EMT 7-1: Pediatric

Welcome to this module on special patient populations and the pediatric patient.
Upon completion of this module, you should be able to:
Explain why pediatric patients need varying approaches to assessment and care.
Identify the developmental considerations for the following age groups: infants, toddlers,
pre-school, middle childhood, and adolescent. Consider the metabolic differences in providing
care to the pediatric patient. Identify the anatomical and physiological
differences to consider in the care of the pediatric patient in the following areas:
head, airway, chest, lung, abdomen, extremities, integumentary system, respiratory system,
circulatory system, nervous system, and spinal column.
Summarize the components of the pediatric assessment triangle (PAT).
Describe the hands-on assessment of the ABCs. Identify the additional assessment techniques
utilized in a SAMPLE history and secondary assessment.
Predict the emotional reaction an EMT may have during and after a pediatric emergency.
Describe general considerations of the assessment process utilized for the pediatric patient.
List specific pathophysiology, assessment and management of the following emergencies
encountered in the pediatric patient: respiratory distress, shock, neurological, gastrointestinal,
toxicology, SIDS, and trauma. You will also be able to:
Explain the importance of including family members in the assessment and management of
a pediatric patient. Explain the rationale for having knowledge
and skills appropriate for dealing with a pediatric patient.
Attend to the feelings of the family when dealing with an ill or injured pediatric patient.
Understand the provider’s own response (emotional) to caring for pediatric patients
By the end of this module, you will be able to conduct a patient interview for a pediatric
patient and demonstrate the assessment of a pediatric patient.
The EMT needs to be aware of the differences in the pediatric patient in a variety of ways.
Children are not just small adults. The illnesses and injuries found in the prehospital environment
are highly age-dependent. For example, infants are more at risk for respiratory infections
because they have not yet built the immunity of older children. Infants are also at risk
for dehydration and abusive injuries because they cannot tend to or defend themselves in
either situation. Think of a child you may know in the toddler years, they move about
quickly, have no fear of investigating new things, and tend to put anything and everything
in their mouths. This behavior puts toddlers more at risk for poisonings, drowning, and
electrical burns. Older school age children tend to be more mobile and adolescents tend
to be at risk for drugs, motor vehicle crashes, and violence.
How the EMT approaches each child is as individual as is the child; however, there are some general
similarities and strategies that work with each age group. If an EMT is not familiar
with children in each age group, it would be a great “best practice” to participate
in activities that cover all developmental stages. The EMT must have a good understanding
of how anatomic differences in each stage impact the treatments provided in the field.
Adjustments in the patient interview and physical exam will also need to be made in order to
successfully assess each age group. The growth and developmental stages that will
be reviewed are broken down by infancy, the toddler years; preschool years; middle childhood;
and, finally, adolescence. Each stage has unique physical development similarities,
common cognitive development benchmarks, ballpark vital signs, and specific treatment considerations
for providing prehospital care. The infant stage is considered to be from
birth to one year. As short of a span this is, there are some general characteristics
that need to be remembered for infant patients. Our discussion will look at developmental
stages from birth to two months, two to six months, and six to 12 months.
From birth to about two months, the young infant should able to turn his or her head,
gaze at an object, and perform sucking skills. The infant at this stage is completely dependent
on someone else. Crying is a good sign for EMS because crying
means the infant’s airway is open. Crying is a form of communication for the infant.
