EMT-Basic Exam: The Basics of Pediatric Care (Infants and Children) - Common Problems in Infants and Children

Many children all over the world experience medical and health emergencies every day. Depending on their age, they may engage in behaviors that cause injury or illness. For example, many young children put small toys in their mouths and choke. They may also occasionally eat things off the ground like dirt, wild mushrooms, or bugs. These events can lead to serious injury or illness, so it’s best to be prepared for anything when you arrive on a call involving a sick or injured child.

The EMT-Basic exam will test your knowledge of how to treat some of the most common pediatric problems you’ll encounter in the field. These include emergencies such as airway obstructions, seizures, and poisonings.

1. Airway Obstructions
You must be familiar with the signs of a partial airway obstruction and a complete airway obstruction, as treating a partial airway obstruction incorrectly could lead to a life-threatening full obstruction. The following table features key symptoms and signs that will help you differentiate between partial and complete airway obstructions in children.

a. Partial Airway Obstruction
As seen in the table above, you may recognize partial airway obstructions by loud coughing, a hoarse voice, and an increased breathing rate. Children with partial airway obstructions are typically awake and will struggle to remove the obstruction on their own. Reassure them and encourage them to cough. Keep their parents nearby at all times. Do not perform a detailed examination on a child if he or she is agitated, afraid, or upset. A physical exam may further upset a child, which will affect his or her breathing rate, possibly leading to further obstruction. Transport the child in an upright position and do not allow the child to lie down, as this may also lead to further obstruction. Unless the child’s mental status or skin color changes, allow physicians at the hospital to remove the obstruction.

b. Complete Airway Obstruction
A complete airway obstruction is considered life threatening and requires EMT-Basics to take immediate action. As seen in the table, children with completely obstructed airways may have skin that appears mottled, pale, or blue. These patients are often unable to speak or cough if they are responsive. Treatment for patients with completely obstructed airways differs according to the patient’s mental status and age.
It is important that you are familiar with the anatomy of a child’s respiratory system (shown in the following figure) and abdominal muscles before performing CPR, ventilation, or finger sweeps for obstructed objects.

Responsive infants have often placed a small object, known as a foreign body, in their mouths and attempted to swallow it. Follow these steps to remove a foreign body from an infant:

1. Position the infant so he or she is face down and the head is lower than the trunk.

2. Deliver no more than five back blows between the infant’s shoulder blades.

3. Turn the infant so he or she is face up, supporting the head and neck.

4. Deliver no more than five chest thrusts over the lower half of the sternum.

5. Repeat steps 1 through 4 until the airway is unobstructed or the infant becomes unresponsive.

EMT-Basics should be familiar with the unique structure of children’s respiratory system in order to provide them with proper care.

If you believe an infant is unresponsive, confirm this condition by tapping the soles of the infant’s feet or gently rubbing the infant’s chest or back. If the infant doesn’t respond, open the airway. The following steps will help you treat an unresponsive infant with a complete airway obstruction:

1. Look, feel, and listen for signs of breathing.

2. If the infant is not breathing, position the head appropriately, cover the infant’s nose and mouth, and deliver two breaths.

3. If the infant is still not breathing, deliver two more breaths and begin CPR.

4. Deliver chest compressions.

5. Check the infant’s airway. If you can see the foreign body, use a finger sweep to remove the object.

6. If you are unable to remove the obstruction, repeat steps 2 through 5.

After an obstruction has been removed, transport the patient to the hospital. At the hospital, physicians will evaluate the airway to determine if permanent damage has occurred.
Because toddlers, preschool, and school-age children are bigger than newborns and infants, EMT-Basics perform a different set of actions when they treat these children for a complete airway obstruction. EMT-Basics should not perform back blows or chest thrusts on these children. Children of this age typically choke on large pieces of food or candy.
If you have determined that the airway is completely obstructed and the child is responsive, coughing may help move the object. If coughing does not help or if the child is unable to cough, perform the following steps to remove the obstruction:

1. Have the child stand upright.

2. Kneel or stand behind the child and place your arms around the child’s waist.

3. Make a fist, cover it with your other hand, and place it on the abdomen.

4. Deliver quick, upward abdominal thrusts until the object is dislodged or the child becomes unresponsive.

If you have determined that a child is unresponsive and suffering from a complete airway obstruction, follow these steps to remove the obstruction:

1. Place the child in a supine position.

2. Perform a tongue jaw lift and look for the obstructed object.

3. If you spot the object, use a finger sweep to remove it.

4. Open the airway and listen, feel, or look for signs of breathing.

5. If the child is not breathing, attempt ventilation.

6. Reposition the child’s head and attempt ventilation again.

7. Start chest compressions.

8. Once again, check for the foreign body.

9. Repeat steps 4 through 8 as necessary.

If you are unable to remove the foreign body from an infant or small child with a complete airway obstruction, follow your local protocol as you transport your patient to the hospital. Call the medical direction physician if you are unsure of how to handle the situation.

