Infancy
The 1st year of life
Neonatal/newborn period
1st month of life
Infants less than 2 months
Spend most of their time eating and sleeping; respond to light, warmth, hunger and sound; sleep for up to 16 hours a day; can turn their heads and focus on faces; they have a sucking reflex for feeding; not able to tell between parents and strangers
Signs of illness in an infant less than 2 months
If all obvious needs have been addressed and they continue to cry inconsolably
Infants from 2-6 months
more active; begin to smile and make eye contact; can recognize caregivers; strong sucking reflex, active extremity movement and vigorous cry; can follow things with their eyes and turn their heads when they hear caregivers; will use both hands to examine
What % of infants will sleep through the night by 6 months?
70%
Signs of illness in 2-6 months
persistent crying and irritability; a lack of eye contact can be a sign of illness, depressed mental status or delay in development
Babies from 6-12 months
begin to babble and say their first words by a year; sit without support, then crawl and eventually take first steps; they are teething and will put anything in their mouths; usually not afraid of strangers but may develop separation anxiety
Signs of illness in 6-12 months
persistent crying and irritability
Assessment of an infant
Plan to do any painful procedures at the end so that the infant is not agitated when you are trying to do a full-body examination
Toddler
1-3 years of age; experience rapid changes in growth and development
Toddlers 12-18 months
beginning to walk; able to open things; explorers by nature and are not afraid; begin to imitate behaviors of older kids and parents; may want to dress like mommy and daddy; knows major body parts if you point to them and can speak 4-6 words; lack of mola
Toddlers 18-24 months
at 18 months toddler can say 10-15 words and by 2 years they can say 100 words; toddler should be able to name object that you point to; they begin to understand cause and affect with things like popup toys and turning light switch on and off; balance and
Assessment of a toddler
Allow toddler to hold any special object; toddlers have a hard time localizing pain because they have limited vocab; begin assessment at the feet; painful procedures may make a lasting impression
Pre-school age
3-6 years; able to use simple language effectively; most rapid increase in language; toilet training is mastered; have a rich fantasy life, which can make them extra fearful of pain; may believe injury is the result of a bad deed; learning which behaviors
Assessment of pre-school age
they can identify painful areas; tell the child what you are doing right before you do it so they have no time to develop frightening fantasies; healthcare providers often assume they understand more than they do at this time; start assessment at feet; us
School-Age children
6-12 years old; beginning to act more like adults; can think in concrete terms, respond sensibly to direct questions; school is important and peer pressure is big; children with chronic illnesses and diseases may become self conscious; children understand
Assessment of school-age children
talk to the child, not just the parents while taking history; you may begin assessment at head; give child appropriate choices so they can have some control over a frightening situation; asking if you can "take" their blood pressure may make them think yo
Adolescents
12-18 years; able to think abstractly and can put their own beliefs and morals into decision making; know between right and wrong; still children on an emotional level; they shift from relying on family to friends; puberty begins; may have very strong fee
Assessment of adolescents
Provide info when they request it; provide them with choices while lending guidance; if possible, have an EMT of same gender examine them; risk-taking behaviors are common; ask about possible pregnancies; try to interview without parents; explain procedur
Differences between pediatric and adult respiratory system
pediatric airway is smaller in diameter and in length, lungs are smaller and the heart is higher in the child's chest; glottis opening (vocal chords) is higher and positioned more to the front and the neck appears to be nonexistent; neck gets proportional
How pediatric airway and other important structures differ from that of adults
-Children have a larger, rounder occiput which requires more careful positioning of the airway
-A proportionally larger tongue relative to the mouth and a more anterior location in the mouth. Child's tongue is also larger relative to the small mandible an
Trachea in infants
same diameter as a drinking straw
How do infants breath?
