Alexander ch44 lecture

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Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 44
Pediatric Emergencies

• Applies a fundamental knowledge of growth,
development, aging, and assessment findings to
provide basic emergency care and transportation
for a patient with special needs.
Advanced EMT
Education Standard

1. Define key terms introduced in this chapter.
2. Discuss the leading reasons that pediatric patients
require medical attention.
3. Explain the special considerations in dealing with the
caregiver of a sick or injured child.
4. Describe the major anatomic, physiological, and
developmental characteristics of pediatric patients in
each of the following age groups: infant, toddler,
preschooler, school-age child, and adolescent.
Objectives (1 of 5)

5. Give examples of modifications of patient assessment
and management techniques that increase the likelihood
of cooperation by patients in each of the following age
groups: infant, toddler, preschooler, school-age child, and
adolescent.
6. Given a description of vital signs for pediatric patients of
various ages, classify the values as normal or abnormal.
7. Use the pediatric assessment triangle to determine a
pediatric patient’s status.
8. Recognize signs of respiratory distress, respiratory
failure, and respiratory arrest in pediatric patients.
Objectives (2 of 5)

9. Describe the presentation and assessment-based
prehospital management of conditions common to
pediatric patients.
10.Demonstrate emergency medical care techniques for
pediatric patients, including airway management, CPR,
fluid resuscitation, management of partial and complete
foreign body airway obstruction, medication
administration, oxygen administration, and ventilation.
11.Describe special considerations for scene size-up in
suspected SIDS.
Objectives (3 of 5)

12.Describe special considerations for assisting family
members in suspected SIDS.
13.Describe the importance of the presence of parents
during pediatric resuscitation.
14.Integrate consideration of a pediatric patient’s size and
anatomy into the assessment of mechanism of injury.
15.Demonstrate removal of a pediatric patient from a child
car seat.
16.Demonstrate proper spinal motion restriction of a
pediatric patient.
Objectives (4 of 5)

17.Recognize indications of child abuse and neglect.
18.Explain special considerations in managing situations in
which you suspect child abuse or neglect.
19.Discuss ways in which you can manage the stress that
can be associated with pediatric calls, both during and
after the calls.
Objectives (5 of 5)

Introduction
• Caring for critically ill or injured child can be
stressful experience for EMS providers.
• Take into account differing epidemiology of illness
and injury in children, and anatomic, physiological,
and psychosocial differences as you evaluate
presenting problem.

Think About It
• What criteria should Vic and Marcel use to
develop a general impression of the patient’s
condition?
• What questions should they ask of the parents?
• How should they proceed with the assessment of
an infant?

Figure 44-1
Anatomic and physiologic considerations in infants and children.

Pediatric Development Review (1 of 8)
• Infants
– 1 month of age to 1 year of age
– Body systems immature
– Liver large for size of abdomen; not well protected
– Abdominal wall thin
– Ribs pliable; transmits energy forces to organs
– Kidneys do not efficiently concentrate urine; increased
risk of dehydration
– Bones softer and less well formed

• Infants (continued)
– Skeletal muscle mass small; less strength, protection,
and heat production
– Head disproportionately large; neck weak
– Greater surface-area-to-volume ratio; increased heat
loss from body
– Prone to hypothermia; must be kept warm
– Airway obstruction can occur very easily; tongue takes
up larger portion of oral cavity
– Nose small and soft
– Lungs fragile and easily damaged

• Infants (continued)
– Respiratory failure/arrest occurs quickly
– Water vapor lost with every breath; leads to
dehydration
– Poor feeding, vomiting, diarrhea, fever can result in
significant dehydration
– Immune system immature; less able to fight infection
– Fever in infants always a concer
– Crying only way of communicating

• Toddlers and preschool children
– Toddler: child 1 to 3 years of age
– Preschoolers: child 3 to 6 years of age
– Head still proportionally large
– Airway small; can be obstructed easily
– Vulnerable to communicable diseases.
– Ear infections and upper and lower respiratory tract
infections common

• Toddlers and preschool children (continued)
– Croup, bronchiolitis, pneumonia, and epiglottitis can
lead to respiratory distress.
– Strangers can provoke anxiety at this age.
– Establish rapport, gain child’s trust, and communicate
in a way the child can understand.

