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Obstetrics & Pediatrics: Infants & Children

Level 2

Infants and Children EMT Refresher Course EMSNeeds.com Continuing Education

Overview | Assessment | Treatment | Roles

Objectives

Infants and Children EMT Refresher Course

In this Infants and Children course you will earn 2 CE hours. This course is accredited for all levels since all EMS personnel are technically First Responders.

At the end of this course you will be able to:

  • Describe assessment of the infant or child.
  • Indicate various causes of respiratory emergencies in infants and children.
  • Summarize emergency medical care strategies for respiratory distress and respiratory failure/arrest in infants and children.
  • List common causes of seizures in the infant and child patient.
  • Describe management of seizures in the infant and child patient.
  • Summarize the signs and symptoms of possible child abuse and neglect.
  • Describe the medical - legal responsibilities in suspected child abuse.
  • Recognize need for First Responder debriefing following a difficult infant or child.

References for content used by permission are on the left side under "EMS Resources." A technical :word: when clicked instantly accesses the EMS glossary online.

There are four sections: Overview, Assessment, Treatment, and Roles. Take the section tests in order by clicking the Take Test button. Your results are saved if you are interrupted. Then do the next section—no lost time or effort with mini-test sections!

EMS Course Levels
Overview

Infant and child patients often cause anxiety for the First Responder. This may be due to a lack of encountering this age group on emergencies. Anohter reason is fear of failure. Understanding the special considerations in dealing with pediatric patients is important in their emergency medical care.

Common problems in infants and children are airway obstruction, respiratory emergencies, and circulatory failure. These little ones are not little adults. Infants and children have specialized needs.

  • Head: The head of an infant is proportionally larger and more easily injured. The single most important maneuver is to ensure an open airway by means of the jaw thrust.
  • Chest: Children have very soft pliable ribs. There may be significant injuries without external signs.
  • Abdomen: The abdomen is a more common site of injury in children than adults and is often a source of hidden injury.
Newborn

Definitions

  • Child Abuse - improper or excessive action so as to injure or cause harm
  • Child Neglect - giving insufficient attention or respect to someone who has a claim to that attention.
  • Cyanosis - bluish color of the skin due to lack of oxygen
  • Intercostal retraction - respiratory difficulty showing between the ribs,
  • Supraclavicular - respiratory difficulty indicated by the neck muscles,
  • Subcostal retractions - respiratory difficulty below the margin ofthe rib.
  • Stridor - high pitched inspiratory sound.
Emergency Stop
Assessment

Approach to Evaluation

  1. Begin assessment from across the room.
  2. Be sure to involve the parents in your assessment and management of infants and children.
    • Agitated parents = agitated child
    • Calm parents = calm child
  3. Observe for mechanism of injury.
  4. Assess the surroundings.
  5. Assess respiration. Small airways are easily blocked by secretions and airway swelling. The tongue is large relative to small mandible and can block airway in an unresponsive infant or child. Check for these:

    • Chest expansion/symmetry.
    • Effort of breathing.
    • Nasal flaring.
    • Stridor (high pitched inspiratory sound), crowing, or noisy.
    • Retractions.
    • Grunting.
    • Respiratory rate.

Positioning the airway is different in infants and children. Do not hyperextend the neck. Infants are nose breathers, so suctioning a secretion-filled nasopharynx can improve breathing problems in an infant.

  • Children can compensate well for short periods of time for respiratory problems and shock.
  • Compensate by increasing breathing rate and increasing their effort of breathing.
  • Compensation is followed rapidly by decompensation due to rapid respiratory muscle fatigue and general fatigue.
  • There is a risk of hypothermia because of their smaller body mass; therefore, keep them warm.

General Impressions

Overall appearance of a well versus sick child depends on several factors:

  1. Mental status.
  2. Effort of breathing.
  3. Color.
  4. Quality of cry/speech.
  5. Interaction with environment and parents:
    • Normal behavior for child of this age is playing and moving around.
    • Assess attentive versus non-attentive by watching eye contact, recognition of parents, and responding to parents calling.
  6. Emotional state (crying, upset, scared).
  7. Response to the First Responder.
  8. Tone/body position.

Hands-on Approach

  1. Palpate brachial or femoral pulse.
  2. Compare central and distal pulses.
  3. Assess skin color, temperature, and condition.
  4. Check extremity injuries and manually stabilize them.
  5. Assure airway position and patency. Use jaw thrust. Suction as necessary with large bore suction catheter.
  6. Provide spinal stabilization.

