Infants and Children

1. Infants and Children Lesson 17

2. Introduction 5-10% of emergency responses involve children Children may be unable to tell you what happened Size/anatomical difference make care different

3. Interacting with Infants, Children, and Caretakers Prevent anxiety/panic in child/caretakers Tell child your name; say you are there to help Be especially sensitive to child�s feelings Ensure a parent/caretaker has been called

4. Interacting with Infants, Children, and Caretakers Stay at child�s level, be friendly and calm Observe child for clues about how best to be reassuring Always be honest with child/caretakers Keep patient and caretakers informed

5. Interacting with Infants, Children, and Caretakers Don�t separate child from caretaker Approach slowly from a safe distance Talk with both the caretaker and the child Observe the child/caretaker before touching the child Remain calm

6. Infants/children are not small adults Differences from adult anatomy/ physiology in most body areas Differences in Anatomy and Physiology

7. Head and Neck Smaller airway easily blocked Tongue relatively larger, can easily block airway When opening airway , don�t hyperextend neck Suctioning secretions from nose can improve breathing problems Head of infant/young child relatively larger/heavier �Soft spots� (fontanels) put head at greater risk 

8. Chest and Abdomen Children compensate for respiratory problems/shock for short periods Compensation followed by rapid decompensation Use of accessory muscles a clear sign of breathing problem

9. Chest and Abdomen More susceptible to hypothermia Blood loss may be fatal More easily dehydrated (diarrhea/vomiting) Internal injuries are more likely with trauma

10. Extremities Bones easily fractured by trauma

11. Assessing Infants and Children Assessment uses same steps as for adults Correct problems threatening airway, breathing, or circulation as soon as found Assessment varies based on age/nature of problem

12. Scene Size-Up Begin by observing scene Note how child/caretakers interact Gather information from caretakers Observe the environment

13. General Impression You can often tell how ill/severely injured child is from a distance Appearance Skin color Body position Eyes

14. General Impression Mental status Quality of crying or speaking Emotional state Behavior Respondse to caretakers How attentive child is to you The child�s effort of breathing may be obvious

15. Initial Assessment Initial assessment follows same steps as adult

16. Airway, Breathing, Circulation

17. Airway Don�t hyperextend neck when using head tilt�chin lift Put folded towel under shoulders for better positioning of airway

18. Airway Look inside mouth for obstructing object Use the jaw-thrust technique for a trauma patient Suction airway if needed

19. Breathing With airway opened, check by looking, listening, and feeling If not breathing, provide ventilations and check pulse

20. Breathing If breathing, assess breathing adequacy: Respiratory rate Chest expansion and symmetry of movement

21. Breathing If breathing, assess breathing adequacy: Effort of breathing: nasal flaring, retractions, grunting Abnormal sounds: stridor, crowing

22. Circulation Check pulse Begin CPR if pulse =60 beats/minute Compare central/peripheral pulses Assess skin color, temperature, and condition

23. Circulation continued Reduced circulation indicated by: Pale, ashen, or cyanotic skin color Cool, clammy skin Capillary refill time = two seconds Control external bleeding with direct pressure

24. History and Physical Examination Maintain spinal immobilization in trauma/unresponsive patient Support head when moving infant Gather assessment information Communicate at level with child, gather information from caretakers

25. History and Physical Examination Examine from toe to head Vital signs normally different from adults Changes occur quickly Assess anterior fontanel on top of skull

26. Normal Vital Signs

27. Airway Management Opening airway Suctioning Use of airway adjuncts

28. Suctioning Using gauze pad sweep mouth or suction Don�t insert tip of rigid catheter deeper than base of tongue For newborn, don�t suction longer than 3-5 seconds at a time With an older infant/child, don�t suction longer than 10 seconds at a time

29. Airway Adjuncts Use oral airway if no gag reflex Remove airway if child gags, coughs, etc. Oral airway not for initial ventilations Device keeps airway open Select size Nasal airways are not usually inserted in children by First Responders

30. Oral Airway Insertion Insert oral airway in upright position Do not rotate 180 � as for adult Open the child�s mouth Use tongue blade to press base of tongue down Insert airway in upright (anatomic) position If tongue blade not available, use index finger to press base of tongue down

