to have the parent or caregiver accompany the child in the ambulance This can help to minimize distress and provide comfort As with any passenger, regardless of where she sits: S hould be safely secured with a seatbelt

90. Section 5 Pediatric Trauma Patients Slide 90

91. Leading Cause of Death: Trauma is the leading cause of death in pediatric patients: Their bodies are smaller and more sensitive than an adult’s They often don’t recognize risks or react to them in time Blunt trauma is the most common injury in children Slide 91

92. Larger/ Heavier Head : Head is larger and heavier in infants and small children so they are more likely to: Land head-first in a fall Propel head-first if unrestrained in a vehicle collision Slide 92

93. Chest Injuries : Children have more elastic chests than adults: Bones in the chest are less likely to break in a crushing mechanism of injury Offers less protection to the vital organs Slide 93

94. Abdominal/Pelvic Injuries : Abdominal injuries are especially harmful in children: Their muscles are not as developed as an adult’s Their organs take up more space in the abdomen Trauma to the pelvic cavity can also cause a lot of bleeding Slide 94

95. Blood Volume : Slide 95 The smaller the patient, the less blood they can afford to lose: Newborn baby’s blood volume is less than: 12 ounces A can of soda An 8-year-old’s blood volume is about: ½ gallon About a 2-liter bottle of soda

96. Trauma Management : To manage a pediatric trauma patient: A ssess and manage the ABCs Treat any immediate life-threatening conditions Provide and maintain stabilization of the head and spine when trauma is suspected   Perform a rapid trauma exam Look for less obvious or hidden injuries Slide 96

97. Pediatric Trauma Management : (cont.) Provide oxygen by nonrebreather mask O r according to your local protocols Assist in ventilations using a bag-valve device if necessary Control any bleeding and treat for shock K eep warm and place a blanket underneath when possible Children have a larger skin surface area in proportion to their body mass, they lose heat more quickly than adults Slide 97

98. Pediatric Trauma Management: (cont.) When performing your physical assessment or obtaining a patient history : K eep in mind that children may not fully communicate the nature of the incident or injuries Slide 98

99. Pediatric Trauma Management: (cont.) Because children may not display early or obvious signs of injury: Try to reconstruct the event to determine what injuries may be likely Continue to provide reassurance M onitor the vital signs during transport Slide 99

100. Abuse or Neglect: Whenever you treat a pediatric trauma patient: C onsider the possibility that abuse or neglect could be a factor Slide 100

101. Abuse or Neglect: (cont.) Look for signs of: Abuse: Psychological Sexual Physical abuse Neglect Slide 101

102. Abuse or Neglect: (cont.) Observe the parent or caregiver’s interaction with the child: Do not offer any judgment of the caregiver Just note any signs of abuse or neglect Slide 102

103. Abuse or Neglect: (cont.) Familiarize yourself with your local requirements in regards to reporting suspected cases of abuse or neglect Slide 103

104. Section 6 Summary Slide 104

105. Summary: Pediatric Assessment Techniques Respiratory Emergencies Transport Considerations Pediatric Trauma Patients Slide 105

106. Summary: Although many of the assessment and care techniques for adults are often the same for children its important to be able to modify techniques based on a patient’s age or their physical and emotional maturity Pediatric emergencies can be challenging events Training and experience will help you successfully assess and manage these patients Slide 106

107. The End Slide 107