2. Respiratory Emergencies
Recognition and the proper treatment of respiratory distress, failure, and arrest by EMS crews save thousands of young lives every year. Approximately 80 percent of all infants and children who experience cardiac arrest experience respiratory arrest first. Understanding the symptoms of respiratory distress will help you to prevent the occurrence of respiratory failure and arrest.

A patient is experiencing respiratory distress if he or she finds it difficult to breathe. If the child does not receive a high volume of oxygen, the condition may escalate rapidly. Signs of respiratory distress include
- Increased breathing rates
- Retractions
- Nasal flaring
- Splotchy or mottled skin
- Overuse of abdominal muscles
- Stridor
- Grunting
- Wheezing

Respiratory distress can lead to respiratory failure if it is not treated immediately. Infants and children in respiratory failure struggle to breathe and often become tired very quickly. Signs of respiratory failure include
- Severe retractions
- Decreased muscle tone
- Severe overuse of abdominal muscles
- Breathing rate of more than 60 breaths per minute or fewer than 20 breaths per minute
- Fatigue

To treat respiratory failure, you must ventilate the child using the highest concentration of oxygen available. During transport, ensure that the child is comfortable and in the supine position. Explain your actions to the child and his or her parents as you place the mask over the child’s nose and mouth and seal it.
Respiratory failure often leads to cyanosis, decreased peripheral perfusion, and decreased mental status. If untreated, it may also cause a child to enter respiratory arrest. In respiratory arrest, a child’s entire respiratory system will shut down.

Symptoms of respiratory arrest include
- Breathing rate of fewer than 10 breaths per minute
- Slow or absent heart rate
- Weak or absent pulse
- Limp muscles
- Unresponsiveness
- Irregular breathing patterns and/or gasping

Respiratory arrest is one of the leading causes of cardiac arrest in children. Young patients suffering from respiratory arrest should be carefully assessed and immediately transported and treated. Using a bag-valve mask, ventilate the child, paying close attention to his or her respiratory rates. Ensure that the airway is open and unobstructed. If you are treating an infant who goes into respiratory arrest with a heart rate of fewer than 60 beats per minute, start chest compressions and call ALS.

3. Seizures
When responding to calls that report a seizing child, remember that children who experience seizures may be ill, injured, or suffering from chronic seizures. After a seizure, children may experience difficulty breathing and a change in mental status. Seizures can result from the following:
- Decreased levels of oxygen
- Head injury
- Low blood sugar
- Chronic medical conditions
- Fever
- Infection
- Poisoning

Although you should be familiar with the causes of seizures, you don’t need to determine what specifically led to your patient’s seizure. Instead, you are responsible for watching your patient’s vital signs and taking note of the events (multiple seizures, convulsions) that occur during transport. This information will be useful to physicians who continue to care for the patient at the hospital. During seizures, keep the child safe from injury and be prepared to suction or remove foreign bodies from the airway. You should also immobilize the patient if any injury to the spine is suspected.

Tip: Remember to ask the child or the parents about any medications the patient is taking when you collect information about the patient’s history.

4. Altered Mental Status
In the midst of numerous types of emergencies, an infant or child’s mental status may worsen. Parents or EMT-Basics may notice a change in mental status if the child does not respond appropriately to his or her environment, if the child is no longer interested in the people or objects around him or her, or if the child no longer recognizes his or her parents by appearance or voice.

Causes of altered mental status include
- Infection
- Poisoning
- Head trauma
- Decreased oxygen levels
- Diabetic emergencies
- Shock
- Seizure

Attain the patient’s focused history from his or her parents, but do not waste time determining the cause of the change. Make sure the airway remains open during transport and ventilate using an oxygen mask if necessary.

5. Poisoning
The age of the child often determines how he or she was poisoned and how much of a substance he or she ingested. When responding to a call in which an infant was poisoned, suspect unintentional poisoning or abuse by the parent or caregiver. If a preschool or school-age patient is poisoned, assume that the child innocently placed the toxic substance in his or her mouth. These children typically only ingest small amounts of substances found on floors or toys. Adolescents who are poisoned typically administer and ingest toxic substances intentionally in hopes of achieving psychological side effects or relief from emotional stress or depression.
At the scene, always perform a scene size-up and employ proper BSI. Some poisons are airborne and may poison you if you inhale or physically encounter the toxin. Look for any bottles or containers that contain the substance in question. Ask the child and his or her parents about the patient’s history with toxins and if any poisonous liquids or powders are available inside the home.
Be prepared to administer suction, artificial ventilation, and high-flow oxygen. A child who ingested a poison may vomit, seize, or become unresponsive. Keep the airway clear and assess for signs of injury. Complete ongoing assessments until you reach the hospital. If you are uncertain about how to proceed, call the medical direction physician, ALS, or your local poison control center.

