Pediatric Challenges

1. PediatricChallenges October 2012 CE Condell Medical Center EMS System Site Code: 107200E -1212 Prepared by Sharon Hopkins, RN, BSN, EMT-P

2. Objectives Upon successful completion of this module, the EMS provider will be able to: • 1. Describe developmental stages in the pediatric population. • 2. Describe anatomical differences in the pediatric population. • 3. Describe components and purpose of the pediatric assessment triangle. • 4. Describe the ABC assessment relative to the pediatric patient.

3. Objectives cont’d • 5. Differentiate between respiratory distress and respiratory failure in the pediatric population. • 6. Discuss a variety of pediatric challenges (ie: FBAO, asthma, RSV, meningitis, chicken pox) • 7. Discuss appropriate interventions for a variety of pediatric emergencies. • 8. Discuss rationale for using 250 ml IV bags in pediatric populations • 9. Actively participate in scenarios of the pediatric population. • 10.Successfully complete the post quiz with a score of 80% or better.

4. So, what’s a normal kid like? • We know each of our own children are different • We know each of our patients are different • We know every call we go on is unique to itself • BUT… • There are similarities that can be drawn for comparison

5. Growth and Development • Developmental stages • Newborn – first hours after birth • Neonates – birth to one month • Infants – 1-12 months • Toddlers – 1 – 3 years • Preschoolers – 3 - 5 years • School-age – 6 – 12 years • Adolescents – 13 – 18 years

6. Newborn – First Hours After Birth • Typical assessment tool – APGAR • Helps identify newborns from those that need routine care at birth from those that need more assistance • Can predict long-term survival • Resuscitation, if needed, follows inverted pyramid for the newborn • Drying, warming, positioning, suction, tactile stimulation are interventions are the first steps • These are usually the only interventions needed for the majority of newborns

7. Inverted Pyramid of Neonatal Resuscitation

8. Neonate – Birth to 1 Month • Common illnesses • Jaundice • Yellow coloring from breakdown of old red blood cells called bilirubin • Bilirubin is broken down by the liver for excretion in stool • Lab test may be required to determine levels • Vomiting • May lead to dehydration • Respiratory distress

9. Neonate cont’d • Fever may be only sign of a problem • ALL infants with fevers need to be evaluated

10. Neonate Assessment • Keep newborn warm • Absence of tears may indicate dehydration • To auscultate breath sounds, helpful to have newborn suck on pacifier • Keep newborn with parent/caregiver to keep child calm • Obtain history from parents/caregiver but observe child for important clues

11. Infant – 1 – 12 months • Double weight by 6 months; triple by 1 year • Should follow movements with their eyes • Muscle development moves from head to toes and from trunk toward extremities • FB obstruction risk high – this population explores their world with their mouths • Increased anxiety to strangers

12. Infant cont’d • Common illnesses and accidents • Febrile seizures Vomiting • Diarrhea Dehydration • Bronchiolitis Car crashes • Croup Child abuse • Poisonings Falls • Airway obstruction Meningitis • Keep child with parent • Assess toe to head to gain their trust

13. Toddler – 1 – 3 years • Increase in motor development • Always seem to be on the move • Becoming braver, more curious & stubborn • Language development begins • Can understand better than they can speak • Avoid questions that allow the child to say “no” • EMS can ask the patient simple questions • Still rely on parent/caregiver for information • Perform exam toe to head approach • Allow child to hold a favorite object if possible

14. Preschooler – 3 – 5 years • Increase in fine and gross motor movement • Language skills increase • If frightened, may not speak especially to strangers • Vivid imaginations • “Monsters” are part of their world • Fear mutilation • Child can provide more information regarding the nature of the call; note the imagination factor though

15. Preschooler cont’d • Allow child to hold some of the equipment • Assess starting with the chest; assess the head last • Watch for misleading comments – remember the wild imagination • Explain what you are doing immediately before performing a task

16. School-aged – 6 – 12 years • Developing personality • Values peers but protective and proud of family • Interview child for history but they may hold back if they were involved in forbidden activity • Be respectful of child’s modesty

