Pediatrics

2. Pediatrics Respiratory Emergencies Parvin . Abasi Member of faculty

3. Respiratory Emergencies ????? ??? : ????? ??? ?????? ?? ????????? ??? ?? ??? ??? ????? ?? ?? ??????????? ????????

4. Pediatric PeriOperative Cardiac Arrest (POCA) Registry 1998-2007: Respiratory events increased from 20 percent to 27 percent. The most common event leading to cardiac arrest in this category was laryngospasm, followed by airway obstruction, inadequate oxygenation, inadvertent extubation, difficult intubation and bronchospasm.

5. Respiratory Emergencies ?????? ????? ? ??? ??? ????? ???? ???? ??? ???? ???? ?? ???? ?????? ?? ?? ? ????????? ???.

6. ????? ??? ?????????? ? ????????

7. Pediatric Airway Considerations ??? ??? ????? ?????? ???? ?? ????????? ????? ?? ??? ???? ??? ???? ??? ????? ?????? ?? ?? ??? ?? ??? ?? ??? ??? ??? ????? ???? ?? ????????? ??? ???? ??? ? ?????? ?????? ????? ?????? ???? ???? ?? ?? ???? ??? ?? ???? ??? ??????? ???? ??? ?????? ??? ????? ????? Airway differences are more pronounced in infants and become less pronounced as children grow toward adulthood.Airway differences are more pronounced in infants and become less pronounced as children grow toward adulthood.

9.  ???? ????????? ? ??????? ?????? ?? ???? ???? ?? ???? ?????? ???? ??????? ???? ?????? ????? ??? Sometimes, what seems like a minor problem such as this may actually have major consequences. Airway assessment for children is the most essential life saving skill an EMT can have. Being attentive to all aspects of the airway is the primary responsibility of pediatric care.Sometimes, what seems like a minor problem such as this may actually have major consequences. Airway assessment for children is the most essential life saving skill an EMT can have. Being attentive to all aspects of the airway is the primary responsibility of pediatric care.

10. Breathing Considerations ?????? ???? ?? ???? ????? ??? ???? ?? ?????? ???????? ?????? ????? ????? ????? ???? ???? ?? ?????? ????????? ?????? ????? ? ???? ????? ?????? Although both children and adult use their diaphragms to breathe, adults are able, by chest expansion alone, to cause air to rush in to the lungs. Children cannot create enough negative pressure in the chest because the chest wall is less developed. Children in respiratory distress compensate rapidly by increasing the respiratory rate then easily fatigue, signaling the onset of respiratory failure. Increased respiratory rate uses much more of the body’s energy supply so that the child will eventually be unable to maintain elevated respiratory rate. Once the child’s breathing slows, his oxygenation is severely impaired and hypoxemia results.Although both children and adult use their diaphragms to breathe, adults are able, by chest expansion alone, to cause air to rush in to the lungs. Children cannot create enough negative pressure in the chest because the chest wall is less developed. Children in respiratory distress compensate rapidly by increasing the respiratory rate then easily fatigue, signaling the onset of respiratory failure. Increased respiratory rate uses much more of the body’s energy supply so that the child will eventually be unable to maintain elevated respiratory rate. Once the child’s breathing slows, his oxygenation is severely impaired and hypoxemia results.

11. Pediatric Airway Considerations

12. Basic Life Support Airway Head-tilt/chin-lift method Big tongue; Forward jaw displacement critical Avoid extreme hyperextension With possible neck injury, jaw thrust

17. Pediatric Respiratory System Poor accessory muscle development Less rigid thoracic cage Horizontal ribs, primarily diaphragm breathers Increased metabolic rate, increased O2 consumption

18. Pediatric Respiratory System Decrease respiratory reserve + Increased O2 demand = Increased respiratory failure risk

19. Patient Assessment Limit to essentials Look before you touch

20. Pediatric Assessment Triangle:First Impression Appearance - mental status, body position, tone Breathing - visible movement, effort Circulation - color

21. Pediatric Assessment TriangleInitial Assessment Appearance - Breathing - airway open, effort, sounds, rate, central color Circulation - pulse rate/strength, skin color/temp, cap refill, BP (? use at early ages)

22. Respiratory problems are described by the severity of the child’s condition: Respiratory Distress Respiratory Failure Respiratory Arrest Three categories of respiratory emergencies; distress, failure and arrest, are commonly used to describe the severity of the respiratory emergency. Each of these categories represent a general group of physical findings, however, not all findings must be present in all cases. For instance, a child in respiratory distress may not be agitated or restless, but be calm and alert. Three categories of respiratory emergencies; distress, failure and arrest, are commonly used to describe the severity of the respiratory emergency. Each of these categories represent a general group of physical findings, however, not all findings must be present in all cases. For instance, a child in respiratory distress may not be agitated or restless, but be calm and alert.

23. Respiratory Distress ??? ??????? ????? ???? ??? ????????? ???? ??? ???? ??? ?????? ????? ???? ????? ???? ????? ?? ???? ????((grunting ?????? ?? ?? ??????? ?? ??? ?????

