32: Pediatric Assessment and Management

Cognitive Objectives (1 of 3)

6-1.4 Indicate various causes of respiratory

emergencies.
6-1.5 Differentiate between respiratory distress and
respiratory failure.
6-1.6 List steps in the management of foreign body
airway obstruction.
 Cognitive Objectives (2 of 3)

6-1.7 Summarize EMS care strategies for

respiratory distress and respiratory failure.
6-1.8 Identify the signs and symptoms of shock
(hypoperfusion) in the infant and child patient.
6-1.9 Describe the methods of determining end
organ perfusion in the infant and child patient.
6-1.10 State the usual cause of cardiac arrest in
infants and children versus adults.
 Cognitive Objectives (3 of 3)
6-1.12 Describe the management of seizures in the
infant and child patient.
6-1.14 Discuss the field management of the infant
and child trauma patient.

• There are no affective objectives for this chapter.

 Psychomotor Objectives (1 of 2)
6-1.21 Demonstrate the techniques of foreign body
airway obstruction removal in the infant.
6-1.22 Demonstrate the techniques of foreign body
airway obstruction removal in the child.
6-1.23 Demonstrate the assessment of the infant
and child.
 Psychomotor Objectives (2 of 2)
6-1.24 Demonstrate bag-valve-mask artificial
ventilations for the infant.
6-1.25 Demonstrate bag-valve-mask artificial
ventilations for the child.
6-1.26 Demonstrate oxygen delivery for the infant
and child.
 Additional Objectives*
Cognitive
1. Describe the steps in positioning an infant and/or child
to maintain an open airway.
2. Summarize neonatal resuscitation procedures.
Affective
None
Psychomotor
3. Demonstrate the techniques necessary in neonatal
resuscitation.
*These are noncurriculum objectives.
 Pediatric Assessment
and Management
• Caring for sick and injured children presents
special challenges.
• EMT-Bs may find themselves anxious when
dealing with critically ill or injured children.
• Treatment is the same as that for adults in most
emergency situations.
 Scene Size-up

• Take note of your surroundings.

• Scene assessment will supplement additional
findings.
• Observe:
– Position of the patient
– Condition of the home
– Clues to child abuse
 Initial Assessment

• Begins before you touch the

patient
• Form a general impression.
• Determine a chief complaint.
• The Pediatric Assessment
Triangle can help.
 Pediatric Assessment Triangle
• Appearance
– Awake
– Aware
– Upright
• Work of breathing
– Retractions
– Noises
• Skin circulation
 Assessing the ABCs
• Ensure airway is open and
position patient.
• Breathing assessment
– Effort
– Obstructions
– Rate
• Circulation assessment
– Rate
– Skin color, temperature,
and capillary refill
 Transport Decision
• Children under 40 lb should be transported in a
child safety seat, if the situation allows.
• Seat should be secured to the cot or captain’s
chair.
• Cannot be secured to bench seat
• Child may have to be transported without a seat,
depending on condition.
 Focused History and Physical Exam

• Should be completed on scene unless severity

requires rapid transport
• Young children should be examined toe to head.
• Focused exam on noncritical patients
• Rapid exam on potentially critical patients
 Vital Signs by Age
Age Respirations Pulse Systolic Blood
(breaths/min) (beats/min) Pressure
(mm Hg)
Newborn: 0 to 1 mo 30 to 60 90 to 180 50 to 70

Infant: 1 mo to 1 yr 25 to 50 100 to 160 70 to 95

Toddler: 1 to 3 yr 20 to 30 90 to 150 80 to 100

Preschool age: 3 to 6 yr 20 to 25 80 to 140 80 to 100

School age: 6 to 12 yr 15 to 20 70 to 120 80 to 110

Adolescent: 12 to 18 yr 12 to 16 60 to 100 90 to 110

Older than 18 yr 12 to 20 60 to 100 90 to 140

 Respirations
• Abnormal respirations are a common sign
of illness or injury.
• Count respirations for 30 seconds.
• In children less than 3 years, count the rise
and fall of the abdomen.
• Note effort of breathing.
• Listen for noises.
 Pulse
• In infants, feel over the brachial or femoral area.
• In older children, use the carotid artery.
• Count for at least 1 minute.
• Note strength of the pulse.
 Blood Pressure
• Use a cuff that covers two thirds of the
upper arm.
• If scene conditions make it difficult to
measure blood pressure accurately,
do not waste time trying.
 Skin Signs
• Feel for
temperature and
moisture.
• Estimate capillary
refill.
 Detailed Physical Exam
and Ongoing Assessment

• Status changes frequently in children.