17. Adolescent – 13 – 18 Years • This age group begins with puberty • Highly variable age – can begin at various ages • Typically 13 for males • Typically 11 for females • Physical maturity does not always equal emotional maturity! • Demanding more independence from parents/caregivers • This group is body conscious and concerned over disfigurement • Respect their sense of privacy

18. Common Fears of Children • Fear of being separated from parents/caregivers • Fear of being removed from family • Fear of being hurt • Fear of being mutilated or disfigured • Fear of the unknown

19. Approach to the Child • Children have a right to be informed • Be as honest as possible but in the appropriate manner • If something will hurt, tell them right before it is done and then quickly perform the task • Don’t want anticipation fear to build • Use plain language appropriate to the age • Also helpful for the parents

20. Metabolic Differences Increasing Risk of Hypothermia • Limited store of glycogen and glucose used for energy • Greater body surface area by weight • Volume loss due to vomiting and diarrhea • Inability to shiver in newborns and neonates • Unable to generate additional heat if needed when cold

21. Typical Anatomical Differences • Larger body surface • More prone to hypothermia • Tongue proportionately larger & floppier • Straight blade preferred during intubation • Smaller airway structures • Airway more easily blocked by minimal swelling • Head heavier and neck muscles less well developed • Higher incidence of head injuries

22. Anatomical Differences cont’d • Head larger in proportion to body • When flat, neck flexes; neutral alignment difficult • Shorter, more flexible trachea • Head extension may close off trachea • Abdominal breathers • Less developed chest muscles • Not typically seen in the adult population • Faster respiratory rate • Muscles tire easily

23. Airway Differences • Infant larynx higher which facilitates infants being nose breathers

24. Primary Assessment • Pediatric assessment triangle • An assessment from across the room when first observing the patient • Visual assessment prior to patient contact • Helps in forming your general impression • Appearance • Breathing • Circulation

25. Pediatric Assessment Triangle • Appearance • Mental status and muscle tone • Breathing • Work of breathing • Respiratory rate and effort • Circulation • Circulatory status • Skin signs and color

26. Continuing the Assessment • Level of consciousness • Can still use AVPU scale • Technique adjusted based on child’s age • “A” if eyes are open; can be alert or confused • “V” if there is a response to noise or yelling when eyes are closed • Response may be whimpering or crying • “P” for any response to noxious/painful/tactile stimuli • This includes withdrawal or any muscle twitch • “U” when they are flaccid and unresponsive

27. Assessment cont’d • A-B-C’s • Airway and respiratory problems are the most common causes of arrest in infants and children • Is airway open? • Is airway patent? • Does the patient require positioning? • Suctioning? • Limit to <10 seconds • Adjuncts? • If yes, which ones???

28. Neutral Position for Airway Control • Jaw thrust with gentle support  Padding under shoulders and back

29. Craniofacial Anomalies • Anomalies may alter normal approaches and cause creative use of equipment • This patient has Crouzon’s syndrome • Malformation of the skull and facial bones • How would you adjust your techniques?

30. Assessing Breathing • Look at the chest • Is the chest rising and falling? • Listen for breath sounds • Do you hear anything? Normal? Abnormal? • Feel for air movement at the patient’s mouth • Evaluate respiratory rate, effort, & color • Cyanosis is a late sign of respiratory failure • Noticed first in mucous membranes of mouth and nail beds • Cyanosis of extremities more likely from shock

31. Assessing Circulation • Visually check the color • Check capillary refill in a central area • More reliable checking the chest or forehead area • Evaluate heart rate • Bradycardia indicates hypoxia & impending arrest • Evaluate peripheral pulses • Loss of central pulses is ominous sign • <1 check brachial or femoral pulses • >1 check carotid pulses • Evaluate end-organ perfusion – skin and brain • Check mental status

32. Respiratory Distress • Most notable sign is an increased work of breathing • Respiratory rates often underestimated • Best to count the rate for a full minute in children • Note a normal mental status increasing to irritability or anxiety • Respiratory rate increasing