24. Treatment of Respiratory Distress Keep the child in a position of comfort. Avoid agitating the child. Provide high concentration oxygen by non-rebreather face mask. If not tolerated, provide blow by oxygen. Keep the child in the position he/she finds most comfortable for breathing. Never force a child with respiratory distress to lie down. Deliver high-concentration oxygen using a nonrebreather mask. Sizing is critical. For good oxygen delivery, the mask must fit the face, with the bottom of the mask resting on the crease of the chin when the top of the mask is placed over the bridge of the nose. Adjust the oxygen flow so that the bag remains inflated when the child breathes in. Children in respiratory distress can respond with increased agitation when EMTs attempt to place the nonrebreather mask. EMTs might try holding the mask near the face instead of against it to avoid agitating the child. If the child does not tolerate this, try simply aiming oxygen tubing near the child's nose. Another possibility is to place the oxygen tubing in a paper cup and let the parents hold the cup while asking the child to pretend to drink from it. Keep the child in the position he/she finds most comfortable for breathing. Never force a child with respiratory distress to lie down. Deliver high-concentration oxygen using a nonrebreather mask. Sizing is critical. For good oxygen delivery, the mask must fit the face, with the bottom of the mask resting on the crease of the chin when the top of the mask is placed over the bridge of the nose. Adjust the oxygen flow so that the bag remains inflated when the child breathes in. Children in respiratory distress can respond with increased agitation when EMTs attempt to place the nonrebreather mask. EMTs might try holding the mask near the face instead of against it to avoid agitating the child. If the child does not tolerate this, try simply aiming oxygen tubing near the child's nose. Another possibility is to place the oxygen tubing in a paper cup and let the parents hold the cup while asking the child to pretend to drink from it.

27. Respiratory Failuer ????? ??????? ?????? ?? ?? ???? ? ????? ????? ?? ??? ???? ??? ???? ?? ???? ?? ????? ??? ????? ????? ????????? ???? ??? ?????? ???? ????? ???? ????? ?? ???? ??? ??? ?? ?? ????? ????? ????? ?????? ?????

28. Respiratory Failure- Sitting Child Assist the child who is able to sit up into the position most comfortable for breathing. Give high concentration oxygen by non-rebreather face mask. Monitor child for response to oxygen or worsening respiratory failure. Give high-concentration oxygen. Prepare for transport. Deliver high-concentration oxygen using a non-rebreather mask. Remember to properly size the mask. As discussed in the treatment of respiratory distress, children can respond with increased agitation when EMTs attempt to place the non-rebreather mask. EMTs might try holding the mask near the face instead of against it to avoid agitating the child. If the child does not tolerate this, try simply aiming oxygen tubing near the child's nose. Another possibility is to place the oxygen tubing in a paper cup and let the parents hold the cup while asking the child to pretend to drink from it. Assess for signs of improvement. A child who is responding to the EMTs‘ interventions will show improved muscle tone. A sleepy child should become more alert. Respiratory effort should decrease and skin color should improve.Give high-concentration oxygen. Prepare for transport. Deliver high-concentration oxygen using a non-rebreather mask. Remember to properly size the mask. As discussed in the treatment of respiratory distress, children can respond with increased agitation when EMTs attempt to place the non-rebreather mask. EMTs might try holding the mask near the face instead of against it to avoid agitating the child. If the child does not tolerate this, try simply aiming oxygen tubing near the child's nose. Another possibility is to place the oxygen tubing in a paper cup and let the parents hold the cup while asking the child to pretend to drink from it. Assess for signs of improvement. A child who is responding to the EMTs‘ interventions will show improved muscle tone. A sleepy child should become more alert. Respiratory effort should decrease and skin color should improve.

29. Respiratory Failure TreatmentChild Unable to Sit Open the airway using head tilt - chin lift or modified jaw thrust. Clear the mouth and gently suction visible vomit or secretions. Nasopharyngeal airway, if needed. Provide high concentration oxygen by non-rebreather face mask. Assure chest rise: Look, listen, and feel for chest rise and air movement. If the airway is blocked with vomit, secretions, small foreign particles, or blood, EMTs should provide gentle suctioning. Since the patient will probably have an active gag reflex, they must carefully control the tip of the device to suction shallowly. After suctioning, EMTs should check for signs of improvement, such as pink color returning to the skin or improved mental status. These improvements should occur almost immediately. If there is no significant improvement, EMTs should reassess the airway, assure that it is open and then, begin ventilations. Assure chest rise: Look, listen, and feel for chest rise and air movement. If the airway is blocked with vomit, secretions, small foreign particles, or blood, EMTs should provide gentle suctioning. Since the patient will probably have an active gag reflex, they must carefully control the tip of the device to suction shallowly. After suctioning, EMTs should check for signs of improvement, such as pink color returning to the skin or improved mental status. These improvements should occur almost immediately. If there is no significant improvement, EMTs should reassess the airway, assure that it is open and then, begin ventilations.

30. Nasopharyngeal Airway A child with respiratory failure who is unable to sit and whose airway cannot be kept clear by positioning and suctioning may require a nasopharyngeal airway. Contraindicated by agitation facial or head trauma If necessary, EMTs may place a nasopharyngeal airway to help keep the air passage between the nose and the back of the throat open for suctioning or oxygen delivery. Nasal airways can be used in conscious children who cannot maintain an open airway. They should not be used in children with facial trauma or head injuries. An oropharyneal airway is contraindicated in a responsive child, and therefore, cannot be considered for the child in respiratory failure. Do not use this airway in an agitated child as it will increase agitation. Increased agitation can easily worsen respiratory distress. With facial or head trauma, the nasopharyngeal airway is not used due to the possibility of internal injuries. Introducing the nasopharyngeal airway into injured areas may cause additional damage to those structures. If necessary, EMTs may place a nasopharyngeal airway to help keep the air passage between the nose and the back of the throat open for suctioning or oxygen delivery. Nasal airways can be used in conscious children who cannot maintain an open airway. They should not be used in children with facial trauma or head injuries. An oropharyneal airway is contraindicated in a responsive child, and therefore, cannot be considered for the child in respiratory failure. Do not use this airway in an agitated child as it will increase agitation. Increased agitation can easily worsen respiratory distress. With facial or head trauma, the nasopharyngeal airway is not used due to the possibility of internal injuries. Introducing the nasopharyngeal airway into injured areas may cause additional damage to those structures.