Through their nose which may require persistent suctioning
Normal respiratory rate for infants
30-60 breaths/min
Children's metabolic rate and oxygen needs
Have higher metabolic rate and twice the oxygen demand as that of an adult (related to size of lung tissues and the volume that can be exchanged)
- increases risk of hypoxia because or apnea or ineffective ventilation efforts
Breathing of a child
Intercostal muscles not well developed so it requires use of chest muscles and diaphragm, so movement of diaphragm dictates how much air they can breath (use caution when applying spinal immobilization)
Listening to breath sounds on pediatric patients
Breath sounds are more easily heard because of thinner chest walls; conversely, it may be difficult to assess for the absence of air movement because the air within the lungs resonates with less surrounding muscle and fat to hinder the sounds
Gastric distention in pediatrics
Can interfere with movement of diaphragm and lead to hypoventilation
Labored breathing in young children
Young children can experience muscle fatigue more quickly than older children, which can lead to respiratory failure if a child has to physically fight harder to breath for a long time
Leading cause of pulmonary arrest in pediatrics
respiratory problems
Pediatric respiratory rates
0-1 month: 30-60
1 month - 1 year: 15-50
1-3 years: 20 -30
3-6 years: 20-25
6-12 years: 15-20
12-18 years: 12-20
Pediatric pulse rates
infant:100-160
toddler:90-150
preschool: 80-140
school-age: 70-120
adolescent: 60-100
Primary method the body uses to compensate for decreased perfusion in children
heart rate increasing (second is vasoconstriction)
Earliest signs of hypoperfusion in kids
Pale skin; vasoconstriction may diminish blood flow to extremities; signs include pulses weak in extremities, bad cap refill and cool hands or feet
Cardiovascular system in pediatrics
Have larger proportional amount of circulating blood volume than adults; more dependent on CO
Pediatrics and shock
They may be displaying normal bp and actually be in shock, because they only need to lose about 1 cup of blood before they go into shock
Nervous system in pediatrics
immature, under-developed and less protected than that of an adult; occipital region is larger, increasing momentum of head during a fall; subarachnoid space is smaller, so there is less cushioning for CNS; brain tissue and cerebral vasculature are fragil
Shaken baby syndrome
baby is shaken and CNS is less protected, so they die; bleeding within the head and damage to the c-spine as a result of intentional, forceful shaking; the infant will be found unconscious with signs of external trauma
Brain in pediatrics
requires more blood flow, oxygen and glucose than adult (but glucose stores are limited)? This means the pediatrics are at risk for secondary brain damage from hypotension and hypoxic events
Spinal cord injuries in pediatrics
less common; if c-spine is injured it is most likely to be an injury to the ligaments because of a rapid movement in the neck during a fall
Altered mental status in pediatrics
most common causes are hypoglycemia, hypoxia, seizures, or drug and alcohol ingestion; may appear sleepy, lethargic, combative or even unresponsive to tactile stimulus
Abdominal organs and injuries to abdominal organs in pediatrics
abdominal muscle structures are less developed, which means less protection from trauma; internal organs are proportionally larger and more to the front; internal organs are closer together and therefore are more at risk for multiple injuries; liver, sple
Signs of shock in children
AMS, tachypnea, tachycardia, bradycardia (late sign)
Bones in children
Weaker and more flexible; contains open growth plates at the ends of long bones, which enable them to grow; open growth plates are weaker than ligaments and tendons, leading to length discrepancies if there is an injury to a growth plate
What to do with sprain and strains in children
Always immobilize because they may actually be stress fractures
Fontanelles
located on anterior and posterior portions of a baby's head; at 18 months the anterior region will close and at 6 months the posterior region will close; bulging is a normal assessment if the baby is crying or coughing or laying on their back or stomach
What does a bulging head on a baby mean?
ICP
What does depression of a baby's head mean?
dehydration
Thoracic cage in children
Highly elastic and pliable because it is primarily composed of cartilaginous connective tissue; this means fractures in ribs are rare and the result of a high-energy injury, so you should suspect underlying damage even if there are no exterior markings
Adolescents and fractures
Since the bones are growing well into adolescents and they are risk takers they are more prone to fractures
Children and bone injuries
Suspect a fracture even if it doesn't look like it because their bones are more flexible; sprains are rare in children because the ligamnets are more developed than the larger long bones
Femur fractures in children
rare in pediatrics, but if it does occur, it is a source of major blood loss
Integumentary system in children
Skin is thinner and there is less subcutaneous fat, so will burn more easily with less exposure to agent
Thermoregulatory system in children
immature, combined with thinner skin and less subcutaneous fat puts them at more risk for hypothermia
Infants younger than 6 months and thermoregulation
can't shiver
What age group is most at risk for hypothermia?