31. Respiratory Emergencies

32. Respiratory Emergencies Airway obstructions Respiratory distress and arrest Respiratory infections Asthma

33. Signs and Symptoms of Mild Airway Obstructions Infant or child is alert and sitting Hear stridor, crowing, noisy breathing Retractions on inspiration Skin pink with good peripheral perfusion Strong pulse

34. Emergency Care of Mild Airway Obstructions Allow child to assume position of comfort Assist a younger child to sit up, not lie down Do not agitate child Encourage continued coughing Follow local protocol re: oxygen

35. Signs and Symptoms of Severe Airway Obstructions No crying or speaking Weak and ineffective cough Cyanosis Cough that becomes ineffective Increased respiratory difficulty and stridor Altered mental status; unresponsiveness

36. Emergency Care of Severe Airway Obstructions Attempt to clear airway Use alternating back slaps/chest compressions in responsive infant Use abdominal thrusts in responsive child Give CPR to unresponsive infant or child

37. Emergency Care of Severe Airway Obstructions continued Check for object in mouth before giving a breath Remove any object you see Never perform blind finger sweep Attempt artificial ventilations with mouth-to-mask technique

38. Respiratory Distress and Arrest Respiratory distress is difficulty breathing Respiratory distress frequently leads to respiratory arrest

39. Signs and Symptoms of Respiratory Distress Respiratory rate =60 breaths/minute in infants 30-40 breaths/minute in children Nasal flaring Intercostal, supraclavicular, subcostal retractions Stridor, grunting, or noisy breathing Cyanosis Altered mental status 

40. Emergency Care for Respiratory Distress Perform standard patient care Allow child to assume position of comfort Ensure appropriate position of head/neck Follow local protocol re: oxygen

41. Blow-By Oxygen Responsive infant/child may resist mask on his/her face Use the blow-by oxygen delivery technique

42. Signs and Symptoms of Respiratory Arrest Breathing rate = 20 breaths/minute in an infant =10 breaths/minute in a child Limp muscle tone Unresponsiveness Slow or absent pulse Weak or absent distal pulses Cyanosis

43. Emergency Care for Respiratory Arrest Perform standard patient care Provide ventilations by mouth or mask Follow local protocol re: oxygen Monitor pulse and provide CPR if needed

44. Respiratory Infections Common in childhood Range from minor to life threatening May affect upper or lower airways Result from infection, foreign bodies, allergic conditions

45. Signs and Symptoms of Respiratory Problems Rapid breathing Noisy breathing Retractions Mental status changes

46. Croup Viral infection of upper/lower airway Frequently occurs in winter months and in evening More common in younger children Often preceded by being ill 1 � 2 days with/ without fever Generally not life-threatening

47. Signs and Symptoms of Croup Hoarseness Stridor A "barking" cough Difficulty breathing

48. Emergency Care for Croup Perform standard patient care Difficult to distinguish from life-threatening epiglottitis If croup persistent, child should see physician Give care for respiratory distress Follow local protocol re: humidified oxygen

49. Epiglottitis Rare, life-threatening infection of epiglottis Epiglottis swells and airway completely obstructed Occurs more frequently in children =4 years of age 

50. Signs and Symptoms of Epiglottitis Child appears ill and frightened High fever Child is sitting up to breathe Saliva may drool from the child�s mouth

51. Emergency Care for Epiglottitis Perform standard patient care Don�t examine mouth or place OPA Allow child to remain in comfortable position Give care for respiratory distress Follow local protocol re: oxygen Ensure immediate transport

52. Bronchiolitis Common cause of respiratory distress in young children Also called RSV (respiratory syncytial virus) Viral infection of smaller airways causing respiratory distress/occasional hypoxia

53. Signs and Symptoms of Bronchiolitis Fever Nasal congestion Increased work of breathing with retractions/use of accessory muscles Markedly abnormal lung sounds with crackles/wheezes together May be cyanotic

54. Emergency Care for Bronchiolitis Perform standard patient care Give care for respiratory distress Follow local protocol re: humidified oxygen If patient has asthma medication inhaler, follow local protocol