31. Nasopharyngeal Airway Caution Children of school age and younger have prominent and delicate adenoidal tissue in their airways. These tissues can be torn, causing bleeding into the airway. If any resistance is met during insertion, stop. Never force a nasopharyngeal airway. Due to the prominence of the adenoidal tissue in these children, nasopharyngeal airways must be considered as adjunct devices only. It may be advisable to call for ALS if additional airway control is needed.Due to the prominence of the adenoidal tissue in these children, nasopharyngeal airways must be considered as adjunct devices only. It may be advisable to call for ALS if additional airway control is needed.

32. Select the correct size: Length - tip of the nose to the earlobe. Diameter - about that of the pinky finger. Lubricate with water soluble jelly and insert gently with bevel facing the nasal septum. It is important to use a correctly sized nasal airway. EMTs should select an airway that is about the same thickness as the patient's little finger. The length should extend from the nostril to the tip of the earlobe. Apply a water-soluble lubricant and slowly insert the airway into the child's nostril, holding the airway at a right angle to the face. The correct insertion distance is from the nose to the earlobe . During insertion, keep the bevel toward the middle of the nose. Direct the airway straight back along the floor of the nasal passage. Suction as necessary to clear secretions. It is important to use a correctly sized nasal airway. EMTs should select an airway that is about the same thickness as the patient's little finger. The length should extend from the nostril to the tip of the earlobe. Apply a water-soluble lubricant and slowly insert the airway into the child's nostril, holding the airway at a right angle to the face. The correct insertion distance is from the nose to the earlobe . During insertion, keep the bevel toward the middle of the nose. Direct the airway straight back along the floor of the nasal passage. Suction as necessary to clear secretions.

34. Respiratory Failure TreatmentChild Unable to Sit If there is no improvement with positioning, airway opening, suctioning and oxygen: Ventilate the child at a rate of 20/min. using a bag-valve-mask, reservoir and high concentration oxygen. Once EMTs have positioned and suctioned the airway and provided high-concentration oxygen, they should prepare the child for transport. If airway positioning, suctioning, nasal airway, and high-concentration oxygen fail to maintain adequate ventilation, EMTs should begin assisted ventilation as described for children in respiratory arrest. Once EMTs have positioned and suctioned the airway and provided high-concentration oxygen, they should prepare the child for transport. If airway positioning, suctioning, nasal airway, and high-concentration oxygen fail to maintain adequate ventilation, EMTs should begin assisted ventilation as described for children in respiratory arrest.

36. Respiratory Arrest A child who makes no or slight breathing effort is in respiratory arrest. Respiratory arrest is accompanied by severe bradycardia or cardiac arrest. Children experiencing respiratory arrest will be unresponsive and limp, with a blue color around the lips and slow or absent respiratory rate and effort. Respiratory arrest is an end process of respiratory failure. The fatigue which led the child from respiratory distress to failure has now become exhaustion. This leaves the child unable to make any sustained effort at breathing. While there may be some slight effort, or an occasional breath, respiratory arrest is present. The periods of apnea (without breathing) will lengthen until all respiratory effort ceases. These children require airway positioning including the head tilt and chin lift or modified jaw thrust, airway clearing with suction, if secretions or vomitus block the airway, and ventilation with a bag-valve-mask. At the same time, the heart rate is slowing because the heart muscle becomes starved for oxygen. The heart cannot pump effectively or quickly without oxygen. Once the heart rate drops below 60 beats per minute, chest compressions are initiated. Children experiencing respiratory arrest will be unresponsive and limp, with a blue color around the lips and slow or absent respiratory rate and effort. Respiratory arrest is an end process of respiratory failure. The fatigue which led the child from respiratory distress to failure has now become exhaustion. This leaves the child unable to make any sustained effort at breathing. While there may be some slight effort, or an occasional breath, respiratory arrest is present. The periods of apnea (without breathing) will lengthen until all respiratory effort ceases. These children require airway positioning including the head tilt and chin lift or modified jaw thrust, airway clearing with suction, if secretions or vomitus block the airway, and ventilation with a bag-valve-mask. At the same time, the heart rate is slowing because the heart muscle becomes starved for oxygen. The heart cannot pump effectively or quickly without oxygen. Once the heart rate drops below 60 beats per minute, chest compressions are initiated.