• School-age children
– 6 through 12 years of age
– Physical proportions more adult-like
– Approval and acceptance important
– Beginning to develop understanding of illness, loss,
death, dying; need adults’ assistance in coping with
fears
– Modesty and need for privacy

• Adolescents
– 12 through 18 years of age
– Vital signs approach adult values
– Physical growth nearly complete in later years
– Brain has not yet developed adult judgment; handles
emotions differently

• Adolescents (continued)
– Sense of invulnerability
– Risky behaviors
– Rates of depression and suicide increase
– Assessment and management of anatomic and
physiological aspects similar to adults
– Keep in mind psychosocial differences.

General Assessment and Management
of Pediatric Patients
• Appropriate equipment; differences between
adults and pediatric patients
• Principles of scene size-up remain the same.
– Stay focused in order to be thorough.
• Take into account reactions and needs of parents
or caregivers.
– Unless parent(s) unable to cooperate, no reason to
separate child from parent(s).

Table 44-1
Equipment for Pediatric Prehospital Care
• Length-based resuscitation tape, such as a Broselow tape
• Pediatric stethoscope
• Pediatric blood pressure cuffs
• Pediatric pulse oximeter sensor
• Pediatric oropharyngeal and nasopharyngeal airways
• Pediatric advanced (supraglottic) airways
• Pediatric oxygen masks
• Pediatric bag-valve-mask device
• Pediatric cervical collars in a variety of sizes
• Bulb syringe
• Blankets for warmth and padding
• 60 gtts/mL IV tubing
• Volumetric IV device, such as a Buretrol
• 24-, 22-, and 20-gauge IV catheters
• 25 percent dextrose
• 10 percent dextrose
• Pediatric long-bone splints
• Pediatric car seat and restraint devices for transport

• Scene size-up
– Potential abuse or neglect requires law enforcement
presence.
– When child abuse or neglect or sudden infant death
syndrome (SIDS) is suspected, there are observations
you must make and document.
– General impression facilitated by use of pediatric
assessment triangle (PAT)

Table 44-2
Indications of Child Abuse and Child Neglect
• Injuries inconsistent with history provided
• Bruises over soft areas (buttocks, abdomen, cheeks, thighs, upper arms), as opposed
to bony areas such as the forehead or shins
• Multiple injuries in various stages of healing
• Unusually fearful child
• Specific wound patterns such as cigarette burns, hand marks, belt buckle impression,
human bite marks
• Clearly delineated burn marks, burn marks in the shape of a specific object
• Lack of adequate supervision
• Injuries to the genitals
• Untreated illness
• Delay in reporting illness or injury
• Malnourishment, lack of food
• Sexual behavior or unusual knowledge of sexual activity
• Unsafe living environment

Figure 44-2
Elements of the pediatric assessment triangle.

• Appearance
– Muscle tone
– Interactiveness
– Consolabilty
– Eye contact
– Speech or crying

• Work of breathing
– Abnormal airway noise
– Abnormal positioning
– Retractions
– Nasal flaring
• Circulation to the skin
– Skin color

• Primary assessment
– If unresponsive and not breathing normally, confirm
unresponsiveness; check for pulse.
– Check infant’s pulse at brachial artery.
– Check carotid pulse of older child.
– If pulse is not detected within 10 seconds, begin chest
compressions according to American Heart Association
(AHA) guidelines.

Table 44-3 (1 of 2)
Pediatric CPR
Patient Age Indication
and Initiation
Hand
Position
Compression
Depth
Compression
Rate per
Minute
Ratio of
Compressions
to Ventilations
Child (one to
eight years)
Unresponsive,
not breathing or
agonal breathing,
no pulse, or heart
rate < 60 with
poor perfusion.
A lone rescuer
performs two
minutes of CPR
and then
activates EMS.
An EMS team
can perform
interventions
simultaneously.
One or two
hands,
depending
on size of
child, over
the lower
half of the
sternum
Two inches or at
least one-third
of the anterior–
posterior
dimension of the
chest
100–120/min 30:2 with one
rescuer; 15:2 with
two Rescuers