Infants less then 1 month, but they should not be over warmed because this can lead to bad neurological outcomes
How much heat loss can occur from the head in children ?
50%
Proper position for airway management in children
Elevated head and/or shoulders
Pediatric assessment triangle (PAD)
allows you to form general impression of the pediatric patient without touching him/her - identifies the general category of the patient's psychological state and to establish urgency for treatment/transport ? Consists of 3 elements:
1. Appearance (muscle
Evaluating appearance in PAD
notes LOC and muscle tone to provide you with info about cerebral perfusion (mentation) and overall function of CNS. Abnormal LOC is characterized by age inappropriate behavior or interactivness, poor muscle tone or poor eye contact with the caregiver or
Pneumonic to help determine if peds patients is sick or not
TICLS - Tone; Interactiveness; Consolability; Look or gaze; Speech or cry
Mentation
patient's cerebral perfusion
Evaluating work of breathing in PAD
Increased work of breathing often manifests as tachypnea, abnormal airway noise (grunting or wheezing), retractions of the intercostal muscles or sternum, or the way the patient positions themselves
Evaluating circulation to the skin in PAD
when CO fails, the body shunts blood from the skin to areas of greater need; look for pallor of the skin or mucous membranes which may be seen in compensated shock, anemia or hypoxia; mottling is caused by constriction of peripheral blood vessels and is a
Hands-on ABC's
Airway; Breathing; Circulation; Disbaility; Exposure
Sniffing position
How you should position the airway of an unconscious pediatric patient; a neutral position the keeps the trachea from kinking and maintains proper alignment
Assessing breathing in children
Use the look, listen , feel technique (how much air is moving through nose and mouth and looking for adequate chest rise and fall) - best to place both hands on their chest to feel for rise and fall; assessing respirations is usually easier if they are si
Breathing in infants
Belly breathing is normal because of soft pliable bones and strong muscular diaphragm
Signs of increased work of breathing in children
-Accessory muscle use: contractions of muscles above the clavicles (supraclavicular retractions), drawing in of muscles between ribs or of the sternum (substernal retractions) during inspiration
-Head Bobbing: head lifts and tilts back during inspiration,
Feeling for pulse in infants
palpate brachial or femoral pulse
Palpating for pulse in children older than 1 year
palpate carotid pulse
What does a strong central pulse indicate?
child is not hypotensive, however it does not rule out compensated shock
What is tachycardia a sign of?
early sign of hypoxia and shock; can also reflect fever, anxiety, pain and excitement
Who is cap refill most reliable for?
children younger than 6 years (things like cold temp may effect cap refill)
Gait
difficulty walking
Wong-Baker FACES Scale
Helps peds patients let you know what their pain level is
What should you expose according to PAT?
allow exposure of face, chest wall and skin
What is considered a significant MOI when a peds patient falls?
Any fall higher than their height , especially with head landing first
When should you use a car seat during transport?
If the patient is less then 40 lbs as long as the situation allows
Car seats
designed to be either forward-facing or rear-facing; should not be mounted in front of ambulance or sideways on a bench seat (use their own car seat if you can)
To mount car seat on stretcher
place head of the stretcher upright; place seat so it's against the back of the stretcher ; secure one of the stretcher straps from the upper portion of the stretcher through the seatbelt positions on the seat and strap tightly and repeat on lower part of
To secure a car seat to a captain's chair
follow manufacturer instructions
What car seat should you use for patients less then 1 years old?
Rear facing because the lack of mature neck muscles
When should you not assess blood pressure?