37. Respiratory Emergencies Croup Epiglottitis Asthma Bronchiolitis Foreign body aspiration Bronchopulmonary dysplasia

38. Laryngotracheobronchitis Croup

39. Croup: Pathophysiology Viral infection (parainfluenza) Affects larynx, trachea Subglottic edema; Air flow obstruction

40. Croup: Incidence 6 months to 4 years Males > Females Fall, early winter

41. Croup: Signs/Symptoms “Cold” progressing to hoarseness, cough Low grade fever Night-time increase in edema with: Stridor “Seal bark” cough Respiratory distress Cyanosis Recurs on several nights

42. Physical ExaminationStridor Stertor Bulky oropharyngeal noise Inspiratory, expiratory, or both Supraglottic Inspiratory Glottic Inspiratory progressing to biphasic Subglottic Inspiratory progressing to biphasic Tracheal Expiratory

45. Croup: Management Mild Croup Reassurance Moist, cool air

46. Croup: Management Severe Croup Humidified high concentration oxygen Monitor EKG IV tko if tolerated Nebulized racemic epinephrine Anticipate need to intubate, assist ventilations

48. Epiglottitis

49. Epiglottitis: Pathophysiology Bacterial infection (Hemophilus influenza) Affects epiglottis, adjacent pharyngeal tissue Supraglottic edema

50. Epiglottitis: Incidence Children > 4 years old Common in ages 4 - 7 Pedi incidence falling due to HiB vaccination Can occur in adults, particularly elderly Incidence in adults is increasing

51. Epiglottitis: Signs/Symptoms Rapid onset, severe distress in hours High fever Intense sore throat, difficulty swallowing Drooling Stridor Sits up, leans forward, extends neck slightly One-third present unconscious, in shock

52. Epiglottitis Respiratory distress+ Sore throat+Drooling = Epiglottitis

53. Epiglottitis: Management High concentration oxygen IV tko, if possible Rapid transport Do not attempt to visualize airway

54. Epiglottitis Immediate Life Threat Possible Complete Airway Obstruction

56. Asthma

57. What is Asthma? A chronic (long-term) condition of the airways   A condition that cannot be cured, but can be controlled

58. Asthma: Pathophysiology Lower airway hypersensitivity to: Allergies Infection Irritants Emotional stress Cold Exercise

59. Asthma: Pathophysiology

60. Asthma: Pathophysiology

62. Asthma: Signs/Symptoms Dyspnea Signs of respiratory distress Nasal flaring Accessory muscle use Suprasternal, intercostal, epigastric retractions

63. Asthma: Signs/Symptoms Coughing Expiratory wheezing Tachypnea Cyanosis

64. Asthma: Physical Exam Patient position? Signs/symptoms of dehydration? Chest movement? Quality of breath sounds?

65. Asthma: Risk Assessment Prior ICU admissions Prior intubation >3 emergency department visits in past year >2 hospital admissions in past year >1 bronchodilator canister used in past month Use of bronchodilators > every 4 hours Chronic use of steroids Progressive symptoms in spite of aggressive Rx

68. A silent chest is an ominous sign of low blood oxygen in the pediatric patient. Breathing Considerations

69. Asthma Silent Chest equals Danger

70. Golden Rule Pulmonary edema Allergic reactions Pneumonia Foreign body aspiration

71. Asthma: Management Airway Breathing Sitting position Humidified O2 by NRB mask Dry O2 dries mucus, worsens plugs Encourage coughing Consider intubation, assisted ventilation

72. Asthma: Management Circulation IV Assess for dehydration Titrate fluid administration to severity of dehydration Monitor ECG

73. Asthma: Management Nebulized Beta-2 agents Albuterol Terbutaline Metaproterenol

74. Asthma: Management Nebulized anticholinergics Atropine Ipatropium

75. Asthma: Management Subcutaneous beta agents Epinephrine 1:1000--0.1 to 0.3 mg SQ Terbutaline--0.25 mg SQ

76. Asthma: Management Avoid Sedatives Depress respiratory drive Antihistamines dry secretions Aspirin High incidence of allergy

78. Status Asthmaticus Asthma attack unresponsive to ?-2 adrenergic agents

79. Status Asthmaticus Humidified oxygen Rehydration Continuous nebulized beta-2 agents Atrovent Corticosteroids Aminophylline (controversial) Magnesium sulfate (controversial)

80. Status Asthmaticus Intubation Mechanical ventilation Large tidal volumes (18-24 ml/kg) Long expiratory times Intravenous Terbutaline Continuous infusion 3 to 6 mcg/kg/min

81. Bronchiolitis

82. Bronchiolitis: Pathophysiology Viral infection (RSV) Inflammatory bronchiolar edema Air trapping

83. Bronchiolitis: Incidence Children < 2 years old 80% of patients < 1 year old Epidemics January through May

84. Bronchiolitis: Signs/Symptoms Infant < 1 year old Recent upper respiratory infection exposure Gradual onset of respiratory distress Expiratory wheezing Extreme tachypnea (60 - 100+/min) Cyanosis

85. Asthma vs Bronchiolitis Asthma Age - > 2 years Fever - usually normal Family Hx - positive Hx of allergies - positive Response to Epi - positive Bronchiolitis Age - < 2 years Fever - positive Family Hx - negative Hx of allergies - negative Response to Epi - negative

86. Bronchiolitis: Management Humidified oxygen by NRB mask Monitor EKG IV Anticipate order for bronchodilators Anticipate need to intubate, assist ventilations

87. Foreign Body Airway Obstruction FBAO

88. FBAO: High Risk Groups > 90% of deaths: children < 5 years old 65% of deaths: infants

89. FBAO: Signs/Symptoms Suspect in any previously well, afebrile child with sudden onset of: Respiratory distress Choking Coughing Stridor Wheezing

