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Ch 35 Pediatric Emergencies
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Notes on Pediatric Emergencies
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Chapter 35 Pediatric Emergencies Notes* Introduction- Children differ automatically, physically, and emotionally from adults - The illnesses and injuries that children sustain, and their responses to them, vary based on age or developmental level- It’s important to remember that children are not small adults (depending on their age, the child may not be able to tell you what is wrong)- Fear of EMS providers and pain can make the child difficult to assess- Parents or primary caregivers may be stressed, frightened, or behaving irrationally- For these reasons, pediatrics (the specialized medical practice devoted to the care of young patients) can be challenging- Once you learn how to approach children of different ages and what to expect while caring for them, you will find that treating children also offers some very special rewards- Their innocence and openness can be appealing- Children often respond to treatment much more rapidly than adults do* Communication With the Patient and the Family- Caring for an infant or child means that you must care for the parents or caregivers as well- Family members or caregivers often need emotional support- A calm parent usually results in a calm child- The parent can often assist you with the child’s care- And agitated parent means that the child will act the same way (which may make the child care more difficult)- Remain calm, efficient, professional, and sensitive* Growth and Development- Many physical and emotional changes occur during childhood- Childhood extends from birth until 18 years old- The thoughts and behaviors of children as a whole are often grouped into five stages:- Infancy:- The first year of life- Toddler:- Ages 1 to 3 years- Preschool age children:- Ages 3 to 6 years- School-age children:- Ages 6 to 12 years- Adolescence:- Ages 13 to 18 years* The Infant- Infancy is usually defined as the first year of life- The first month after birth is called the neonatal or newborn period* 0 to 2 Months- Infants less than two months spend most of their time sleeping or eating- Infants cannot tell the difference between parents and strangers- Crying is one of the main modes of expression (Soothing an infant should be relatively easy for the parent or caregiver, such as holding, cuddling, or rocking the infant. Hearing is generally well developed at birth, so calm and reassuring talk is often helpful as well)- An inconsolable infant, after all obvious needs have been addressed, could be a sign of significant illness - Their heads have a relatively large surface area which predisposes them to hypothermia - They sleep for up to 16 hours per day between feeding times and parent or caregiver interactions- And fence at the stage have a sucking reflex for feeding- How to control is limited, but infants can turn their heads and focus on faces- Have poor thermoregulation (These factors predispose them to hypothermia, so parents or caregivers will often bundle infants to keep them warm) * 2 to 6 Months- Infants at this stage are more active (which makes them easier to evaluate)- They begin to smile and make eye contact- Spend more time awake- Can recognize their parents or caregivers, may follow a bright light with their eyes, and turn their head toward a loud sound or familiar voice- Healthy infant at this stage will have:- Strong sucking reflex- Active extremity movement- A vigorous cry - Potential indicators of serious illness, depressed mental status, or a delay in development:- Persistent crying- Irritability- Lack of eye contact - Will use both hands to examine objects and explore the world- About 70% of infants will sleep through the night by six months (at this point in development, infants will begin to rollover) * 6 to 12 Months- During this stage, infants begin to babble and by the first year, they may say their first word- They can sit without support, progress to crawling, and finally, begin to walk (This predisposes this age group to increased exposure to physical dangers)- At this age, infants are teething and tend to explore the world by picking things up and placing them in their mouths- They may begin to cry if separated from their parents or caregivers (this behavior is called separation anxiety)- One way you can limit the infant’s agitation is to let the parent or caregiver hold them as you start your physical assessment- As with the younger infants, persistent crying or irritability can be a symptom of serious illness * Assessment - Begin your assessment by observing the infant from a distance (preferably in a parent’s or caregiver’s arms; this will avoid separation anxiety and often make the assessment of the infant easier) - Provide as much sensory comfort as possible (warm your hands and the end of the stethoscope and offer a pacifier if the parent or caregiver allows it) - Do any painful procedures at the end of the assessment process- Complete each procedure efficiently and avoid interruptions- Explain each procedure to the parent or caregiver before you perform it (because the procedure and the infant’s reaction may be upsetting)* The Toddler - After infancy, until 3 years of age, a child is called a toddler- Toddlers experience rapid changes in growth and development* 12 to 18 Months- Because they are explores by nature and not afraid, injuries in this age group increase - Toddlers begin to imitate the behaviors of older children and parents and may express the desire to dress like their mommies or daddies- They know major body parts would you pointed them and may speak 4 to 6 words- Because of lack of molars, they may not be able to fully chew their food (leading to an increased risk of choking)* 18 to 24 Months- The mind of the toddler develops rapidly- At the beginning of this stage, the toddler may have a vocabulary of 10 to 15 words (by 2 years of age, a toddler should be able to pronounce approximately 100 words)- When you point to a common object, toddlers should be able to name it- They begin to understand cause-and-effect with such activities as playing with pop-up toys and turning on and off the lights - Their gait and balance also improve rapidly during this period (Running and climbing are skills that develop)- They tend to cling to their parents or caregivers and often have a special object such as a blanket or teddy bear that comforts them when they are separated (be sure to use any comforting objects when available to help calm them)* Assessment- May have stranger anxiety- May resist separation from the parent or caregiver- Demonstrate