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Objectives - Describe physical, behavioral, and intellectual developmental changes that occur across the life span. - Differentiate, assess, and treat pediatric respiratory emergencies. - Differentiate, assess, and treat causes of pediatric shock. - Differentiate, assess, and treat causes of pediatric altered mental status and pediatric seizures. A person’s body from infancy to elderly goes through many changes. Patients who are very young or very old often have conditions not otherwise seen in the population of people between the ages of 8 and 55. Calls for pediatric patients often evoke feeling of fear and anxiety in EMS practitioners largely because of unfamiliarity with changes in medication dose, fear of a sudden decline in patient stability, or fear of a difficult assessment because the child cannot verbalize a complaint in the same manner an adult might.
We will explore changes throughout the life span, beginning with the newborn infant and progressing through late adulthood. Then the differences between adult assessment and physical examination findings will be compared with the pediatric anatomy. Finally, pediatric emergencies and their treatments will be addressed. 1. Vital Sign Changes Vital signs change the most over the life span between newborn and adolescence. Generally, the younger person will have a faster heart rate and respiratory rate than the adult ≥18 years. These will gradually slow down to what is familiar for adults. The younger person will have a lower blood pressure to begin with at birth that will gradually increase to adulthood. Normal Vital Sign Ranges Throughout the Life Span
Infants, 1 Month to 1 Year Old Infants go through many rapid changes throughout the 1st year of their lives, in addition to the change from fetal circulation to normal circulation. Infants will approximately triple their birth weight by their 1st birthday. The lungs also will rapidly expand and develop faster during their 1st year than at any time after. The infant’s respiratory system is different from an adult’s in many ways. Infants breathe using their diaphragm primarily and are, therefore, referred to as belly breathers. Their intercostal muscles are weak and play nearly no role in breathing. Infants have a proportionally larger tongue than adults, meaning it takes up more space in their mouths than an adult. The airway is much narrower and shorter than an adult. The airway diameter roughly approximates the diameter of the child’s pinky.
Infants have the following reflexes: - Moro Reflex. Also known as the startle reflex, the moro reflex sees the infant opening up his or her arms and spreading the fingers as if to grab at something. - Rooting Reflex. Brushing an infant’s cheek makes the infant turn in the direction of that cheek and look for, or root, for a nipple. - Sucking Reflex. The infant will instinctively suck on anything placed in his or her mouth. - Palmar Reflex. Touching the infant’s palm causes the infant to grasp onto that item. The fontanels are the soft spots located on the top of the infant’s head. The anterior fontanel is located where the 2 parietal bones and the frontal bone meet, and the posterior fontanel is located at the vertex of the head at the intersection of the parietal bones and the occipital bone. Two others are located on the lateral skull; however, they are not easily palpable. The fontanels will close by the 18th month of life. Toddlers and Preschoolers, 1–5 Years Old During this age, children grow rapidly, expanding their musculoskeletal system and further developing alveoli and bronchioles in their ever-expanding lungs. Potty training occurs during this stage. Children also begin to explore their world because they have begun to walk early in this stage. Falls are common because even though they can walk, their ability to balance may not yet have caught up. They often will place things in their mouth as part of their exploration, so choking and poisoning are a concern in this age group. During this age group, particularly for preschoolers, it is helpful to involve the children in their own care whenever possible. Although it is not advisable to give them an option regarding treatment between receiving or not, for example, “Should I start this intravenous line or not?” it will be helpful to ask, instead, “Should I start this intravenous line in your right or left arm?” This option will give children ownership over their care and, by extension, trust in the provider. School-Age Children, 6–12 Years Old Development in this age group slows to a steadier pace compared with that of earlier age groups. Later in this group, puberty will begin, along with all the changes it brings. Women will likely experience menarche when they are this age. As children get older, their reasoning methods change and develop. During preconventional reasoning, they make decisions either to get what they want or simply avoid punishment. Conventional reasoning follows and is rooted in getting approval from peers and society. Finally, postconventional reasoning follows as they begin to make decisions based on their beliefs and conscience. Adolescents, 13–17 Years Old During this time, teenagers