90. FBAO: Management Minimize intervention if child conscious, maintaining own airway 100% oxygen as tolerated No blind sweeps of oral cavity Wheezing Object in small airway Avoid trying to dislodge in field

91. FBAO: Management Inadequate ventilation Infant: 5 back blows/5 chest thrusts Child: Abdominal thrusts

98. Questions?????

99. Bronchopulmonary Dysplasia BPD

100. BPD: Pathophysiology Complication of infant respiratory distress syndrome Seen in premature infants Results from prolonged exposure to high concentration O2 , mechanical ventilation

101. BPD: Signs/Symptoms Require supplemental O2 to prevent cyanosis Chronic respiratory distress Retractions Rales Wheezing Possible cor pulmonale with peripheral edema

102. BPD: Prognosis Medically fragile, decompensate quickly Prone to recurrent respiratory infections About 2/3 gradually recover

103. BPD: Treatment Supplemental O2 Assisted ventilations, as needed Diuretic therapy, as needed

104. Endotracheal Intubation Proper tube size Same size as child’s little finger Child > 1 year: [(Age + 16 ) / 4]

105. Endotracheal Intubation Children < 8 years old Small tracheal diameter Narrow cricoid ring Uncuffed tubes Infants, small children Narrow, soft epiglottis Straight blade

106. A child may have pronounced retractions of the chest wall because the chest wall is less muscular and has more flexible bones. Extra effort of breathing may include the chest, abdomen, neck and head. Literally, the child uses his body to keep up the respiratory effort. Once the respiratory system begins to fail (respiratory failure), the heart is affected. Because oxygen is depleted, the heart is unable to maintain a rapid rate, and bradycardia results.Extra effort of breathing may include the chest, abdomen, neck and head. Literally, the child uses his body to keep up the respiratory effort. Once the respiratory system begins to fail (respiratory failure), the heart is affected. Because oxygen is depleted, the heart is unable to maintain a rapid rate, and bradycardia results.

107. Respiratory Emergencies Lesson 4 Instructor Note: While this lesson is an integral portion of the program, it can also be used independently for review. Please distribute handouts: Rapid First Impression of Pediatric Respiratory Emergencies, CUPS Assessment for Pediatric Respiratory Emergencies, and Assessment Findings for Pediatric Respiratory Emergencies before the start of this lesson. Respiratory problems arising from medical emergencies and trauma are the most common cause of death in children. Early recognition and treatment of respiratory problems by EMTs can greatly improve the outcome and prevent worsening of the child’s condition. In the last two lessons, the steps of rapid first impression and initial assessment have been discussed and explained. In this lesson, these principles will be applied to the management of respiratory problems. These management decisions should be based upon the seriousness of the child’s condition, regardless of the cause. Instructor Note: While this lesson is an integral portion of the program, it can also be used independently for review. Please distribute handouts: Rapid First Impression of Pediatric Respiratory Emergencies, CUPS Assessment for Pediatric Respiratory Emergencies, and Assessment Findings for Pediatric Respiratory Emergencies before the start of this lesson. Respiratory problems arising from medical emergencies and trauma are the most common cause of death in children. Early recognition and treatment of respiratory problems by EMTs can greatly improve the outcome and prevent worsening of the child’s condition. In the last two lessons, the steps of rapid first impression and initial assessment have been discussed and explained. In this lesson, these principles will be applied to the management of respiratory problems. These management decisions should be based upon the seriousness of the child’s condition, regardless of the cause.

108. Provide Oxygen First Every child with significant trauma or respiratory emergency NEEDS OXYGEN ASAP Instructor Note: Some students may be confused about this because they have heard that oxygen has caused blindness in newborns or lung tissue damage in children. The truth is that for in-hospital, long term (i.e., more than 24 hours) care, continuous delivery of high concentration oxygen may be inappropriate. However, the prehospital setting is a totally different situation. High concentration oxygen, in the prehospital setting is known to be life saving for children and has absolutely no contraindications. Demand valve devices are not used for children because they operate at excessive pressures and those pressures can be difficult or impossible to control. The lab skills included in this lesson are ventilation with BVM and airway adjuncts.Instructor Note: Some students may be confused about this because they have heard that oxygen has caused blindness in newborns or lung tissue damage in children. The truth is that for in-hospital, long term (i.e., more than 24 hours) care, continuous delivery of high concentration oxygen may be inappropriate. However, the prehospital setting is a totally different situation. High concentration oxygen, in the prehospital setting is known to be life saving for children and has absolutely no contraindications. Demand valve devices are not used for children because they operate at excessive pressures and those pressures can be difficult or impossible to control. The lab skills included in this lesson are ventilation with BVM and airway adjuncts.