Table 44-3 (2 of 2)
Pediatric CPR
Patient Age Indication
and Initiation
Hand
Position
Compression
Depth
Compression
Rate per
Minute
Ratio of
Compressions
to Ventilations
Infant (less
than one year)
Unresponsive,
not breathing or
agonal breathing,
no pulse, or
heart rate, 60
with poor
perfusion.
A lone rescuer
performs two
minutes of CPR
and then
activates EMS.
An EMS team
can perform
interventions
simultaneously.
Two fingers
over the
sternum just
below the
intermamma
ry line or two
thumbs
encircling if
two rescuers
are present
One and one-half
inches or at least
one third of the
anterior–posterior
dimension of the
chest
100–120/min 30:2 with one
rescuer; 15:2 with
two Rescuers
Source: American Heart Association. 2015. “Highlights of the 2015 American Heart Association Guidelines Update for
CPR and ECC.” Dallas, TX: American Heart Association. https://eccguidelines.heart.org/wp-
content/uploads/2015/10/2015-AHA-Guidelines-Highlights-English.pdf

• Primary assessment (continued)
– Common cause of cardiac arrest in pediatric patients
is hypoxia due to respiratory failure and respiratory
arrest.
– AHA allows for EMS provider judgment in making
ventilation higher priority during cardiopulmonary
resuscitation (CPR).
– If patient is responsive, or unresponsive but breathing,
assess airway, breathing, and circulation.

Figure 44-3
(A) When a child is supine without padding beneath the shoulders, the neck can flex,
resulting in airway obstruction. (B) Pad beneath the shoulders to maintain proper alignment
of airway structures, with the neck in a neutral position.

– Assess for partial or complete airway obstruction.
– Use padding under shoulders of smaller patients.
– Assess need for assisted ventilations.
 Be prepared to intervene quickly with any child who has signs
of respiratory distress.
– If hypoxia is evident or likely, provide supplemental
oxygen.
– Use blow-by oxygen.

Figure 44-5
Administering oxygen to an infant using the blow-by method.

– Children’s blood volume small; shock can occur with
little volume loss
– Control hemorrhage; high index of suspicion for
internal bleeding based on MOI
– Keep patient with blood loss warm.

• What are the signs of shock (hypoperfusion) in an
infant or child?

• Secondary assessment
– Younger pediatric patient’s inability to give chief
complaint; limited language skills to elaborate on chief
complaint
– Obtaining medical history may be difficult if parent is
not available on scene.
– Obtain SAMPLE history and chief complaint using
OPQRST to best of your ability.

• Secondary assessment (continued)
– Specific history questions to ask:
 Displaying normal activity level?
 Recent fever or illness?
 Is there a rash?
 Volume of oral intake? Urinary output?
 Diarrhea or vomiting?
 Current or past medical problems?
 Birth complications? Premature?
 Up to date on vaccinations?

– Level of responsiveness determined using AVPU
method; Pediatric Glasgow Coma Scale more precise
assessment
– Know normal values of pediatric vital signs.

Table 44-4
Pediatric Glasgow Coma Scale
Eye opening
> One Year
4 Spontaneous
3 To verbal command
2 To pain
1 No response
< One Year
Spontaneous
To shout
To pain
No response
Best motor response
> One Year
6 Obeys
5 Localizes pain
4 Flexion withdrawal
3 Flexion abnormal
(decorticate rigidity)
2 Extension (decerebrate
rigidity)
1 No response
< One Year
Localizes pain
Flexion withdrawal
Flexion abnormal
(decorticate rigidity)
Extension (decerebrate
rigidity)
No response
Best verbal response
Five Years
5 Oriented and converses
4 Disoriented and
converses
3 Inappropriate words
2 Incomprehensible sounds
1 No response
Two to Five Years
Appropriate words and
phrases
Inappropriate words
Cries and/or screams
Grunts
No response
0–23 months
Smiles, coos, cries
appropriately
Cries
Inappropriate crying and/or
screaming
Grunts
No response

Table 44-5
Normal Pediatric Vital Signs
Age Group
Respiratory
Rate (per minute)
Heart Rate
(per minute)
Systolic Blood
Pressure in mHg
Temperature
in °F
Newborn 30 to 60 100 to 180 70 to 90 98 to 100
Infant 25 to 40 100 to 160 70 to 90 98 to 100
Toddler 24 to 30 80 to 130 72 to 100 98.6 to 99.6
Preschool child 22 to 34 80 to 120 78 to 104 98.6 to 99.6
School-age child 18 to 30 70 to 110 80 to 115 98.6
Adolescent 12 to 20 60 to 105 88 to 120 98.6

– Blood pressures are difficult to obtain (< 3 years old)
and interpret.
– Capillary refill time is an indication of perfusion status
in young children.
– Base physical exam on chief complaint, overall
presentation, and history.