The infant will cry if hungry, angry, in pain, or uncomfortable. Crying usually will cease
when the problem is addressed. However, once basic needs have been met, persistent crying
can be a sign of significant illness or injury. The EMS professional should consider the cause
of the crying by physical examination, observation of the environment, and thorough interviewing
of the caregivers. An infant should be able to be aroused rather easily. If the EMT can
not arouse the infant, consider it a possible emergent situation. All small children, especially
infants have large craniums; their heads, in proportion to their bodies, are larger
than an adults. The neck muscles on small infants are not well developed, resulting
in limited head control. It is important for the EMT to always support the head and neck
when caring for an infant. Infants also do not have enough body fat for insulation, so
it is important the EMT keep the infant warm. Since heat escapes from the head rather easily,
and the infant’s head is so large in proportion to the rest of the body, always attempt to
keep the head covered. If clothing needs to be removed for assessment, attempt to remove
and replace clothing sequentially in order to retain body heat. Always remember to warm
hands and equipment before touching an infant. Once the infant starts to cry because of the
“shock” of cold hands or a cold stethoscope, it is much harder to complete an adequate
assessment. Respiratory illness are the most common medical problems seen infants and the
major causes of death include Sudden Infant Death Syndrome (SIDS), unintentional suffocation,
and child abuse. As the infant grows physically, they are able
to voluntarily smile and increase and hold more eye contact with others especially when
they begin to recognize familiar faces. They tend to use both hands to hold onto objects
and start to examine things held in their hands. Some studies show that 70 percent of
infants tend to sleep through the night by the age of six months. Somewhere between two
and six months, caregivers begin to notice intentional rolling over by the infant. Neck
muscles are increasing in strength and the infant should be able to hold his or her head
up longer. This stage also includes an increased awareness of surroundings and the ability
to start examining and exploring the body such as finding the toes on the end of their
feet. In this age range, patient care considerations
are very consistent with the birth to two month old infant. Always keep the infant warm
by covering their head and removing and replacing clothing sequentially. Persistent crying or
irritability can be a sign of serious illness, and the lack of eye contact when sick could
also be a sign of a depressed mental status or delayed development in the child. Good
physical assessments and in-depth questioning of the caregiver will help determine if the
mental status and eye contact is normal for the infant. Neck muscles are becoming stronger
at this age but head control is still limited, so protect the head and neck when lifting
and moving the child. As the infant begins to recognize familiar faces, stranger anxiety
also begins to develop. From six to twelve months, infants typically
show increased mobility over time by beginning to crawl. These precious kids are now able
to start sitting up without any support and they move away from grasping items with their
palms, to more of a pincher grasp by learning how to use their thumbs and fingers. Constant
supervision is usually needed because everything a child picks up usually ends up in their
mouths. At this age, the child usually begins to develop baby teeth, allowing them to start
eating solid, albeit soft, foods. Cognitively at this age, children are starting
to babble and use their first words. First time parents anxiously wait for those first
“mama or dada” sounds to come out of their child’s mouth. Separation anxiety from parents
continues to increase as the child may now protest or withdraw given a separation.
In this age range, patient care considerations are again very consistent with the birth to
two month old infant. Always keep the child warm by covering their head and removing and
replacing clothing sequentially. Persistent crying or irritability can be a sign of serious
illness or injury; try to determine the cause. Because of increased mobility and exploration,
this age range is now more at risk for foreign body airway obstructions, aspirations, or
poisonings. Separation anxiety can be lessened by keeping the child and the parent together
during the evaluation and even letting mom or dad help out with the process. If the child
is stable enough, having him or her remain in a parent’s lap may help move the assessment
and interventions along. However, if the child is unstable because they are seriously ill
or injured, it may be necessary to keep the parents separate from the child. If possible,
give the parents a job or role that allows them to help, but not be in the way of the
assessment or interventions. Later in the presentation, you will learn
that your assessment of a pediatric patient can begin from literally across a room. A
general impression of the child can tell the trained EMT a lot, even before any vital signs
are obtained. You will soon learn how to use the Pediatric Assessment Triangle (PAT) when
assessing pediatric patients. Vital signs are important to obtain, but the identification
of immediate life threats will routinely be made by assessing the child’s appearance,
work of breathing, and circulation to the skin. Those three components comprise the
PAT. Patients in this age range will typically
have heart rates of 100 to 160 beats per minute, depending on the child’s age. The younger
the child, the faster the heart beats. From birth to a few months after, the number