109. Assess his appearance: Mental state Muscle tone and body position Skin The steps of the Rapid First Impression involve assessing appearance, including mental state, body position and skin color, followed by breathing and circulation. His appearance: His mental state is a form of anxiety, as he is not interacting with the concerned adults around him, but concentrating on his own breathing effort. He is alert enough to keep himself in an upright position, but his mental state is not normal. Body position is stiff, with his position maintained by leaning forward (tripod position) and tilting back his head (sniffing position). This is a combination of body positions commonly seen in children who are experiencing respiratory distress. By assuming this posture, the child is moving the work of holding himself upright from his chest muscles to his arms. This, then, allows the child to use his chest muscles only for breathing. Simultaneously, he has tilted his head back into the sniffing position. This position allows him to open his airway as much as possible, again, a sign of respiratory distress. His skin is pale, which indicates that his blood oxygen is low, but is being maintained at a level adequate for him to maintain his upright position. The steps of the Rapid First Impression involve assessing appearance, including mental state, body position and skin color, followed by breathing and circulation. His appearance: His mental state is a form of anxiety, as he is not interacting with the concerned adults around him, but concentrating on his own breathing effort. He is alert enough to keep himself in an upright position, but his mental state is not normal. Body position is stiff, with his position maintained by leaning forward (tripod position) and tilting back his head (sniffing position). This is a combination of body positions commonly seen in children who are experiencing respiratory distress. By assuming this posture, the child is moving the work of holding himself upright from his chest muscles to his arms. This, then, allows the child to use his chest muscles only for breathing. Simultaneously, he has tilted his head back into the sniffing position. This position allows him to open his airway as much as possible, again, a sign of respiratory distress. His skin is pale, which indicates that his blood oxygen is low, but is being maintained at a level adequate for him to maintain his upright position.

110. Continue RFI assessment: Breathing Effort Circulation Is his condition urgent or non-urgent? What is the severity of the respiratory emergency? What are your first actions? Although you are not yet able to determine the breathing rate, there are signs of extra effort of breathing in that you can see his neck muscles are being used to move air. In the rapid first assessment, circulation is not yet ascertainable beyond the skin, which is pale. His condition is urgent, as there are multiple findings that are not normal; mental state, body position, skin color and extra effort of breathing. This child has severe respiratory distress. Remember that, although we are using three categories of respiratory emergencies, there are degrees of respiratory distress from mild to moderate or severe. He is not, as yet, in respiratory failure, as he is maintaining his oxygenation. Although you are not yet able to determine the breathing rate, there are signs of extra effort of breathing in that you can see his neck muscles are being used to move air. In the rapid first assessment, circulation is not yet ascertainable beyond the skin, which is pale. His condition is urgent, as there are multiple findings that are not normal; mental state, body position, skin color and extra effort of breathing. This child has severe respiratory distress. Remember that, although we are using three categories of respiratory emergencies, there are degrees of respiratory distress from mild to moderate or severe. He is not, as yet, in respiratory failure, as he is maintaining his oxygenation.

111. One EMT should position him/herself at the child’s eye level, speak calmly and introduce the responders. The child’s condition is urgent. Therefore, transportation should be initiated quickly. However, it is essential to avoid agitating this child. Take a moment to explain who you are and what you intend to do before you touch him. How agitation affects breathing: A child with respiratory problems who is agitated or frightened by EMTs will begin breathing harder and faster. This leads to increased resistance in the air passages, which in turn worsens breathing problems. EMTs may understand this concept better if they think about breathing through a narrow paper straw. When they breathe at a normal rate, air moves easily through the straw. If they exercise vigorously until they’re breathing hard, then try again, the straw will tend to collapse. A similar principle is at work when children are breathing hard through narrow air passages. Because the child is breathing harder and faster, he will require more oxygen to support his breathing, but because he is in respiratory distress already, he is unable to get this additional oxygen. As a result, the child will develop more severe respiratory distress or even begin to experience respiratory failure, if agitated. EMTs who spend a few moments to assure the child of their ability to help and explain their intended actions prior to performing them can successfully avoid unnecessary agitation.How agitation affects breathing: A child with respiratory problems who is agitated or frightened by EMTs will begin breathing harder and faster. This leads to increased resistance in the air passages, which in turn worsens breathing problems. EMTs may understand this concept better if they think about breathing through a narrow paper straw. When they breathe at a normal rate, air moves easily through the straw. If they exercise vigorously until they’re breathing hard, then try again, the straw will tend to collapse. A similar principle is at work when children are breathing hard through narrow air passages. Because the child is breathing harder and faster, he will require more oxygen to support his breathing, but because he is in respiratory distress already, he is unable to get this additional oxygen. As a result, the child will develop more severe respiratory distress or even begin to experience respiratory failure, if agitated. EMTs who spend a few moments to assure the child of their ability to help and explain their intended actions prior to performing them can successfully avoid unnecessary agitation.

112. A second EMT should speak with the adults to gather information about what happened to the patient. The adults in the group are teachers and parents who are escorting a first grade class on an outing. The patient’s parents are not among them. One of the adults tells you that “he seemed fine” until about 20 minutes ago, when he told her that he couldn’t breathe. Whenever the patient is a child, there is at least one other person to be considered; the parent or caregiver. The role of the second EMT is to reassure these adults, obtain information about the child and to communicate with them about the treatment and transportation of the child. Gathering information about the circumstances that brought about this condition is also helpful. The child may not be able to adequately explain what occurred, while an adult is more likely to possess and articulate this valuable information.Whenever the patient is a child, there is at least one other person to be considered; the parent or caregiver. The role of the second EMT is to reassure these adults, obtain information about the child and to communicate with them about the treatment and transportation of the child. Gathering information about the circumstances that brought about this condition is also helpful. The child may not be able to adequately explain what occurred, while an adult is more likely to possess and articulate this valuable information.

113. After introducing yourself and explaining that you are there to help, the child tells you “I . . . can’t . . . breathe.” You hear no stridor or gurgling noises. What does this indicate about the child? What is your next action? The airway is open, as the child can speak and no stridor or gurgling is heard. Continue with next slide. The airway is open, as the child can speak and no stridor or gurgling is heard. Continue with next slide.