– Unusual lethargy, flat affect, lack of interest in
surroundings
– Unusual patterns of bruising; injuries unusual in child;
unusual pattern or location
– Rashes and petechiae; possible infection or allergic
reaction
– Absence of tears can be sign of dehydration
– Drainage or bleeding from ear
– Signs of possible toxic ingestion; discoloration or burns
around the mouth; unusual odor

– In infant, fontanelles bulging or depressed
– Distended abdomen
– Child favors, protects, refuses to use an extremity

• Clinical-reasoning process
– Be prepared to change general impression and
patient’s priority for transport.
– Epidemiology of illnesses and injuries are different in
children than in adults.
– Pediatric population: compensates well for illnesses
and injuries short term

• Clinical-reasoning process (continued)
– Energy stores limited; can deteriorate with little warning
– High index of suspicion for shock and impending
respiratory failure based on MOI and nature of illness
(NOI)
– Whenever possible, transport pediatric patients to
facility with pediatric emergency department.

• Treatment
– Always use equipment and supplies appropriate for
pediatric patients.
– Use basic life-support measures for managing airway,
breathing, circulation.
– Lower volume and higher rate of ventilations

Table 44-6
Pediatric Bag-Valve-Mask Ventilation
Age Ventilations
per Minute
Approximate Volume
per Breath
Neonate 30 6 to 8 mL/kg (approximately 20 to
30 mL), use bag-valve-mask
with no greater than 250 mL volume
Infant 20 to 25 6 to 8 mL/kg (approximately 20 to
80 mL), use a bag-valve-mask device
with 250 to 500 mL volume
Child, one to
eight years
12 to 20 7 mL/kg (approximately 70 to
200 mL)

• Treatment (continued)
– If spinal motion restriction is required, place padding
under body to avoid hyperflexion of cervical spine.
– Use cervical collars and splinting devices appropriate
to child’s size.
– If dehydrated, has lost blood volume, or requires
intravenous medications, start IV; follow your protocols.
– Particularly prone to hypothermia

• Reassessment
– Pediatric patients can deteriorate quickly; reassess
frequently.
– Compare subsequent findings to baseline findings to
identify trends.
– Monitor effects of any treatments initiated.

Pediatric Medical Emergencies
• Respiratory emergencies
– Asthma, infectious respiratory illnesses, cystic fibrosis,
anaphylaxis.
– Pediatric patients can deteriorate rapidly from
respiratory distress to respiratory failure to respiratory
arrest.
– Quickly identify problem; take measures to restore
ventilation and oxygenation.

• Respiratory emergencies (continued)
– May display grunting with expiration
– Nasal flaring; retraction above clavicles and between
ribs may be prominent; may also demonstrate belly
breathing
– As hypoxia develops, pediatric patients exhibit
bradycardia.

Table 44-7
Indications of Pediatric Respiratory Distress
• Abnormal sounds, such as stridor, crowing, wheezing, grunting, hoarseness, snoring, coughing, gagging, gasping
• Tachypnea
• Bradypnea
• Tachycardia
• Bradycardia
• Diminished air movement
• SpO2 < 95%
• Tripod position
• Suprasternal or intercostal retractions
• Use of neck muscles
• Nasal flaring
• Head bobbing
• Cyanosis or pallor
• Fatigue/lethargy
• Seesaw breathing
• Unresponsiveness or limp muscle tone

– Immediate intervention in pediatric patient who appears
lethargic, limp, or cyanotic
– Pediatric asthma patients may exhibit dry cough;
indicates inflammation of lower airways.
– Begin oxygen administration; use humidified oxygen, if
available.