Kids who are younger than 3 years because it doesn't tell you much about their circulation and color is a better indicator
Cuff size for bp
must use a cuff that covers 2/3 of the upper arm; if it is too small, the bp will be falsely high; if cuff is too big, bp will be falsely low
Tool to determine bp in children 1-10 years
70 +(2 x child's age in years)=systolic bp
How to assess vitals in children younger than 3
evaluate respirations by assessing rise and fall of belly; assess pulse rate by counting at least 1 minute
Order of taking vitals
first assess respirations, then pulse, then bp
Most common cause of respiratory emergencies in children
asthma
What counts as bradycardia in infants and children?
less then 80 bpm in kids and less then 100 bpm in infants
**Begin CPR immediately if bradycarida occurs because that means they are in decompensated shock
Croup
Infection of the airway below the vocal cords, usually caused by a virus; they have a bark seal cough
Epiglottitis
infection of the soft tissue in the area above the vocal cords
Signs and symptoms of upper airway obstruction
decreased or absent breath sounds and stridor
Stridor
Usually caused by swelling of the area around or above the vocal cords
Signs and Symptoms of lower airway obstruction
wheezing and/or crackles
Wheezing
caused by air traveling through narrowed air passages within the bronchioles
Crackles
caused by flow of air through liquid, present in the air pouches and smaller airways in the lungs
Best place to auscultate breath sounds in peds
listen to both sides of the chest at the level of the armpit
How to treat unconscious patient with clear airway obstruction
Chest compressions mimics coughing
Asthma
acute spasm of the bronchioles, associated with excessive mucous production and with swelling of the mucous lining of the respiratory passages; common sign is wheezing (trouble on expiration) and then easy inspiration
Common causes for asthma attacks
upper respiratory infection and exercise
Treatment for asthma
Bronchodilator (albuterol, a beta-2 agonist) via a meter-dose inhaler (MDI) with a spacer-mask device; if you assist ventilations use slow gentle breaths
Status asmathicus
prolonged asthma attack that is unrelieved may progress into this; the child will be frightened and frantically trying to breath, while using all accessory muscles; it is a true emergency
Leading cause of death in children worldwide
Pneumonia
Pneumonia
general term that refers to an infection of the lungs; often a secondary infection; could also occur from chemical injury after an accidental ingestion, or a direct lung injury from a near drowning; children with diseases causing immunodeficiency increase
Signs and symptoms of pneumonia
Unusually rapid breathing, grunting, or wheezing, nasal flaring, tachypnea, crackles, hypothermia or fever; also may exhibit unilateral diminished breath sounds
Bronchiolitis
Specific viral illness of newborns and toddlers, often caused by respiratory syncytial virus (RSV) that causes inflammation of bronchioles and make them fill with mucous; RSV is highly contagious through droplets and can survive on surfaces; more common i
Pediatric Resuscitation tape measure
best way to get properly sized equipment for kids weighing up to 75 lbs; **Red to head
Weird time when not to use OPA
children who may have ingested a caustic or petroleum-based product, because it may induce vomiting
When to use NPA
for patients who are conscious with altered LOC (rarely used in infants younger than 1 year)
NPA on kids
External diameter should not be larger than the diameter of the nares and there should be no blanching of the nares after insertion **insert tip into the right naris with the bevel pointing toward the septum (should extend from tip of nose to the tragus)
What happens if NPA is too log?