Child Abuse and Neglect

Child abuse is defined as improper or excessive action so as to injure or cause harm, while child neglect is giving insufficient attention or respect to someone who has a claim to that attention. The First Responder must be aware of condition to be able to recognize the problem.

Physical abuse and neglect are the two forms of child abuse that the First Responder is likely to suspect. Some signs and symptoms of abuse are listed below:

  • Multiple bruises in various stages of healing.
  • Injury inconsistent with mechanism described.
  • Patterns of injury such as cigarette burns, whip marks, and hand prints.
  • Repeated calls to the same address.
  • Fresh burns, not just any burns, but those cause by scalding or a glove, dip pattern, or burns inconsistent with the history presented, or untreated burns.
  • Parents seem inappropriately unconcerned.
  • Conflicting stories.
  • Fear on the part of the child to discuss how the injury occurred.
  • CNS injuries - shaken baby syndrome with symptoms:
    • Unresponsive/seizure
    • Severe internal injuries
    • No evidence of external injuries

Signs and symptoms of neglect are often obvious:

  • Lack of adult supervision.
  • Children appearing malnourished
  • Unsafe living environment.
  • Untreated chronic illnesses such as asthma with no medications.
  • Untreated soft tissue injuries.

Airway Obstructions

Partial airway obstruction is evident in an infant or child who is alert and sitting. Listen and observe for these signs:

  • Stridor (high pitched inspiratory sound), crowing, or noisy.
  • Retractions on inspiration.
  • Pink.
  • Good peripheral perfusion.
  • Still alert, not unresponsive.

Complete obstruction and altered mental status or cyanosis and partial obstruction is evident when there is no crying or speaking where:

  • Child's cough becomes ineffective.
  • Increased respiratory difficulty is accompanied by stridor (high pitched inspiratory sound).
  • Patient loses responsiveness.
  • Altered mental status.

Respiratory Emergencies

Respiratory distress precedes respiratory failure and is indicated by any of the following:

  • Respiratory rate >60 in infants.
  • Respiratory rate > 30/40 in children.
  • Nasal flaring.
  • Intercostal retraction (between the ribs), supraclavicular (neck muscles), subcostal retractions (below the margin of
    the rib).
  • Stridor (high pitched inspiratory sound).
  • Cyanosis.
  • Altered mental status (combative, decreased mental status, unresponsive).
  • Grunting.

Respiratory Failure/Arrest

  • Breathing rate less than 10 per minute in a child.
  • Breathing rate of less than 20 per minute in an infant.
  • Limp muscle tone.
  • Unresponsive.
  • Slower, absent heart rate.
  • Weak or absent distal pulses.
  • Cyanosis and a slow heart rate.

Circulatory Failure

Circulatory failure that is uncorrected is also a common cause of cardiac arrest in infants and children. Signs and symptoms of circulatory failure are below:

  • Increased heart rate.
  • Unequal central and distal pulses.
  • Poor skin perfusion.
  • Mental status changes.

Seizures

Seizures, including seizures caused by fever (febrile), should be considered potentially life-threatening and may be brief or prolonged. Assess for injuries which may have occurred during seizures.

A variety of conditions cause seizures such as:

  • Fever.
  • Infections.
  • Poisoning.
  • Low blood sugar.
  • Trauma.
  • Decreased levels of oxygen.
  • Unknown cause.

To gather more information about the history of seizures, ask the following questions:

  1. Has the child had prior seizure(s)?
  2. If yes, is this the child's normal seizure pattern?
  3. Is the child on a seizure medications?
  4. Could the child have ingested any other medications?

Sudden Infant Death Syndrome (SIDS)

Signs and symptoms of sudden death of infants occurs in the first year of life. Many causes are not clearly understood. The baby is most commonly discovered in the early morning.