– For patients in respiratory failure, immediately establish
airway, assist with ventilations, and provide
supplemental oxygen.
– Intravenous fluids are beneficial with asthma to reverse
or prevent dehydration; follow protocols.
– Be prepared to provide airway and start ventilations by
bag-valve-mask device.

– Haemophilis influenza B (Hib) vaccination all but
eradicated epiglottitis in this age group.
– If epiglottitis suspected, do not place anything in
mouth; do not agitate patient.
– Transport without delay.
– Laryngotracheobronchitis (croup): viral infection of
lower airway, worsens at night, “seal bark” cough
– Humidified oxygen preferred to prevent drying,
irritation, and further swelling of airway.

– Pertussis: serious, sometimes fatal disease that
causes coughing fits; may last 10 or more weeks
– Patients gasp for air following coughing fits; “whooping”
cough.
– DTaP vaccine not recommended until 2 months of age;
series of five vaccinations to confer immunity.

– Bronchiolitis: acute viral lower airway disease; children
2 months to 2 years of age
– Airway constriction; expiratory wheezing, tachypnea,
signs of respiratory distress
– Respiratory syncytial virus (RSV) common cause
– Assess significant dehydration; consider fluid
replacement if dehydration severe.

– Except in newborns, cough and fever common early
signs of pediatric pneumonia
– Tachypnea, respiratory distress, lethargy, irritability,
vomiting
– Assist ventilations if respiratory failure or arrest.
– Continuous positive airway pressure (CPAP), if
permitted by protocol, may be beneficial for patients in
severe respiratory distress.

– Upper respiratory infections with rhinorrhea and cough
common
– Often accompanied by low-grade fever and can result
in otitis media.
– In infant’s, nasal secretions can significantly obstruct
breathing.

– Anaphylaxis: respiratory emergency with signs of upper
or lower airway obstruction (dyspnea, stridor,
wheezing)
– Include questions about allergies and exposure to
allergens.
– Determine if child has epinephrine autoinjector and
whether it has been used.

– Cystic fibrosis (CF): two defective genes, one inherited
from each parent, results in production of extremely
viscous mucus
– In respiratory tract, thick secretions obstruct airways
and lead to life-threatening infection.
– Do not withhold oxygen; humidified preferred; IV fluids
may assist in hydrating mucus.
– CPAP useful for impending respiratory failure.

• Pediatric cardiovascular disorders
– Cardiac arrest is usually due to hypoxia.
– Adolescents known to suffer cardiac arrest during
strenuous activity.
– Cardiac arrest occurs from commotio cordis, which is a
direct blow to chest at vulnerable point in cardiac cycle.
– For adolescents, early chest compressions with
minimal interruption, rapid defibrillation

• Pediatric cardiovascular disorders (continued)
– Most pediatric cardiac problems are due to congenital
abnormalities.
– Uncorrected congenital heart defects can lead to poor
perfusion and hypoxia.
– Treat patient for shock; pay particular attention to
correcting hypoxia and improving circulation.

• Sudden Infant Death Syndrome (SIDS)
– SIDS: sudden death of infant under 1 year of age that
cannot be explained despite case investigation and
autopsy; diagnosis of exclusion
– Apparent life-threatening event (ALTE): combination of
apnea, color change, limpness, choking, or gagging
– MUST transport all infants with ALTE to emergency
department for evaluation

(continued)
– In the absence of signs of presumptive death, begin
CPR in suspected SIDS patient; transport with
continuing resuscitative efforts.
– All cases of sudden, unexpected death fall under the
jurisdiction of medical examiner.
– If child is not a candidate for resuscitation, treat scene
as potential crime scene.

Table 44-8
Documenting the Scene in Suspected Sudden
Infant Death Syndrome
• How was the child found on your arrival?
• Where was the child when the parents found him? What kind of surface was the child on when found?
• Were there any pillows, loose bedding, stuffed animals, or other objects where the child was found that could have
posed an asphyxiation hazard?
• What clothing was the child wearing? Could it have posed an asphyxiation hazard?
• If the child was in a crib, were there any signs of defect, such as an opening in which the child could have become
wedged?
• What was the general condition of the residence?
• Who was present at the scene, and what was the demeanor of each?
• Was rigor mortis or livor mortis present?
• What was the skin temperature of the patient?
• Were there any apparent injuries or marks?