it may stimulate the vagus nerve and slow the heart rate or enter the esophagus, causing gastric distention
Blow-by technique
at 6L/min, it provides more than 21% oxygen; hold it 1"-2" away from the child's nose or mouth
Nasal Cannula
1-6 L/min delivers oxygen at 24%-44%; the prongs should not fill the nares entirely (if the nares blanch, select a smaller cannula)
Nonrebreathing mask
at 10-15 L/min it gives up to 90% oxygen (regular reservoir bag should deflate or inflate completely as they breath)
BVM
at 15L/min It provides nearly 100% oxygen *Mask volume should be small to decrease dead space and avoid rebreathing carbon dioxide, however the bag should contain at least 450 mL of air; use an infant bag (not a neonatal bag) for infants youger than 1 yea
When to use BVM on a kid
If their respirations are less than 12 or more than 60, if they have an altered LOC, and/or an inadequate tidal volume
One-rescuer BVM
With infants and toddlers, support the jaw with only your 3rd fingertip; be careful not to compress the area under the chin because you may push the tongue into the back of the mouth and block the airway; give 12-20 breaths per minute (each ventilation sh
How children react to decreasing oxygen levels
They become hypoxic and their hearts slow down and become weaker and weaker with each beat
Survival rate of kid with cardiac arrest vs respiratory arrest in prehospital setting
3-5% in cardiac arrest and 75% in respiratory arrest
Most common causes of shock in peds
-traumatic injury with blood loss (especially abdominal)
-Dehydration from diarrhea or vomiting
-Severe infection
-Anaphylaxis
-disease of the heart
-pneumothorax
-cardiac tamponade or pericarditis
How do pediatric patients respond to fluid loss?
increasing heart rate, increasing respirations, and showing signs of pale or blue skin
Signs of shock in children
*Greater than 25% of blood volume loss significantly increases risk for shock
-Tachycardia, poor cap refill, mental status change (versus tachycardia, hypotension and mental status changes in adults and loss of 30-40% of blood increasing risk of shock in
What heart rate suggests shock in children?
anything above 160 bpm
Other signs and symptoms of shock in infants and what to ask family
-Decrease in urine output (fewer than 6-10 diapers)
-Absence of tears even when the child is crying
-Sunken fontanelle
-Changes in LOC and behavior
Pneumonic that reflects major causes of AMS in peds
AEIOU TIPS
Alcohol; Epilepsy, endocrine, electrolytes; Insulin; Opiates and other drugs; Uremia
Trauma, temperature; Infection; Psychogenic; Poison; Shock, stroke, space-occupying lesion, subarachnoid hemorrhage
Common causes of seizures
abuse, electrolyte imbalance, fever, hypoglycemia, infection, ingestion, lack of oxygen. Meds, poisoning, seizure disorder, recreational drugs use, head trauma, idiopathic
Signs of seizures in infants
may be very subtle, consisting of abnormal gaze, sucing motions, or "bicycling" motions
Febrile seizures
Common in children between 6 months and 6 years; typically occurs on first day of illness and has to do with the rate of increase of the temp; characterized by general tonic-clonic seizure activity and lasts less than 15 min with a short postictal state;
Meningitis
Inflammation of meninges, caused by infection by virus, bacteria, fungi, or parasites; can lead to permanent brain damage and death
Individuals at greater risk for meningitis
males, newborns, geriatrics, people with AIDS or cancer (compromised immune systems), people with history of brain, spinal cord or back injury, children who have had head trauma, children with shunts, pins or other foreign bodies within their brains or sp
VP shunts
Puts kids at an especially high risk for meningitis; VP shunts drain excess fluid from the brain into the abdomen; they have tubing that can usually be felt and seen just under the scalp
Signs and symptoms of meningitis
altered LOC, fever, seizures (early sign), patient will often refuse to move their neck ,lift their legs or curl into a "C" because the increased tension within the spinal canal stretches the meninges; infants younger than 2-3 months can have apnea, cyano
Neisseria meningitides
Bacterium that causes rapid onset of meningitis symptoms and can lead to shock and death; patients typically have small, pinpoint, cherry-red spots or a larger purple/black rash and are at serious risk for sepsis, shock and death (all peds patients who ha
Common source of GI upset in peds
lactose intolerance and appendicitis
Appendicitis
common in peds and if untreated can cause peritonitis and shock; common signs are rebound tenderness, fever and pain upon palpation of the right lower quadrant
Common sources of poisoning in children
alcohol, aspirin and acetaminophen, household cleaning products, houseplants, iron, prescription meds, street drugs, vitamins
How to treat peds patients exposed to poison
perform an external decontamination (remove tablets or fragments from mouth and wash or brush poison from skin); sometimes you may need to give activated charcoal- usual does is 1g/ kg of body weight; usual peds dose is 12.5-25 g
Dehydration in infants and children
They are at greater risk than adults because their fluid reserves are smaller ; young children compensate for fluid loss by decreasing blood flow to extremities and directing it to vital organs
What temperature is considered to be abnormal?