experience a growth spurt, gaining height along with bone and muscle mass. The girl’s growth spurt typically finishes before the boy’s. Their body shapes take on that of an adult. If it has not happened yet, menarche will happen during this time frame. Teenagers also increase their need for privacy and struggle for independence from their parents. They will prefer to have all medical questions directed to them and allow them to tell their story. The parents need to be involved in decision making because adolescents are still dependents to the parents and guardians. Adolescents may not share all information with EMS, especially if the information is sensitive in nature, such as involving drug or alcohol use or sexual activities. With this in mind, it may be helpful to have 1 member of the team interview the parents or guardians away from the child while another interviews the patient. Adulthood, 18–60 Years Old During the course of this time frame, chronic conditions become noticeable. The body that was performing at its optimal level at about 25 years old has started to lose muscle mass, and fatty deposits have started to increase. Later in this stage, women begin menopause and can begin to develop menopause-related osteoporosis. If the person has had children, they will have already grown and likely moved out of the house. During this time, those who are parents will now have to readjust to a home without children, often referred to as the empty nest syndrome. Late Adulthood, >61 Years Old Declines in functioning of nearly every system are noticeable in patients during this age range. Long-term cardiovascular atherosclerotic buildup starts elevating blood pressure and increases the risk for ACS and CVA. Chronic respiratory diseases increase, where even nonsmokers who have lived in urban areas can begin to show signs of COPD. Type 2 diabetes may be diagnosed and contribute to the risk factors for other disease processes. During the decline, patients begin to no longer be able to do the things that they were once able to do. They also may start seeing friends and family members die. They may have continual aches and pains and become partially or completely dependent on pain medications. These—combined with feeling unneeded because they are now retired and their children are no longer at home—can all contribute to intense feelings of depression. 2. Pediatrics Paramedics often say that pediatric calls are the call they fear most. Although it is true that children cannot be treated simply as small adults, they are not something to be feared. Here, our goal is to allay that fear so that you can be more confident when you arrive to the side of a sick infant or toddler. Major Anatomic and Physiological Differences Allusions were made to a couple specific anatomic and physiological differences earlier because they appear in specific age groups. Here, the discussion will focus on the major differences between children and adults and include the impact of the difference on prehospital assessment and treatment. The differences will be listed in head-to-toe order, not necessarily the order in which they would be found during a physical examination and not necessarily in any particular order of importance. - Children have a higher surface-area-to-volume ratio, which means they are at greater risk of hypothermia in any exposure. They generally have less fatty tissue to act as insulation, which serves to only increase the potential for hypothermia. - A smaller absolute circulating blood volume means that blood loss becomes more significant at lower volumes. Children actually have more circulating blood per kilogram than adults (relative volume). - Children’s higher circulating blood volume per kilogram combined with their ability to more adequately constrict blood vessels means that they will be able to maintain blood pressure longer than an adult. This also means that they are in compensated shock for a longer period of time, resulting in a more sudden crash of the blood pressure as they enter decompensated shock. - The fontanels remain open up to 1 year: the posterior fontanel closes at 1.5–3 months, and the anterior fontanel closes at about 12–18 months. Until the fontanels close, they can be a great assessment tool for evaluating hydration status and ICP. If the fontanel is sunken, the infant is significantly dehydrated. If it is bulging out of the skull, the ICP is increased, possibly as the result of a head injury or hydrocephalus. - The head of a child is much larger relative to the rest of the body. This can cause the child to often “lead with the head” during falls from any height, thus increasing the chances of sustaining significant head injuries even under less than significant mechanisms. - The occiput of the head extends beyond the back of the child. This means that traditional immobilization methods may cause the child’s neck to flex, potentially compromising the airway and the cervical spine. Padding under the shoulders will be necessary to relieve this. - The airway is shorter and narrower than that in an adult. Also, the tongue takes up more space in the mouth. - The airway is narrowest at the cricoid ring in children compared with the vocal cords in the