(continued)
– Do not misinterpret normal signs of death as signs of
abuse.
– In cases of pediatric resuscitation, allow parents to be
in attendance if possible.
– In all cases, parents require emotional support.
– Recognize signs of acute stress reaction in yourself
and others who responded; be prepared to seek
assistance.

• Infectious diseases
– Meningitis: viral or bacterial; inflammation and swelling
of meninges that surround central nervous system.
– Viral meningitis is less severe; bacterial meningitis can
be fatal.
– Viral meningitis: fever, headache, photophobia, stiff
neck
– Bacterial meningitis: seizures and altered mental status

• Infectious diseases (continued)
– Meningococcal bacteria can enter blood, causing
damage to blood vessels, with bleeding into organs
and skin (purpura).
– Fever and chills; vomiting; diarrhea; joint, muscle,
abdominal or chest pain; tachypnea; cold hands and
feet
– Meningococcemia can be fatal.

• Neurologic disorders
– Child seizures
 Fever (common cause)
 Epilepsy
 Toxins
 Drugs
 Metabolic disturbances (check for hypoglycemia)
 Trauma
 Intracerebral hemorrhage
 Tumors

• Neurologic disorders (continued)
– Febrile seizures: related to rate fever increases; short
in duration with limited postictal state
– Do not bundle febrile child in blankets; do not allow
child to become chilled.
• What does mnemonic AEIOU-TIPS stand for?

• Neurologic disorders (continued)
– Hydrocephalus: imbalance between formation and
outflow or absorption of cerebrospinal fluid.
– Large head with bulging fontanelles and separation of
cranial sutures
– Once fontanelles are closed, increased intracranial
pressure (ICP) can lead to headaches, changes in
vision, cognitive difficulties, decreased responsiveness,
and respiratory arrest.
– Treat with ventriculostomy shunt.

• Diabetes
– In children, usually insulin-dependent diabetes mellitus
(IDDM), Type II increasing
– Death from complications of undiagnosed diabetes
 Diabetic ketoacidosis (DKA)
 Cerebral edema from untreated or poorly treated diabetes
 Hypoglycemia

• Diabetes (continued)
– Signs and symptoms
 Altered mental status: Obtain blood glucose level in all patients
with altered mental status.
 Severe, persistent diaper rash; yeast organisms
 Lethargy or malaise
 Weight loss
 Thirst
 Frequent urination

• Diabetes (continued)
– Look for severe dehydration, presence of ketone odor,
Kussmaul’s respirations, vomiting, decreased level of
responsiveness.
– Hypoglycemia: patients being treated for diabetes;
occurs suddenly with irritability; behavioral changes;
pale, cool skin; seizures; decreased level of
responsiveness
• What are the signs of dehydration for children?

• Gastrointestinal disorders
– Gastroenteritis; vomiting and diarrhea
– Constipation common
– Vomiting and diarrhea are often due to viruses and
foodborne illness.
– Abdominal pain: appendicitis, urinary tract infection,
DKA, hernias, bowel obstruction, intussusception,
volvulus, pyloric stenosis, swallowed foreign bodies

• Eye, ear, nose, and throat disorders
– Conjunctivitis, styes, chalazia
– Orbital and periorbital cellulitis―medical emergencies
– Foreign bodies in eyes, ears, nose
– Otitis externa, otitis media often common
– Epistaxis common; usually anterior site
– Pharyngitis

• Behavioral emergencies
– Depression, mood disorders, substance abuse and
addiction, anxiety disorders, eating disorders, impulse
control disorders
– Risk of suicide increases in adolescents.
– Your safety can be jeopardized by a child or adolescent
with behavioral emergency, just as it can be by adult
patient.

• Toxicologic emergencies
– Curiosity
– Underdeveloped sense of taste
– Inability to recognize consequences of behavior
– Poor supervision
– Poor childproofing
– Drug and alcohol abuse
– Suicide attempts

• Toxicologic emergencies (continued)
– Constant awareness of mental status, airway, breathing
– Pediatric dosage of activated charcoal is 1 gram/kg,
with minimum of 15 grams; follow your protocols or
advice of poison control or online medical direction.
Adult dose is usually 25–50 g.