the assessment on a doll or stuffed animal first if possible- They may be unhappy about being restrained or held for procedures- Toddlers can have a hard time describing or localizing pain (Pain in the abdomen may be expressed as “my tummy hurts”)-Use visual clues or Wong-Baker FACES pain scale - They may be distracted by a toy in order to assess their vital signs- Begin your assessment at the feet or away from the location of pain if possible - Persistent crying or irritability can be a symptom of serious illness or injury- Previous medical experiences may lead to hesitation towards you- If a parent or caregiver is unavailable, reassure the child using simple words and a calm, soothing voice * The Preschool-Age Child (3 to 6 Years)- Children in this stage are able to use simple language effectively (The most rapid increase in language occurs during this stage of development) - They have a rich imagination and can be fearful about pain (They may believe injury is a result of earlier bad behavior) - The risk of foreign body airway obstruction continues to be high at this age* Assessment - Preschool age children can understand directions, be more specific in describing their sensations, and identify painful areas when questioned - Despite increased ability to communicate, much of the history must still be obtained from the parents or caregivers - Communicate simply and directly- Appealing to the child’s imagination may facilitate the examination process - Never lie to the patient (Once you have lost your pediatric patient’s trust, it will be a challenge to regain it)- They may be easily distracted by games or a toy, or conversation- Begin the assessment at the feet and move toward the head (similar to assessing a toddler)- Use adhesive bandages to cover the site of an injection or other small wound (because the preschool-age child might be worried about keeping their body together in one piece)- Modesty is developing at this stage, so keep the child covered as much as possible * School-Age Years (6 to 12 Years)- Children in this stage begin to act more like adults- They can think in concrete terms, respond sensibly to direct questions, and help take care of themselves- School is important at this stage and concerns about popularity and peer pressure occupy a great deal of time and energy (children with chronic illness or disabilities can become self-conscious because of concerns about fitting in with their peers)- At this stage, children begin to understand death is final (but their understanding of what death is and why it occurs is still unrealistic) * Assessment - Assessment begins to be more like an adult assessment- To help gain trust, talk to the child, not just the parent or care giver- The child is probably familiar with the process of a physical exam- Start with the head and work toward the feet (as in an adult patient) - If possible, give the child choices in (only ask the type of questions that let you control the answer and do not bargain or debate with the child) - Allow the child to listen to their own heartbeat through the stethoscope- These children can understand the difference between physical and emotional pain- Give them simple explanations about what is causing the pain and what will be done about it- Ask the parents or caregivers for advice about which distraction will work best * Adolescents (12 to 18 Years)- At this stage, personal morals begin to develop- Adolescents are physically similar to adults (but they are still children on the emotional level)- Puberty begins in this stage- They are concerned about body image and appearance- They have strong feelings about privacy - This is the stage of experimentation and risk taking behaviors- Often feel “indestructible”- Struggle with independence, loss of control, body image, sexuality, and peer pressure * Assessment - Adolescents can often understand very complex concepts and treatment options- Allow them to be involved in their own care- An EMT of the same gender should perform the physical examination, if possible, to lessen the stress of the event- Allowed them to speak openly and ask questions- Risk-taking behaviors are common- Can ultimately facilitate development in judgment, and shape identity- Can also result in trauma, dangerous sexual practices, and teen pregnancy - Female patients may be pregnant- They may not want their parents to know this information- Try to interview without the parent or caregiver present - Get them talking to distract them * Anatomy and Physiology- The body is growing and changing rapidly during childhood- You must understand the physical differences between children and adults and alter your patient care accordingly * The Respiratory System- Anatomy of pediatric airway differs from adults in several ways:- Pediatric airway a smaller in diameter and shorter in length- Lungs are smaller- Heart is higher in a child’s chest- Glottic opening is higher and positioned more anteriorly, and the neck appears to be nonexistent- As children develop, the neck gets proportionally longer as the vocal cords and epiglottis achieve anatomically correct adult position - The occiput is larger and rounder (this requires more careful positioning of the airway)- The tongue is larger relative to the size of the mouth and in a more anterior location in the mouth (the child’s tongue can easily block the airway)- Long, floppy, U-shaped epiglottis in infants and toddlers is larger than adult’s - Rings of cartilage in the trachea are less developed and may easily collapse if the neck is flexed or hyperextended- The upper airway has a narrowing funnel shape compared to the cylinder shape of the lower airway- The diameter of the trachea in infants is about the same as a drinking straw- The airway is easily obstructed by secretions, blood, or swelling(Infants are nose breathers and may require suctioning and airway maintenance)(Respiratory rate of 20 to 60 breaths/min is normal for a newborn) - Children have an oxygen demand twice that of an adult (increases risk for hypoxia) - The muscles of the diaphragm dictate the amount of their child inspires- Anything that places pressure on the abdomen of a young child can block the movement of the diaphragm and cause respiratory compromise(Use caution when applying to straps of a spinal immobilization device because it may hinder the tidal volume)The anatomy of a child’s airway differs from that of an adult in several ways:-The back of the head is larger in a child. -The tongue is proportionately larger and is located more anterior in the mouth. - The trachea is smaller in diameter and more flexible. -The airway itself is lower and narrower (funnel-shaped)
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