adult. - Infants are obligate nose breathers for the first few months of life. This means that any amount of mucus can dramatically affect their ability to breathe. Sometimes, suctioning the nares are all the child needs to alleviate difficulty in breathing. - Children have a higher basal metabolic rate than adults, which means, by extension, that they have a greater O2 demand. O2 demand can exceed 7 mL/kg/min in newborns compared with approximately 3.5 mL/kg/min in adults. This increase in O2 demand is achieved with a faster respiratory rate despite a tidal volume similar to that of an adult. - The alveolar minute volume is increased in children as well, which results in a diminished functional reserve capacity. Therefore, lung infections and trauma can have a dramatic effect on oxygenation. Respiratory distress and shock can set in much more suddenly in such a child. - The chest wall of a child is extremely pliable, even well into adolescence. This can lead to significant injuries to the organs underlying the ribs, even in the absence of rib fractures. Any bruising across the chest of a child should be considered significant until proven otherwise via x-ray at the hospital. - The spine of a child is much more pliable than that of the adult because the tendons are not as taut. This can result in SCIWORA and a lack of assessment evidence that can indicate a spinal injury. Maintain a high index of suspicion with any significant mechanism of injury. - Abdominal organs are more anterior and less protected by the rib cage. Therefore, abdominal trauma can be more significant in younger children, even with relatively minor mechanisms such as low-speed motor vehicle crashes in the presence of properly placed restraints. Specific Pediatric Emergencies Respiratory Problems and Hypoxia Children’s breathing problems are classified as respiratory distress, respiratory failure, or respiratory arrest. Respiratory Conditions and Treatment
Tip: There is no hard and fast break point between respiratory distress and respiratory failure, so spending time classifying the patient is neither necessary nor helpful. Beginning more aggressive treatment earlier in the course of treatment, however, is always better than waiting until symptoms worsen. Respiratory Emergencies Please refer to this guide for information on the following respiratory emergencies: asthma, anaphylaxis, croup, and epiglottitis. Cystic Fibrosis Cystic fibrosis is a genetic disease that often is discovered early in life, usually by the 2nd birthday. Its hallmark is excessive, thick secretions of mucus in the lower airways and a high salt content in sweat. Patients have a difficult time clearing these secretions and often are hospitalized for infections such as pneumonia and bronchiolitis. Treatment for a patient with cystic fibrosis is largely symptomatic and may include bronchodilators, humidified O2, and possibly positive pressure ventilation. Pertussis Commonly known as whooping cough, pertussis is caused by an infection with bacteria and transmitted via respiratory droplets. Its symptoms are similar to the common cold, with a runny nose, sneezing, and coughing, but as the disease worsens with time, the cough will take on the characteristic “whoop” sound with inspiration. The coughing can become so severe that the patient presents with respiratory distress and cyanosis. If pertussis is suspected, take airborne precautions, including surgical mask and eye protection. Bronchiolitis Bronchiolitis is a swelling of the lower airways similar in nature and presentation to asthma, but it resulting from a viral infection called respiratory syncytial virus. Because asthma is rare in children under 1 year old, the virus is most likely causing the symptoms. Regardless of the ultimate cause, the treatments are identical. Albuterol or nebulized racemic epinephrine should be administered; in severe cases, positive pressure ventilation may be needed as the patient moves from respiratory distress to failure. Figure: Bronchiolitis Treatments
Children in respiratory distress often benefit from supplemental O2. With their relatively low tidal volumes and high metabolic O2 demand, any disease process that affects alveolar ventilation or respiration should receive high-flow supplemental O2. A child who is still responsive may not tolerate a face mask despite needing that volume of O2. In this case, blow-by O2 across the nares can be similarly effective without stimulating anxiety in the child. The child’s caregiver can be a resource in a situation such as this because the caregiver may be more successful at holding the tubing near the child’s face.
Initiation of positive pressure ventilation should begin at the 1st sign of a decrease in respiratory effort or level of consciousness. Ensure that the proper size BVM is used for ventilation but avoid overinflation of the lungs. Children’s lungs are more susceptible to barotrauma from forceful ventilation compared with an adult’s lungs, and it is not uncommon for a rescuer to use an adult bag on the child. If this is the case ensure that the ventilation volume is just enough to see the chest rise and that the person providing the positive pressure ventilation is focused on that critical job.