Shock and Trauma in Pediatric Patients
(1 of 13)
• Pediatric mechanisms of injury (MOI)
– Most common MOI in pediatric patients due to blunt
forces
– In motor vehicle collisions (MVCs), high index of
suspicion for multiple injuries (head and neck)
– Restrained pediatric occupants can suffer serious
injury from airbag deployment and seat belts.

Table 44-10 (1 of 2)
2011 Guidelines for Field Triage of Injured Patients
Vital Signs and Level of Responsiveness
 Glasgow Coma Scale < 14 or
 Systolic blood pressure < 90 mmHg or
 Respiratory rate < 10 or > 29 breaths per minute (< 20 in infant < one year old)
Anatomy of Injury
 All penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee
 Chest wall instability or deformity (e.g., flail chest)
 Two or more proximal long-bone fractures
 Crushed, degloved, or mangled extremity
 Amputation proximal to wrist or ankle
 Pelvic fracture
 Open or depressed skull fracture
 Paralysis
Mechanism of Injury and Evidence of High-Energy Impact
 Falls
 Adults > 20 ft (1 story = 10 ft)
 Children > 10 ft or two to three times patient’s height
 High-risk auto crash
 Intrusion > 12 in. occupant site; > 18 in. any site
 Ejection (partial or complete) from automobile
 Death in same passenger compartment
 Vehicle telemetry data consistent with high risk of injury
 Auto versus pedestrian/bicyclist thrown, run over, or with > 20 mph impact
 Motorcycle crash > 20 mph

Table 44-10 (2 of 2)
2011 Guidelines for Field Triage of Injured Patients
Special Patient or System Considerations
 Age
 Risk of injury death increases after age 55 years
 Children should be preferentially triaged to pediatric-capable trauma centers
 Anticoagulation and bleeding disorders
 Burns
 Without other trauma: triage to burn facility
 With trauma mechanism: triage to trauma center
 Time-sensitive extremity injury
 End-stage renal disease requiring dialysis
 Pregnancy > 20 weeks
 EMS provider judgment

(2 of 13)
• Pediatric mechanisms of injury (MOI) (continued)
– Injuries of child struck by vehicle depend on speed of
vehicle and patient’s height in relation to vehicle.
– High-speed impact: head, neck, multiple internal organ
injuries

(3 of 13)
• Assessment and management
– Three most common causes of pediatric trauma death
following injury: hypoxia, massive hemorrhage,
traumatic brain injury
– In pediatric patient with suspected cervical-spine
trauma, maintain head in neutral position, placing
folded towel or blanket under shoulders.
– If child does not have gag reflex, insert oropharyngeal
airway.

(4 of 13)
• Assessment and management (continued)
– Prehospital endotracheal intubation in pediatric
patients associated with worse outcomes
– Traumatic brain injury, shock, and chest trauma can
result in need for assisted ventilations.
– Use supplemental oxygen; adjust rate and depth
according to patient’s size.
– Hyperventilation is a common mistake in trauma
patients; can worsen cerebral edema, impair cardiac
output.

(5 of 13)
• Assessment and management (continued)
– Control external hemorrhage; high index of suspicion
for internal bleeding.
– Keep patient warm.
– Monitor mental status, vital signs, signs of perfusion to
detect emerging shock.
– Bradycardia and tachycardia are concerns.
– Capillary refill reliable sign of perfusion in pediatric
patients.
– If shock is suspected, infuse IV/IO fluids in a bolus of
20 ml/kg; unstable/critical patient.

Figure 44-7
The Rule of Nines, used to calculate the percent of body surface involved in burns, is
altered in infants and children to account for their proportionately larger heads.

(6 of 13)
• Considerations in spinal motion restriction
– Car seat used to assist in manual stabilization of spine
during extrication; seat and child removed from vehicle
as unit, then transfer child to immobilization device
– Padding may be required under shoulders to properly
align cervical spine.
– Child’s smaller size increases need for padding along
sides of body to prevent him from sliding from side to
side on backboard.