6. Fever
A child has a fever if his or her body temperature is above 100.4°F (38°C). Although fevers alone are not usually life threatening, the factors that may cause fevers can be extremely dangerous. For example, fever is a symptom of bacterial meningitis, a serious and often life-threatening illness.
Look for, and obtain information about, the following while performing a trunk-to-head examination and focused history:
- Mental status
- Motor activity
- Irritability
- History of illness
- Vomiting or diarrhea
- Rash

After ensuring an open airway, adequate breathing, and adequate circulation, treatment should begin with attempts to prevent the child’s body temperature from rising. Ask the child’s parent to remove articles of clothing, being careful not to produce shivering. The muscular contractions during shivering will raise the body temperature. If this occurs, replace the clothing. Do not bathe or splash the patient with cold or ice water, as this will almost surely cause shivering. Arrange for immediate transport to the nearest medical care facility. Perform ongoing assessments during transport and be prepared to provide emergency care if the patient begins to seize.

7. Shock
Hypoperfusion, also known as shock, occurs when the cardiovascular system fails to supply vital organs with oxygenated blood. If shock is not treated immediately, it can cause irreversible damage or death. Causes of shock in infants and children include
- Blood loss
- Infection
- Vomiting
- Diarrhea
- Dehydration
- Trauma

Tip: Although cardiac problems rarely cause shock in young children, the possibility does exist.
Children in shock may breathe rapidly and their skin may become pale and clammy. Their pulse may also become weak or absent. Use capillary refill to assess blood pressure for children under the age of 6. If in shock, capillary refill time will occur slowly. A child in shock may also become unresponsive or may be unable to output urine or form tears due to dehydration.
If ALS is unable to respond to an emergency in which a child is in shock, transport the child to a hospital immediately. The focused history and physical examination can be performed while in transit, as shock patients should be transferred as soon as the scene is secure and they are immobilized. During transport, keep the child warm and elevate the legs. If you suspect an injury has occurred, stabilize the child’s spine.

8. Near-Drowning
If a child dies from suffocation within 24 hours of being underwater, he or she has drowned. If a child survives an underwater event beyond 24 hours, then he or she has suffered from a near-drowning. Drowning is one of the most common causes of death in children under the age of 14.
Infants, toddlers, and preschool children typically drown after falling into pools, lakes, or ponds. These children are often unsupervised and may not know how to swim or float. Adolescents often drown due to an inability to react after consuming drugs or alcohol. Drowning may also be a direct result of a head or spinal injury after diving into shallow water. If exposed to cold air or water temperatures a child may become hypothermic and die.
Many times, a patient in need of a water rescue is removed from the water before EMS arrives on the scene. If the child is still in the water, however, only attempt to rescue the child if you have had adequate training in water rescues. Remember that your safety comes first in these instances.
Once the patient is pulled from the water, open the airway, provide oxygen and suction, ventilate, and start chest compressions if needed. Immobilize the spine if an injury is suspected. If a patient has been submerged in cold water for a prolonged period, check his or her pulse for a full minute before beginning resuscitation efforts. Transport near-drowning victims to the hospital. Here, the patient will be monitored for secondary drowning, or the deterioration of the respiratory system within 96 hours of being underwater.

9. Sudden Infant Death Syndrome
When an infant dies unexpectedly and there is no information in the child’s history or autopsy that points to a cause of death, medical examiners often label the child as a victim of sudden infant death syndrome, or SIDS. Usually, SIDS affects children between the ages of 1 month to 1 year.
When you respond to a call for an unresponsive infant, be prepared to examine the child for rigor mortis. If rigor has not yet set in, attempt to resuscitate the child and transport him or her to a hospital. While on the scene, pay careful attention to your surroundings and document anything that raises a question or appears suspicious. Doctors often misdiagnose infants who are victims of abuse with SIDS. Even if you suspect abuse, never place blame on the parents. Instead, offer them your support.

Tip: Cases in which children die can severely affect the emotional health of EMT-Basics. If you are emotionally affected after responding to an incident that results in the death of a child, request a critical incident stress debriefing (CISD). 

Related Topics You Should Review:
- Performing CPR in adolescents and adults
- Recognizing signs of lower airway obstructions due to illness
- Locating the xiphoid process
- Ventilating infants and small children
- Administering charcoal in poison emergencies