Intubation of children should be performed for any of the following reasons: - Poor seal of the mask to the face - The need for extended resuscitation times - Cardiac or respiratory arrest - Head or facial injury - Inability to protect and maintain the airway (because patient is obtunded) Selecting the size of the ETT can be difficult in a child. In children <8, the size of the airway at its narrowest point can be approximated by comparing the size of the ETT to the pinky of the child. The diameter also can be calculated by adding 16 to the patient’s age in years and then dividing the result by 4. Tip: This equation will give you the anticipated size for an uncuffed tube. If you have only cuffed tubes, reduce the tube size by 0.5 mm. For example, an 8-year-old child would get a 6.0 uncuffed tube: (16 + 8)/4 = 6. For a cuffed tube, this child would likely get a 5.5 cuffed tube. When preparing to intubate, in addition to having suction and other ancillary equipment prepared, always have available a tube 1 size higher and 1 size smaller than the expected size tube. If the benefit to the child outweighs the possible risks, then the child should be intubated. The risks, in many cases, can be anticipated ahead of time, with steps taken to mitigate them.
The risks of intubation include the following: - Damage to teeth and gums from using the upper teeth or gums as a fulcrum - Trauma and swelling to the oropharynx, tongue, and epiglottis - Worsened hypoxia from prolonged intubation attempts - Unrecognized esophageal intubation - Stimulation of an intact gag reflex and resultant vomiting - Increased ICP - Bradycardia from vagus nerve stimulation The child who is intubated should be constantly reassessed specifically for tube displacement and the effects of barotrauma. Use the mnemonic DOPE to assess the child, especially when changes in ventilatory status present. - D: Displacement - Check that the tube is still in the trachea with auscultation of the lungs and direct laryngoscopy. - Check that the tube has not been pushed deeper and is still at the same centimeter mark at which it was originally placed.
- O: Obstruction - Mucus, blood, vomit, or other secretions can obstruct the tube, preventing ventilation or exhalation. - Suction the tube using a soft-suction catheter.
- P: Pneumothorax - Increased difficulty ventilating the patient is indicative of a developing pneumothorax. - Assess for signs of a pneumothorax, including tracheal deviation, JVD, and absent or diminished lung sounds. These can be very difficult to evaluate in the infant who has a minimal neck that can hide JVD and tracheal deviation.
- Ensure O2 is flowing. - Evaluate tubing for crimping or kinks. This should include the ETT. - If using a mechanical ventilator, replace it with a BVM and manually ventilate for a few minutes. Tip: DOPE is the mnemonic you will need to know for the test. However, it can sound rather crude if you were to say to your partner, “Check the DOPE,” in the presence of the child’s caregivers. Not only that, but the mnemonic places evaluation and treatment of a pneumothorax ahead of equipment failure. Instead, POET is an alternate mnemonic for evaluating a patient who is intubated. The letters stand for placement, obstruction, equipment, and tension pneumothorax, and it sounds a little friendlier to say, “Check the POET!” Shock Shock in any person regardless of age is the lack of perfusion to end organs. Children can experience the same types of shock as an adult. The major difference between children and adults is that children will be able to remain in compensated shock for longer period of time. However, when the time comes that the child can no longer maintain blood pressure, it is because the child has completely exhausted every compensatory mechanism available. The blood pressure drops alarmingly fast, often without warning; if the child is not already receiving aggressive pressure support therapy, irreversible shock is imminent. Compensated shock is characterized by tachycardia in the child. Young children do not sweat nearly as readily as older children and adults. Pallor centrally and mottling of the skin peripherally should be concerning because both indicate shunting of blood from the peripheral circulation to the central circulation. Capillary shunting in children is more successful than in adults, so seeing this should alert the paramedic to begin treatment. As the shock progresses and compensated shock becomes decompensated, the child will become lethargic. As the child becomes lethargic, he or she begins to no longer respond to familiar surroundings. Children will no longer cry when they are taken away from their parents or regular caregivers. If they can still make a sound, it will be a weak whimper that is short lived after a painful stimulus. Peripheral pulses will no longer be palpable, and central pulses will remain strong before fading later. A child who is first encountered in this state should receive