of times a infant breathes is usually around 40 to 60 times per minute. As the child nears
the age of one, the breathing rate slows down, yet the volume of air inspired steadily increases
given larger lungs. Even though it is not recommended to measure
blood pressures in the pre-hospital setting for children under the age of three, it is
important to have an understanding of normal systolic numbers for all age groups. Systolic
pressures begin around 70 at birth and increase to about 90 at the age of one year. Obtaining
blood pressures in a infant or toddler under three is a difficult procedure to accomplish
and children tend to compensate so well during a crisis; if we see drastic blood pressure
changes, it is usually because the child is in grave distress. An EMT can appropriately
care for an infant by assessing and reporting PAT findings, along with the patient’s heart
and respiratory rate. Temperatures during this age range tend to
be from 98 to 100 degrees Fahrenheit. Again, measuring temperatures may be limited to children
who present with a fever. Common convenient temperature monitors, such as tympanic thermometers,
are not considered to be very reliable. Be sure to follow your local protocols regarding
obtaining a temperature in an infant patient. Watch out, because children in the 12 to 18
months age group tend to move like lightening, so to speak, which increases their vulnerability
to and risk for injuries because they have not yet developed adequate caution in their
exploration of their new environment. An EMT should be able to use words like tummy, leg,
arm, eye, and head when assessing a child because, by this age, children should know
most of their major body parts and will be able to point to those parts when asked simple
questions about “owies” and “booboos.” The EMT needs to be careful when asking permission
to do anything to the child because their favorite word is “NO.” It is sometimes
better to give the child a choice of action such as, “should I listen to your tummy
first or your back first?” as opposed to absolute questions that require a yes or no
answer. Providing choices gives the child a chance to participate without interrupting
your assessment. There is an increased suspicion of strangers at this age so, if the child
is stable, try to have the parent or caregiver hold the child (if possible) and involve them
in the assessment and treatment process. As with previous age ranges, persistent crying
or irritability can be a serious sign. Always look for a cause before ruling out a child’s
persistent crying. More teeth are now available, but the child may not be able to grind up
the food adequately before swallowing due to a lack of molars, so there is a risk of
food aspiration while eating. With their new found freedom, it may be hard to keep a child
still while performing an assessment. Again, utilize mom or dad in the assessment process
for efficiency. Kids might think their injury or illness is a punishment for either doing
or not doing something, so it is important to reassure the child on a regular basis.
As with much of the population, this age range fears pain and is afraid of needles, so extra
reassurance is needed during interventions, especially if they are invasive. It is important
to let the child know what you are going to do, when you are going to do it, and why.
Sometimes, if you allow the child to bring along a favorite toy, blanket, or stuffed
animal, you can distract the child and decrease his or her level of anxiety. As long as they
are stable, children in this age group respond best to a torso-to-head physical exam. That
gives the EMT time to build a connection with the child without becoming overbearing. Using
the equipment in a way to make a game out of the assessment will help the child be more
comfortable and cooperative. Examples of this technique would be blowing up a glove into
a “balloon” and then drawing a funny face on it for the child to play with, using the
oxygen mask as a Santa beard, or even having the child “blow out the light” like a
candle on the pen light to increase tidal volume while assessing lung sounds. There
are a lot of tricks you will learn or even develop when dealing with all age groups;
these are just examples of a few. Physical development in the 18 to 36 month
age range gives the child improved gait and balance. They begin to run and climb on all
available furniture and surfaces in their path, which increases their risk of injuries
due to falls. They begin to have a better understanding of cause and effect. For example,
if they touch the stove, it might be hot, resulting in an “owie.” But just as with
the younger toddler range, the children might think their injury or illness is a punishment
for either doing or not doing something, so it is important to reassure the child on a
regular basis. The EMT should be able to obtain additional information from the child because
of an increased vocabulary. Emotionally, this age group dislikes separation
from their parents. As long as the child is stable, keeping the parents involved in the
process will probably encourage cooperation for the child. Find out about a favorite toy
or object and allow the child to hold on to it if possible. Just as the 12 to 18 month
range, this age range fears pain and is afraid of needles, so extra reassurance is needed
during interventions such as obtaining a blood glucose or an injection of mediation. It still
remains important to let the child know what you are going to do, when you are going to
do it, and why. Sometimes, if you allow the child to bring along a favorite toy, blanket,
or stuffed animal, you can distract the child and decrease the level of anxiety. As long
as they are stable, children in this age group respond best to a trunk-to-head physical exam.