114. Explain to the child what you are going to do and then do it. Provide high concentration oxygen by non-rebreather mask, without delay. Prepare for transport. Although the initial assessment will reveal more complete information about the patient’s problem, it is clear from the rapid first impression that the child has an urgent respiratory problem. There is no reason to delay oxygen administration. Prepare the child for your impending actions:“I’m going to put a mask on your face to help your breathing. It won’t hurt, but it will feel tight on top of your nose and cheeks.” As soon as oxygen is being provided, preparation for transportation should be made. Explain this to the child. Arrange for one of the adults to accompany him. The child should be moved to the transport vehicle as smoothly and comfortably as possible. This child should be placed on a wheeled stretcher or chair device and kept as upright as possible. Initial assessment should then be performed. Although the initial assessment will reveal more complete information about the patient’s problem, it is clear from the rapid first impression that the child has an urgent respiratory problem. There is no reason to delay oxygen administration. Prepare the child for your impending actions:“I’m going to put a mask on your face to help your breathing. It won’t hurt, but it will feel tight on top of your nose and cheeks.” As soon as oxygen is being provided, preparation for transportation should be made. Explain this to the child. Arrange for one of the adults to accompany him. The child should be moved to the transport vehicle as smoothly and comfortably as possible. This child should be placed on a wheeled stretcher or chair device and kept as upright as possible. Initial assessment should then be performed.

115. You have moved the child with an adult to your transport vehicle and are preparing to leave for the hospital. What actions should you now take? Humidify the oxygen. Now is the time for the initial assessment. Humidify the oxygen. Now is the time for the initial assessment.

116. The initial assessment reveals the following: Airway - The child can speak in short sentences only. He allows you to raise his shirt. You see that he is using his abdominal muscles to move air out of his lungs. You do not hear gurgling or stridor. What do these findings suggest? Treatment? What’s next? The child is able to speak, although only in short sentences. Therefore, he is moving some air, however, the volume is insufficient to allow him to speak normally. The child is using his neck and abdominal muscles to move air. These are signs of extra effort of breathing. The absence of gurgling and stridor indicate that the source of the problem is not in the upper airway. You can now confirm that the airway is open, without the potential for upper airway compromise. You have also discovered additional signs of respiratory distress (speaking in short sentences, abdominal muscle use). Humidified, high concentration oxygen by non-rebreather face mask is already in place. The next task is to perform the initial assessment of breathing.The child is able to speak, although only in short sentences. Therefore, he is moving some air, however, the volume is insufficient to allow him to speak normally. The child is using his neck and abdominal muscles to move air. These are signs of extra effort of breathing. The absence of gurgling and stridor indicate that the source of the problem is not in the upper airway. You can now confirm that the airway is open, without the potential for upper airway compromise. You have also discovered additional signs of respiratory distress (speaking in short sentences, abdominal muscle use). Humidified, high concentration oxygen by non-rebreather face mask is already in place. The next task is to perform the initial assessment of breathing.

117. Breathing Assessment: Both sides of the chest are rising equally and deeply, with extra effort noted on expiration. With a stethoscope, you hear whistling sounds over the lungs when the patient breathes out. The tracheal sounds are normal. Continue with the next slide.Continue with the next slide.

118. There are 16 breaths in 30 seconds. The skin is pale, but some slight pink tones are now in his face. What do these findings suggest? Treatment? What’s next? The chest wall has equal movement, depth and rhythm. This suggests that there is no localized problem such as pneumothorax or chest wall injury. The presence of whistles over the lungs describes wheezes. Wheezes are the sound heard when air is trapped by spasm and mucous in the larger air passageways. These sounds are pronounced on expiration, which is also characteristic of wheezes. The absence of whistles over the trachea also confirms that the problem is in the lower airways in the lungs and not the upper airway. The respiratory rate is 32/min. This rate is slightly above the normal range for a child of this age, however, consider that the rate is being sustained with a lot of extra work. It is not always possible for a child to greatly raise his breathing rate due to the extreme effort and additional time each breath requires. In this case, the extra work is pronounced during expiration. In the absence of respiratory distress, breathing out is normally a passive process, requiring very little effort. In this child, however, breathing out is hard work and requires extra time. The pink skin tone is a sign that the child is responding to the high concentration oxygen administration. Although he remains in respiratory distress, his blood oxygen level is improving. Continue the oxygen treatment and assess circulation.The chest wall has equal movement, depth and rhythm. This suggests that there is no localized problem such as pneumothorax or chest wall injury. The presence of whistles over the lungs describes wheezes. Wheezes are the sound heard when air is trapped by spasm and mucous in the larger air passageways. These sounds are pronounced on expiration, which is also characteristic of wheezes. The absence of whistles over the trachea also confirms that the problem is in the lower airways in the lungs and not the upper airway. The respiratory rate is 32/min. This rate is slightly above the normal range for a child of this age, however, consider that the rate is being sustained with a lot of extra work. It is not always possible for a child to greatly raise his breathing rate due to the extreme effort and additional time each breath requires. In this case, the extra work is pronounced during expiration. In the absence of respiratory distress, breathing out is normally a passive process, requiring very little effort. In this child, however, breathing out is hard work and requires extra time. The pink skin tone is a sign that the child is responding to the high concentration oxygen administration. Although he remains in respiratory distress, his blood oxygen level is improving. Continue the oxygen treatment and assess circulation.