Figure 44-8
Indications of child abuse: (A) burns to the feet caused by dunking the child’s feet in hot
water (© SPL/Science Source) (B) bruising resulting from physical abuse. (© Biophoto
Associates/Science Source)
(A) (B)

(7 of 13)
• Burns
– Children have thin skin; can be burned at much lower
temperature, shorter duration of exposure to heat than
adults
– Many accidental childhood burns can be prevented
through safety measures.
– One in five burns in children is a result of child abuse
or child neglect; burn patterns should increase your
suspicion.

(8 of 13)
• Drowning
– Primary respiratory impairment resulting from
submersion in liquid medium
– Incidence higher in toddlers and in adolescent males.
 Most toddler drownings occur in bathtubs and swimming
pools.
 Risk-taking behavior and alcohol implicated in adolescent
male group.

(9 of 13)
• Drowning (continued)
– Drowning: asphyxia resulting in hypoxia and acidosis
– Most children who survive drowning rescued within 2
minutes of submersion.
– Death occurs due to: asphyxia, cardiac arrest, acute
respiratory distress syndrome (ARDS), multiple organ
dysfunction syndrome (MODS).

(10 of 13)
– If patient still in water, perform rescue only if it is safe to
do so.
– Otherwise, await trained water rescue personnel.
– Remove from water as quickly as possible.
– If unresponsive, begin chest compressions according
to CPR guidelines for patient’s age.
– Transport all patients who have been submerged in
water.

(11 of 13)
– For patients in cardiac arrest, begin chest
compressions immediately.
– Consider airway management, ventilation early.
– Follow your protocols regarding measures to treat
hypothermia in drowning patients.

(12 of 13)
• Child abuse and neglect
– Child abuse: improper, intentional, or excessive action
that causes injury or harm to child
– Child neglect: inadequate provision of attention or
respect to person entitled to it
– In many states, you are considered mandatory reporter
of suspected child abuse or neglect.

(13 of 13)
• Child abuse and neglect (continued)
– You are ethically obligated to report suspicions.
– Reporting depends on your protocols and laws in your
jurisdiction.
– First priorities: scene safety, providing medical
treatment for child
– Carefully document all pertinent information.

Table 44-11
Documenting Suspected Child Abuse or Neglect
 Document objectively. Do not make assumptions or draw conclusions. For example, you could document that the
patient stated he was struck with a belt buckle or that the patient has a three-inch by two-inch U-shaped bruise on his
back, but you cannot state that (in your opinion) the patient was beaten with a belt buckle.
 Objectively document and precisely describe all injuries by their appearance and locations. Make drawings if
possible.
 Place in quotation marks any relevant statements made by the patient, witnesses, or caregivers.
 Document the conditions of the surroundings.
 Document relevant aspects of the child’s appearance, such as what he was wearing, for example, if he was found
outside in cold weather but not wearing a coat, or if the child is unkempt or appears thin or emaciated.
 Document the behavior of the child and caregivers.

Chapter Summary (1 of 6)
• Pediatric patients not only smaller but also have
anatomic, physiological, psychosocial differences
you must consider in assessment and
management of emergencies.
• Epidemiology of injury and illness different in
pediatric age group.

• Keys to successfully managing pediatric calls:
– Knowledge of pediatric differences
– Use of equipment designed for pediatric patients
– Ability to maintain composure

• Key differences in pediatric patients:
– Airway and airway management techniques
– Increased susceptibility to hypothermia and
dehydration
– Subtle signs and symptoms of shock despite significant
blood loss

• More vulnerable to effects of infectious illness; can
lead to airway obstruction or respiratory distress,
respiratory failure, or respiratory arrest.
• Hypoxia is the leading cause of cardiac arrest in
pediatric patients.

• SIDS and ALTE affect infant age group.
– Related signs can mimic indications of possible child
abuse.
– Document scene carefully as potential crime scene
without implying that parents in any way at fault for
situation.
– Recognize, document, and report suspected child
abuse and neglect.

• Pediatric patients can receive different patterns of
trauma than adults subjected to same
mechanisms because of anatomical differences.
• Blunt mechanisms most common in pediatric
population, likely to produce multisystem trauma.
• Whenever possible, transport critically ill or injured
pediatric patients to facility capable of specialized
pediatric care.

Alexander ch44 lecture

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