• The PAT can help with reassessment.
• Repeat vital signs frequently.
• If child deteriorates, repeat the initial assessment.
 Care of the Pediatric Airway (1 of 2)
• Position the airway.
• Position the airway in a neutral sniffing position.
• If spinal injury is suspected, use jaw-thrust
maneuver to open the airway.
 Care of the Pediatric Airway (2 of 2)
• Positioning the airway:
– Place the patient on a
firm surface.
– Fold a small towel
under the patient’s
shoulders and back.
– Place tape across
patient’s forehead to
limit head rolling.
 Oropharyngeal Airways
• Determine the appropriately
sized airway.
• Place the airway next to the
face to confirm correct size.
• Position the airway.
• Open the mouth.
• Insert the airway until flange
rests against lips.
• Reassess airway.
 Nasopharyngeal Airways (1 of 2)
• Determine the appropriately
sized airway.
• Place the airway next to the
face to make certain length
is correct.
• Position the airway.
• Lubricate the airway.
 Nasopharyngeal Airways (2 of 2)
• Insert the tip into the
right naris.
• Carefully move the tip
forward until the flange
rests against the
outside of the nostril.
• Reassess the airway.
 Assessing Ventilation
• Observe chest rise in older children.
• Observe abdominal rise and fall in younger
children or infants.
• Skin color indicates amount of oxygen getting
to organs.
 Oxygen Delivery Devices
• Nonrebreathing mask at 10 to
12 L/min provides 90% oxygen
concentration.
• Blow-by technique at 6 L/min
provides more than 21%
oxygen concentration.
• Nasal cannula at 4 to 6 L/min
provides 24% to 44% oxygen
concentration.
 BVM Devices
• Equipment must be the right size.
• BVM device at 10 to 15 L/min provides 90%
oxygen concentration.
• Ventilate at the proper rate and volume.
• May be used by one or two rescuers
 One-rescuer BVM Ventilation
A B

C D
 Airway Obstruction
• Croup
– A viral infection of the airway below the level of
the vocal cords
• Epiglottitis
– Infection of the soft tissue in the area above the
vocal cords
• Foreign body airway obstructions
 Signs and Symptoms
• Decreased or absent breath
sounds
• Stridor
• Retractions
• Difficulty speaking
 Signs of Complete
Airway Obstruction
• Signs and symptoms
– Ineffective cough (no sound)
– Inability to cry
– Increasing respiratory difficulty, with stridor
– Cyanosis
– Loss of consciousness
Removing a Foreign Body Airway
Obstruction (1 of 5)
• In an unconscious child:
– Place the child on a firm, flat surface.
– Inspect the upper airway and remove any
visible object.
– Attempt rescue breathing.
– If ventilation is still unsuccessful, position
hands on the abdomen.
 Removing a Foreign Body Airway
Obstruction (2 of 5)
• Give five abdominal thrusts.
• Open airway again to try and
see object.
• Only try to remove object if
you see it.
• Attempt rescue breathing.
 Removing a Foreign Body Airway
Obstruction (3 of 5)
• If unsuccessful, reposition
head and attempt
ventilation again.
• Repeat abdominal thrusts if
obstruction persists.
Removing a Foreign Body Airway
Obstruction (4 of 5)
• In a conscious child:
– Kneel behind the
child.
– Give the child five
abdominal thrusts.
– Repeat the technique
until object comes out.
 Removing a Foreign Body Airway
Obstruction (5 of 5)
• If the child becomes
unconscious, inspect the
airway.
• Attempt rescue
breathing.
• If airway remains
obstructed, repeat
thrusts.
 Management of Airway
Obstruction in Infants
• Hold the infant facedown.
• Deliver five back blows.
• Bring infant upright on the thigh.
• Give five quick chest thrusts.
• Check airway.
• Repeat cycle as often as
necessary.
Neonatal Resuscitation
• Resuscitation measures include:
– Positioning airway
– Drying
– Warming
– Suctioning
– Tactile stimulation
Neonatal Equipment
 Additional Efforts
• Deliver chest compressions
at 120 per minute.
• Coordinate chest
compressions with
ventilations at a ratio of 3:1.
• If meconium is present,
suction infant vigorously.
 BLS Review
• Cardiac arrest in children is commonly due to
respiratory arrest.
• Many causes of respiratory arrest
• For purposes of pediatric BLS:
– Infancy ends at 1 year of age.
– Childhood extends to 8 years of age.
– Children older than 8 years of age are
treated as adults.
 Determine Responsiveness
• Gently tap on shoulder and speak loudly.
• If responsive, place in position of comfort.
• If you find an unresponsive child when you are not
on duty:
– Provide BLS for about 1 minute.
– Call EMS system.
 Airway
• Airway may be obstructed by tongue.
• Use head tilt-chin lift technique or jaw-thrust
maneuver to open the airway.
• Jaw-thrust maneuver is safer if possibility of
neck injury exists.
 Breathing
• Look, listen, and feel.
• Provide rescue
breathing if needed.
• Perform Sellick
maneuver to prevent
gastric distention.
 Circulation
• Assess circulation after airway is open and two
rescue breaths have been given.
• Check for pulses.
• Evaluate for other signs of circulation.
• Do not spend more than 10 seconds trying to find a
pulse.
 Infant CPR (1 of 2)
• Place infant on firm
surface and maintain
airway.
• Place two fingers in the
middle of the sternum.
• Use two fingers to
compress the chest about
1/2" to 1" at a rate of
100/min.
 Infant CPR (2 of 2)
• Allow sternum to return briefly to its normal
position between compressions.
• Coordinate rapid compressions and
ventilations in a 5:1 ratio.
• Reassess the infant for return of breathing and
pulse after 1 minute, then every few minutes.
 Child CPR (1 of 2)
• Place child on firm
surface and maintain
airway with one hand.
• Place heel of other
hand over lower half of
the sternum.
– Avoid the xiphoid
process.
• Compress chest about
1" to 1 1/2" at a rate of
100/min.
 Child CPR (2 of 2)
• Coordinate compressions with ventilations in
a 5:1 ratio, pausing for ventilations.
• Reassess for breathing and pulse after about
1 minute and then every few minutes.
• If the child resumes effective breathing, place
child in recovery position.
 AED Use in Children
• Children over 8 should use the adult AED protocol.
• Children ages 1-8:
– 1 minute of CPR before AED
– Use AED with pediatric capabilities.
– Adult AED may be used in local protocols.
• Do not use on an infant under 1 year old.
 Trauma (1 of 2)