anything over 100.4 degrees
Common causes of fevers in peds
infection (like pneumonia, meningitis, UTI), status epilepticus, neoplasm (cancer), ingestion of aspirin, arthritis and systemic lupus erythematosus (rash across nose), high environmental temp
Neoplasm
cancer
Systemic lupus erythermatosus
rash across nose
How hyperthermia differs from fever
Hyperthermia is an increase in body temp caused by an inability of the body to cool itself; hyperthermia is typically seen in warm environments (like closed car on a hot day)
Second most common cause of unintentional deaths among children in the US
drowning; children younger than 5 are at particular risk
Number one killer of children in the US
trauma (more children die of injuries in 1 year than all other causes combined)
Children who are hit by car
If the car makes an attempt to stop, the bumper will dip down and hit the child lower than the resting bumper level; also children tend to turn and face the car before being hit as opposed to turning away like adults tend to do
Common signs and symptoms of head injuries in children
Often times they will have nausea and vomiting after trauma to the head
Immobilization of children
Place towels under the shoulders and torso then put on c-collar; secure torso before head
**Around 8-10 years, children no longer need padding under torso to keep neutral position
*If securing child onto adult backboard, place padding around them
Immobilizing a patient in a car seat
stabilize head and leave all car seat straps in place; place c-collar or rolled towels along side patient to fill voids in car seat; secure padding using tape; secure car seat to stretcher
Immobilizing a patient out of the car seat
Stabilize head in neutral position; lay the seat down in the reclined position on a hard surface and position peds board between the patient and the surface that they are resting on; slide patient into position on the board; place towels under the back fr
Chest injuries in peds
More often due to blunt trauma; chest wall flexibility can produce a flail chest; since their chest is so flexible they may not show external signs of major injuries, but they may still have severe internal injuries
Abdominal injuries in peds
Always consider shock in children with abdominal injuries
Burns in children
Usually considered more serious than in adults because of the surface area to body mass ratio (which means greater fluid and heat loss); they also do not tolerate burns as well; more likely to go into shock, develop hypothermia and experience airway probl
Minor burns in peds
partial-thickness burns involving less than 10% of BSA
Moderate burns in peds
Partial-thickness burns involving 10-20% of BSA
Severe burns in peds
Any full-thickness burn; any partial-thickness burn involving more than 20% of BSA; any burn involving hands, feet, face, airway or genitalia
Growth of long bones
occurs from the ends at specialized growth plates
Growth plates
Vary in position from child to child; potential weak spots in the bone that often gets injured in trauma; incomplete or greenstick fractures are likely because children's bones are more flexible
JumpSTART Triage
intended for kids younger than 8 years or less than 100 lbs
Green in JumpSTART
Kids who can walk or jump (except infants)
Yellow inJumpSTART
patients breathing spontaneously, with peripheral pulse and appropriate response to painful stimuli
Red in JumpSTART
apnea responsive to positioning or recue breathing (less than 15 breaths or more than 45 breaths), respiratory failure, breathing but without pulse, inappropriate painful response
Pneumonic for assessing possible child abuse
CHILD ABUSE: Consistency of injury with child's developmental age; History inconsistent with injury; Inappropriate parental concerns; Lack of supervision; Delay in seeking care; Affect; Bruises of varying ages; Unusual injury patterns; Suspicious circumst
Age of most victims of rape
Usually older than 10
Sudden Infant Death Sydrome (SIDS)
cause of death remains unexplained; leading cause of death in infants younger than 1 year (most cases occur in infants youger than 6 months); children often discovered in the morning
Risk factors for SIDS
Mother younger than 20, if mother smoked during pregnancy, low birth weight
Apparent life threatening event (ALTE)
near miss SIDS"; infants who are not breathing and cyanotic and unresponsive when found by the family, but resume breathing and regain color with stimulation; characterized by distinct change in muscle tone (limpness) and choking or gaging; after they ar