55. Asthma Common medical problem in children Causes periodic attacks of difficulty breathing Results from an abnormal spasm of lower airways Attacks range from minor to life-threatening

56. Signs and Symptoms of Asthma Attack Difficulty breathing, rapid irregular breathing Coughing, wheezing Exhaustion In severe attack: Altered mental status Cyanosis

57. Emergency Care for Asthma Attack Perform standard patient care Give care for respiratory distress Follow local protocol re: humidified oxygen If patient has asthma medication inhaler, follow local protocol

58. Shock

59. Shock Commonly occurs from bleeding, traumatic injury, and fluid loss from prolonged vomiting/diarrhea May occur rapidly and quickly become life-threatening May be delayed in children Common cause of cardiac arrest in infants/ children

60. Signs and Symptoms Of Shock Rapid (early) or slow (late) weak pulse Unequal central and peripheral pulses Poor skin perfusion, delayed capillary refill Cool, clammy, pale skin Altered mental status 

61. Emergency Care for Shock Perform standard patient care Follow local protocol re: oxygen Monitor pulse carefully and provide CPR if needed Raise the legs if spinal/traumatic injury not suspected Keep the patient warm but not overheated Monitor vital signs frequently while awaiting EMS

62. Seizures

63. Causes of Seizures High fever Epilepsy Infections Head injuries Poisoning Low oxygen levels Low blood sugar Other causes

64. Seizures Potentially life threatening You don�t need to know cause to give care Febrile seizures common in children = 5 years Most will be over by the time you arrive at the scene After a seizure (except a febrile seizure), child appears sleepy/confused

65. Assessing Seizures Perform standard assessment Assess for injuries that may occur Gather the history from caretakers: Has the child had prior seizure(s)? Is this child's usual seizure pattern? How long did it last? Does child take seizure medication? Could child have ingested any other medication/potential toxins?

66. Signs and Symptoms of Seizures Altered mental status Muscle twitching, convulsions, rigid extremities May be brief or prolonged Loss of bowel and bladder control

67. Emergency Care for Seizures Perform standard patient care Protect patient from environment Loosen any constricting clothing Ask bystanders (except caretakers) to leave Assure airway remains open Never restrain patient Don�t put anything in mouth

68. Emergency Care for Seizures continued If patient is bluish, ensure airway is open/give ventilations After seizure, place an unresponsive patient in recovery position Be prepared to suction to maintain airway Follow local protocol re: oxygen Report assessment findings to additional EMS personnel

69. Altered Mental Status

70. Causes of Altered Mental Status Low blood sugar Poisoning Seizures Infection Head trauma Any condition that causes decreased oxygen levels

71. Assessing Altered Mental Status Perform standard assessment Ask caretakers about any history of diabetes, seizures, or recent trauma Monitor patient�s vital signs

72. Signs and Symptoms of Altered Mental Status in an Infant Or Child Drowsiness Confusion, agitation Behavior described as unusual by caretakers

73. Emergency Care for Altered Mental Status Perform standard patient care Place unresponsive patient in recovery position Follow local protocol re: oxygen

74. Sudden Infant Death Syndrome (SIDS)

75. Sudden Infant Death Syndrome (SIDS) Unexpected/sudden death of normal/healthy infant during sleep Causes not well understood Leading cause of death between 1 week- 1 year of age in the U.S. Peak incidence occurs between 2 - 4 months of age

76. Sudden Infant Death Syndrome (SIDS) continued More common during winter months and in males Not due to external suffocation from blankets/ pillows Not related to child abuse or vomiting/ aspiration of stomach contents

77. Assessing SIDS Perform standard assessment In addition, ask caretakers about circumstances: When was infant put to bed? When was he/she last seen? What position was infant in when found? How did infant look when found? Was there anything unusual in environment? Infant�s general health recently?