Extremity injuries in children are generally managed

in the same manner as those in adults.
 Trauma (2 of 2)
• Be alert for airway problems on all children with
traumatic injuries.
• Give supplemental oxygen to all children with
possible:
– Head injuries
– Chest injuries
– Abdominal injuries
– Shock
• If ventilation is required, provide at 20 breaths/min.
 Immobilization
• Any child with a head or back injury should
be immobilized.
• Young children may need padding beneath
their torso.
• Children may need padding along the sides
of the backboard.
 Immobilization in a Child Safety
Seat
• Assess child for injuries and
seat for visible damage.
• If child is injured or seat is
damaged, remove child to
another transport device
• Apply padding around child to
minimize movement.
• Move seat to ambulance and
secure according to the
manufacturer’s instructions.
 Removing a Child from
a Child Safety Seat
• Remove both the child and the seat from the
vehicle.
• Place immobilization device behind the child.
• Slide child into place on device.
 Signs and Symptoms
of Respiratory Emergencies
• Nasal flaring
• Grunting respirations
• Use of accessory muscles
• Retractions of rib cage
• Tripod position in older children
 Emergency Care
• Provide supplemental oxygen in the most
comfortable manner.
• Place child in position of comfort.
– This may be in caregiver’s lap.
• If patient is in respiratory failure, begin
assisted ventilation immediately.
– Continue to provide supplemental
oxygen.
 Shock
• Circulatory system is unable to deliver sufficient
blood to organs.
• Many different causes
• Patients may have increased heart rate,
respirations, and pale or mottled skin.
• Children do not show decreased blood pressure
until shock is severe.
 Assessing Circulation
• Pulse: Above 160 beats/min suggests shock
• Skin signs: Assess temperature and
moisture
• Capillary refill: Is it delayed?
• Color: Is skin pink, pale, ashen, or mottled?
 Emergency Medical Care
for Shock
• Ensure airway.
• Give supplemental oxygen.
• Provide immediate transport.
• Continue monitoring vital signs
en route.
• Contact ALS for backup as
needed.
 Seizures
• May present in several different ways
• A postictal period of extreme fatigue or
unresponsiveness usually follows seizure.
• Be alert to presence of medications, poisons,
and possible abuse.
 Febrile Seizures
• Febrile seizures are most common in children
from 6 months to 6 years.
• Febrile seizures are caused by fever.
• Generally last less than 15 minutes
• Assess ABCs and begin cooling measures.
• Provide prompt transport.
 Emergency Medical Care
of Seizures (1 of 2)
• Perform initial assessment, focusing on the
ABCs.
• Securing and protecting the airway is the
priority.
• Place patient in the recovery position.
• Be ready to suction.
 Emergency Medical Care
of Seizures (2 of 2)
• Deliver oxygen by mask, blow-by, or nasal cannula.
• Begin BVM ventilation if no signs of improvement.
• Call ALS for backup if appropriate.
 Dehydration
• Determine if child is vomiting or has diarrhea
and for how long.
• “How many wet diapers has the child had
during the day?” (6 to 10 is normal)
• “What fluids are the child taking?”
• “What was the child’s weight before the
symptoms started?”
• “Has the child been normally active?”
Emergency Medical Care
for Dehydration
• Assess the ABCs.
• Obtain baseline vital signs.
• ALS backup may be needed for IV
administration.