33. Respiratory Distress • Retractions • Nasal flaring in infants • Head bobbing – trying to inhale more oxygen • Grunting – increasing peep on exhalation • Wheezing • Gurgling • Stridor

34. Sternal retractions Tripod position Nasal flaring Respiratory Distress

35. Signs of Respiratory Distress • Children use tremendous energy to maintain homeostasis • When compensatory mechanisms have been exhausted, they crash fast • If you were surprised the patient crashed, then you probably missed the signs

36. Respiratory Failure • Uncorrected respiratory distress • Irritability/anxiety deteriorating to lethargy • Marked tachypnea now presenting as bradypnea • Marked retractions now presenting as agonal respirations • Poor muscle tone • Marked tachycardia now presenting as bradycardia • Central cyanosis • Hypoxia

37. Respiratory Failure cont’d • If immediate and appropriate interventions are not taken, the patient will respiratory arrest • The pediatric patient that moves into respiratory arrest is difficult to manage • Outcomes are not predictable • The best treatment is prevention and avoidance of this stage

38. Pediatric Challenges • Foreign bodies with airway obstruction • Asthma • Dehydration • Meningitis • Chicken pox

39. Airway Obstruction • Could be from foreign body or internal swelling • Typical sequence of events from aspiration • Coughing • Choking • Gagging • Wheezing • Complete occlusion

40. Views of Epiglottis • Normal view epiglottis and vocal cords on left • Collapse of the epiglottis on right

41. Foreign Body Airway Obstruction FBAO • You never know what they put in their mouths • Case file: • 2 year-old presents with acute airway obstruction • History of noisy breathing and hoarseness for multiple months • Patient presents with labored breathing, rapid respiratory rate, very anxious appearing, is drooling • What intervention is required in the field?

42. FBAO • If patient is able to exchange air, provide rapid transport in position of comfort • If unable to breath, provide abdominal thrusts if <1 • Continue thrusts until improvement or collapse • If patient collapses and stops breathing, perform CPR • Stop to look in mouth prior to the ventilations • Prepare equipment • Magill forceps • Intubation equipment

43. FBAO • Lateral x-ray results reveal FB • Surgical intervention to remove FB swallowed by 2 y/o

44. Asthma • Lower airway disease • Reversible chronic inflammatory disorder • Evidence of bronchospasm and excessive mucous production • Can be induced by multiple triggers • Symptoms represent phases of the attack

45. Asthma • First phase – release of histamines • Bronchoconstriction • Bronchial edema • May respond to inhaled bronchodilators • Second phase – inflammation of bronchioles • Additional edema decreasing more airflow • Need anti-inflammatory agent (ie: corticosteroids)

46. Asthma • Continued attack • Continued swelling of mucous membranes in bronchioles • Plugging of airways by mucous plugs • Sputum production increases • Airflow restricted in exhalation • Lungs hyperinflated on exhalation • Vital capacity decreased • Gas exchange decreased in alveoli • Hypoxemia worsens

47. Asthma • Important assessment aspects • Ask if the patient has ever been intubated for an attack • Clue patient may deteriorate quickly • What is their posture/positioning? • Sitting up & leaning forward (tripod) indicates respiratory distress • Are they able to speak in full sentences? • 2-3 word sentences indicate respiratory distress

48. Asthma Diagnosis • Differentiated usually by history taking • History of previous episodes • Use of inhalers • Usually sitting up, leaning forward, tachypneic • Unproductive cough • Use of accessory muscles • Bilateral wheezing • Silence is ominous – exchange of air is limited

49. Asthma Management • Goals: • Correct hypoxia • Provide supplemental oxygen • Reverse bronchospasm • Administer nebulized bronchodilator medications • Decrease inflammation • Medication added at the hospital

50. Bronchodilator • DuoNeb • Albuterol 2.5 mg / 3 ml • Atrovent (Ipratropium) 0.5 mg / 2.5 ml • Document by name of meds used and dosage • May repeat Albuterol neb treatment if no improvement • In severe cases, prepare for intubation with in-line treatment • May bag the patient forcing medication into the airway while preparing the intubation equipment