78. Signs and Symptoms of SIDS Cardiac and respiratory arrest Skin cyanotic or mottled Most commonly discovered in early morning

79. Emergency Care for SIDS Perform standard patient care Take body substance isolation precautions Try to resuscitate the infant unless the body is stiff Lividity is normal, not sign of abuse Comfort, calm, and reassure the caretakers Avoid any comments that might suggest blame to caretakers

80. Trauma

81. Trauma Common emergency in childhood Leading cause of death in children Blunt trauma causes the most injuries Pattern of injury may be different from that in adults

82. Common Causes of Trauma Motor vehicle crashes Unrestrained infants/children have head/neck injuries Restrained infants/children have abdominal/lower spine injuries Infant/booster seats often improperly fastened

83. Common Causes of Trauma continued Being struck by a vehicle while riding a bicycle Being struck by a vehicle while walking Falls from a height or diving into shallow water Burns Sports injuries to head and neck Child abuse and neglect

84. Common Types of Injury Anatomical differences make certain types of injury more likely Abdominal injuries Extremity injuries Burns

85. Assessing Trauma Perform standard assessment Examine responsive child from toe to head Suspect certain types of injuries based on MOI Smaller amounts of blood loss can result in shock; signs of shock may occur later

86. Emergency Care for Trauma Perform standard patient care Use jaw thrust to open airway Use head tilt-chin lift if unsuccessful Suction airway as needed Manually stabilize head and neck 

87. Emergency Care for Trauma continued Manually stabilize extremity injuries Treat shock Follow local protocol re: oxygen Ensure transport as soon as possible

88. Child Abuse & Neglect

89. Suspected Child Abuse and Neglect Abuse: an intentional improper/excessive action injuring or causing harm May include psychological abuse and sexual abuse Neglect: failing to provide basic needs

90. Who Is Abused Any child, although some more likely to be abused Child abuser can come from any geographic, religious, ethnic, occupational, educational, or socioeconomic group Abuser is usually a caretaker or someone in role of parent Most abusers of children were themselves abused as children

91. Multiple bruises/ burns in various stages of healing Injury inconsistent with MOI described by caretakers Bite marks Signs and Symptoms of Abuse

92. Cigarette burns Whip marks Hand prints Injuries to genitals, inner thighs, or buttocks Rope burns Repeated calls to same address Suspicious patterns of injury or marks on skin:

93. Signs and Symptoms of Abuse continued Unusual burns Scalding A glove or dip pattern Burns inconsistent with history presented Untreated burns Caretakers inappropriately unconcerned Caretakers with uncontrollable anger

94. Signs and Symptoms of Abuse continued Conflicting storiesChild fearful to discuss how injury occurred Child�s obvious fear of caretaker Obvious or suspected fractures in child younger than 2 years of age More injuries than are usually seen in same age Injuries scattered on many areas of the body

95. Signs and Symptoms of Neglect Lack of adult supervision Child appears malnourished Clothing inappropriate for environment Unsafe living environment

96. Signs and Symptoms of Neglect continued Signs of drug/ alcohol abuse Untreated chronic illness (asthmatic with no medications) Untreated soft-tissue injuries Delayed call for help

97. Assessing Suspected Abuse or Neglect Perform standard assessment Obtain as much information as possible Document all information on patient report

98. Emergency Care When Abuse is Suspected Perform standard patient care Don�t accuse caretakers in the field Treat patient�s injuries appropriately Protect child from further abuse, if necessary Report objective information to EMS unit

99. Emergency Care When Abuse is Suspected continued Save evidence of physical/ sexual abuse File a report as required by state law and local protocol: Remain objective Report what you see/ hear Do not comment on what you think Maintain confidentiality about the call

100. Shaken Baby Syndrome Pattern of injury resulting when caretaker shakes infant Also occurs in young children Infant may have severe internal injuries, including brain or spinal injuries Infant may be unresponsive or experiencing seizures

101. Emergency Care for Shaken Baby Syndrome Perform standard patient care Manually stabilize the head and neck Follow local protocol re: oxygen Ensure transport as soon as possible

102. First Responder Stress Death/serious injury can cause strong emotional reactions/stress Stress likely in instances of serious child abuse or neglect Providing care while family members/ caretakers are very emotional is stressful

103. First Responder Stress Don�t react personally to others� emotions or behavior Realize that many patients may die regardless of care provided Talk with family/friends Seek professional help Critical Incident Stress Management programs are available