Trauma

Injuries are the leading cause of death in infants and children. There are several types of injuries that cause trauma:

  • Blunt Injury is most common, but the pattern of injury may be different from adults. Motor vehicle crashes cause trauma. Unrestrained passengers have head and neck injuries. Restrained passengers have abdominal and lower spine injuries. Why? Infant and booster seats are often improperly fastened, resulting in head and neck injuries. If a child is struck by a a car or truck while riding bicycle, head injury, spinal injury, abdominal injury may result. For pedestrians struck by a vehicle, the most common injury is abdominal with internal bleeding, possibly painful, swollen, deformed thigh and head injury.
  • Falls from heights or diving into shallow water cause head and neck injuries.
  • Burn Injury (See separate course on this topic.)
  • Sports Injuries (head and neck) occur more often in school settings.
  • Abuse and Neglect trauma may be hidden but overt signs and symptoms often reveal the emotional and physical damage.

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surroundings

 

 

 

 

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hands-on approach

 

 

 

 

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pink

 

 

 

well vs sick

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

respiratory

 

 

accident

Treatment

Before beginning treatment, complete a scene size-up before initiating emergency medical care. After completing an initial assessment on all patients:

  1. Comfort, calm, and reassure the parents while awaiting additional EMS resources.
  2. Try to resuscitate unless the baby is stiff.
  3. Assure patency of airway.
  4. Be prepared to artificially ventilate/suction.
  5. Avoid any comments that might suggest blame to the parents. Parents will be in agony from emotional distress, remorse, and guilt.
  6. Place in recovery position.
  7. Protect the patient from the environment.
  8. Ask bystanders (except parents) to leave the area.
  9. Place patient in the recovery position if no possibility of spine trauma.
  10. Never restrain the patient.
  11. Do not put anything in the patient's mouth.
  12. Have suction available.
  13. If the patient is bluish, assure airway and artificially ventilate.
  14. Report assessment findings to additional EMS resources.

The position to open an airway is different in children and infants.

  1. Use the head-tilt chin-lift.
  2. Do not hyperextend.
  3. Place a folded towel under the shoulders to assist in maintaining position.
  4. Use the jaw thrust with spinal stabilization.
  5. Apply suctioning with appropriate bulb syringe sizing, depth, and techniques.

Clearing complete obstructions: Follow the American Heart Association Guidelines of Foreign Body airway Obstructions for Infants and Children.

Airway Adjuncts

In oral airways, airway adjuncts are not for initial artificial ventilation. The patient should not have a gag reflex. To determine sizing, measure from the corner of the mouth to the tip of the ear. Nasal airways are usually not used in children by First Responders.

Techniques of insertion using a tongue depressor:

  1. Insert tongue blade to the base of tongue.
  2. Push down against the base of tongue while lifting upward.
  3. Insert oropharyngeal airway following the anatomic curve (upright) without rotation.

Relationship to Airway Module

Often seizure patients will have significant oral secretions. Place these patients in the recovery position when the convulsions have ended. Patients who are actively seizing, bluish, and breathing inadequately should be ventilated, if possible. Altered mental Status is caused by a variety of conditions:

  • Low blood sugar
  • Poisoning
  • Post seizure
  • Infection
  • Head trauma
  • Decreased oxygen levels

Emergency Medical Care

  • Allow a position of comfort; assist younger child to sit up; do not lay down. They may sit on parent's lap.
  • Do not agitate the child.
  • Clear airway by using iInfant foreign body procedures or child foreign body procedures.
  • Attempt artificial ventilations with mouth-to-mask technique.

checkup

 

 


Roles and Responsibilities

The First Responder must have an understanding of the unique aspects of dealing with infants and children. In addition, the First Responder must realize the aspect of having multiple patients. A child cannot be cared for isolated from the family. A calm, professional, reassuring First Responder may help to minimize psychological impact of transport to parent and child.

  1. Complete the First Responder assessment that includes a scene size-up before initiating emergency medical care.
  2. Complete an initial assessment on all patients.
  3. Complete a physical exam as needed.
  4. Complete on-going assessments.
  5. Comfort, calm, and reassure the patient while awaiting additional EMS resources.
  6. Support oxygenation and ventilation.
  7. Observe heart rate and check for signs of cardiac arrest, seizure, etc. and describe.

If you suspect child abuse or neglect, do not accuse in the field. Accusation and confrontation delays transportation. Instead:

  • Report objective information to the transporting unit. Reports are required by state law.
  • Comply with local regulations.
  • Remain objective.
  • Report what you see and what you hear.
  • Do not comment on what you think.

There may be a definite need for First Responder Debriefing, especially in cases of abuse and neglect or serious injury/death of a child.

scene size-up


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