119. Assess circulation: On comparison, central and peripheral pulses are strong, the skin of both the trunk and extremities is warm and pale. Capillary refill is less than 2 seconds. You count 60 beats in 30 seconds when you assess the pulse rate. What do these findings suggest? Treatment? What’s next? The skin is pale, which indicates less blood oxygen is reaching the skin either because the heart is not pumping well enough or because the blood being pumped by the heart does not contain sufficient oxygen. In this assessment, respiratory distress is the cause of low blood oxygen level. The strength of central and peripheral pulses is nearly equal, suggesting that the child is not experiencing a problem with delivery of the blood, but with the lack of oxygen the blood contains. The normal capillary refill time, the warmth of the skin also support that the pumping action of the heart is not the cause. The heart rate of 120/min. is a high-normal value for this child. It is particularly high when you consider that the child is essentially at rest; sitting quietly, in a position of comfort. This increased heart rate is occurring because of the respiratory distress. The treatment indicated is to continue high concentration oxygen and reassessment for response to the oxygen treatment. Assess for disability and determine the CUPS assessment. The skin is pale, which indicates less blood oxygen is reaching the skin either because the heart is not pumping well enough or because the blood being pumped by the heart does not contain sufficient oxygen. In this assessment, respiratory distress is the cause of low blood oxygen level. The strength of central and peripheral pulses is nearly equal, suggesting that the child is not experiencing a problem with delivery of the blood, but with the lack of oxygen the blood contains. The normal capillary refill time, the warmth of the skin also support that the pumping action of the heart is not the cause. The heart rate of 120/min. is a high-normal value for this child. It is particularly high when you consider that the child is essentially at rest; sitting quietly, in a position of comfort. This increased heart rate is occurring because of the respiratory distress. The treatment indicated is to continue high concentration oxygen and reassessment for response to the oxygen treatment. Assess for disability and determine the CUPS assessment.

120. Assess AVPU: The child tells you his name, that he was on a class trip to the carnival and the correct day of the week. Using AVPU, what is his level of responsiveness? What does this finding indicate? Treatment? CUPS? What’s next? At this time the child is able to speak and is alert according to the AVPU scale because he is oriented to person, place and time. Compare this finding with that of the RFI where he was not interacting with the adults around him because he was concentrating on his breathing efforts. What has occurred to cause this improvement? His mental state has improved as a result of the high concentration oxygen he has been receiving. This improvement indicates that blood oxygen levels are rising. The treatment indicated is continuation of the high concentration oxygen. His CUPS status is P, potentially unstable. Initially, when first encountered, the patient’s CUPS would have been U as he had compromised breathing as demonstrated by his change in mental state, body position and muscle tone and pale skin color. At this time, both his skin color and mental state are improving, although he continues to have respiratory distress, therefore his status is P. Treatment now is to obtain a focused history, repeat the initial assessment, looking for further signs of improvement, and continued high concentration oxygen.At this time the child is able to speak and is alert according to the AVPU scale because he is oriented to person, place and time. Compare this finding with that of the RFI where he was not interacting with the adults around him because he was concentrating on his breathing efforts. What has occurred to cause this improvement? His mental state has improved as a result of the high concentration oxygen he has been receiving. This improvement indicates that blood oxygen levels are rising. The treatment indicated is continuation of the high concentration oxygen. His CUPS status is P, potentially unstable. Initially, when first encountered, the patient’s CUPS would have been U as he had compromised breathing as demonstrated by his change in mental state, body position and muscle tone and pale skin color. At this time, both his skin color and mental state are improving, although he continues to have respiratory distress, therefore his status is P. Treatment now is to obtain a focused history, repeat the initial assessment, looking for further signs of improvement, and continued high concentration oxygen.

121. Using the SAMPLE format, you find the following S Signs and symptoms of respiratory distress A Allergies: Child says only to girls M Medications: Child doesn’t know P Past Medical Problems: Unknown L Last food was a bag lunch from home E Events: He went on a scary spinning ride and rode a pony before he got sick. The child is unable to provide past medical history, however, he gives some information about the events leading up to his respiratory distress.. Ask the class to discuss possibilities for the cause of the problem. Environment Was he allergic to the pony or come into contact with an unknown allergen? Stress: Did the “scary” spinning ride provoke the problem by inducing a stressful situation from which he could not immediately escape? Without more information, it is impossible to declare absolutely the cause of this problem, however, discuss with the class that the course of treatment would be the same, despite the cause, because the treatment decisions were based upon the child’s condition. The child is unable to provide past medical history, however, he gives some information about the events leading up to his respiratory distress.. Ask the class to discuss possibilities for the cause of the problem. Environment Was he allergic to the pony or come into contact with an unknown allergen? Stress: Did the “scary” spinning ride provoke the problem by inducing a stressful situation from which he could not immediately escape? Without more information, it is impossible to declare absolutely the cause of this problem, however, discuss with the class that the course of treatment would be the same, despite the cause, because the treatment decisions were based upon the child’s condition.

129. What are Common signs & symptoms of Asthma? Coughing (day, night, or with exercise) Difficulty breathing/Shortness of breath Wheezing (a whistling noise) Chest tightness Trouble sleeping/ waking at night Not able to exercise or have normal activity Low peak flow meter reading