aggressive fluid resuscitation and pressor support as soon as possible with vascular access most likely started with an intraosseous line. Hypotension will be profound as the child begins to decompensate. The minimum SBP in a child can be calculated based on the child’s age. The minimum blood pressure is calculated by adding 70 to twice the age in years. Anything approaching this value should be concerning because it will become significant shock. Anything below this value should be treated aggressively. Treatment for Shock The cornerstone of shock treatment in the child is fluid resuscitation. Therefore, vascular access in the child in shock is essential. The access may be intravenous or intraosseous, and fluid should be able to flow freely or with pressure added to the intravenous bag. For the child in symptomatic shock who is tachycardic with other signs such as pale cool mottled skin or altered mental status, fluid should be given as a bolus of 20 mL/kg. This dose may be repeated up to 3 times before blood or blood products are required. Once the vascular access has been obtained and the fluids are being administered, treatment should be targeted to the cause or type of shock. Anaphylactic Shock - Epinephrine, 1:1,000 solution, 0.01 mg/kg up to a maximum dose of 0.3 mg intramuscularly - Diphenhydramine, 0.5–1 mg/kg to a maximum of 50 mg - Methylprednisolone, 0.5 mg/kg to a maximum of 60 mg Neurogenic Shock - Methylprednisolone, 0.5 mg/kg to a maximum of 60 mg Septic Shock - Aggressive fluid therapy is the most important treatment. Administration in excess of 60 mg/kg may be required. - Treat hypoglycemia with 0.5–1 g/kg of a 25% dextrose solution to a maximum of 50 g. Hypoglycemia may not be initially present, but after the administration of fluids, the patient may be come relatively hypoglycemic. Cardiogenic Shock - Fluid bolus should be administered slowly—and the patient reassessed frequently during the bolus—to ensure that the patient does not become fluid overloaded. - Contact medical control for the preferred pressor medication and dose if needed. Often in children, the preferred pressor is epinephrine 0.1–1 mcg/kg/min as an intravenous or intraosseous infusion, titrated to the desired effect. Altered Mental Status AEIOU-TIPS
Treatment for any of these reasons is largely the same as in the adult population. Every patient with an altered mental status should be checked for low blood sugar even if there is no history of diabetes. Overdoses and Poisonings Overdoses and poisonings in children can be widely varied and can be either accidental or intentional. Younger children are more likely to have accidentally overdosed on medications thinking that they are candy. These overdoses can be catastrophic and should be treated symptomatically with appropriate supportive care. Older children are more likely to intentionally overdose on prescription medications or street drugs. Older children also may do this with the intent of achieving a euphoric state or to execute a plan of suicide. Again, these should be treated symptomatically. Seizures Seizures in children can be caused by a number of factors. Hypovolemia, sepsis, underlying abnormalities, epilepsy, and fever are all common reasons for a child to seize. It may not be possible to determine the exact cause in the field. Febrile seizures are most common, but the child should be assessed to rule out other causes for seizures, including head injuries and stroke. A febrile seizure occurs when a child’s temperature rises very quickly, often as the result of an infection rather than environmental hyperthermia, although hyperthermia is possible as well. Febrile seizures occur in children between the ages of 6 months and 6 years. A child who has had a febrile seizure in the past is predisposed to having another febrile seizure. Treatment for this type of seizure most often is supportive. This type of seizure seldom requires intervention because it typically lasts less than 5 minutes, and the child returns to normal within an hour of the event. Anticonvulsants are not usually indicated for this reason. Rapid, active cooling often is contraindicated as well because the resulting rapid drop in core body temperature could precipitate another seizure. If the child is bundled up or under multiple blankets, removing the child from the blankets is all the cooling that would be recommended in this situation. Children having an epileptic seizure, on the other hand, will require more aggressive interventions. These children should receive O2 to maintain a pulse oximetry reading of >95%, and high-flow O2 during ongoing seizures regardless of the pulse oximetry. Establishment of an intravenous line is recommended as soon as the seizure activity subsides.
Anticonvulsant medications should be administered according to the patient’s weight. It is best to use a length-based tape to determine the doses of the medications.
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