That gives the EMT time to build a connection with the child without becoming overbearing.
Remember, using the equipment in a way to make a game out of the assessment will tend
to make the child more comfortable and cooperative. Typical vital signs during the toddler years
are as follows: Heart rates range from 80 to 130 beats per
minute. Respiratory rates range from 20 to 30 respirations per minute. Systolic blood
pressures range from 70 to 100 millimeters of mercury. Temperatures range from 96.8 to
99.6 degrees Fahrenheit. During the preschool years (three to six years
old), children tend to become more mobile and active in activities and sports. This
increase in activities also increases their exposure to traumatic incidents and makes
this age group more vulnerable to injury. Toilet training usually occurs during the
early preschool age range (although some do start as toddlers). Preschoolers have the
most rapid increase in their language during this period and can answer simple questions
appropriately. Thinking tends to be of the magical nature and rules tend to be absolute,
so some of the fears for this age group tend to be irrational. The child might be frightened
of his or her own injury, especially if it is bloody, because the child might see it
as permanent. Emotionally, this age group learns acceptable
and unacceptable behaviors and preschool children tend to have tantrums when they do not get
what they want. The fear of “stranger danger” is developing given exposure to all the educational
lessons provided by the media and parents. Modesty starts to show itself given the dislike
of being undressed by someone and this age group commonly fears permanent injury.
This age range is more trusting and friendly to strangers than toddlers, but they still
have anxiety with stranger danger. The EMT should be able to elicit more information
regarding the illness or injury due to the increased language capability of the patient.
As with any patient, respect their modesty when performing the exam. If possible, begin
the exam with the chest and abdomen, then proceed to the head and extremities. Kneel
down to the child’s level and allow the child to help with the exam. Appeal to the
child’s magical thinking; an example is to tell a child that the “magic smoke”
from the nebulizer will help him or her feel better. Have a healthy understanding that
this age group really fears pain, along with the sight of blood or injuries, so adjust
your words and interventions appropriately. Let the child know what you are going to do
and if it will hurt when you do so. Typical vital signs during the preschooler
years are as follows: Heart rates range from 80 to 120 beats per
minute. Respiratory rates range from 20 to 30 respirations per minute. Systolic blood
pressures range from 80 to 110 millimeters of mercury. Temperatures range from 96.8 to
99.6 degrees Fahrenheit. In middle childhood (six to 12 years of age),
physical development changes are observed with the loss of baby teeth and the eruption
of permanent, adult teeth. This age range is highly mobile and at a higher risk of injury.
During middle childhood, kids tend to begin thinking with greater logic, so they can communicate
more effectively. School and friends become an important part of life. Popularity and
peer pressure affect self-consciousness and self-esteem. They still like to have a parent
nearby in an emergency, but independence starts to show. They like to act “grown up” but
their fears are still similar to that of a preschooler. They are afraid of blood and
pain and they still fear permanent injury or disfigurement with injuries.
When responding to an emergency for a child between the ages of six and 12 years, try
to provide simple explanations for illnesses and subsequent treatments. You may see more
cooperation if you also provide a senses of control by giving the child a choice in the
order of treatments, if possible. As always, respect the patient’s modesty and re-cover
any exposed areas after the physical exam. Engage the child in a conversation by asking
questions about school or topics familiar to them.
Typical vital signs for a child in middle childhood are as follows:
Heart rates range from 70 to 110 beats per minute. Respiratory rates range from 20 to
30 respirations per minute. Systolic blood pressures range from 80 to 120 millimeters
of mercury. Temperature begins to approach a normal adult temperature of 98.6 degrees
Fahrenheit. If you are keeping track of trends, you will
notice as the child increases in age, the pulse rate drops, the respiratory rate drops
slightly, and the systolic blood pressure increases slightly. Body temperature slowly
approaches what we consider normal in the adult.
Adolescence is the transition period between childhood and adulthood. There are a lot of
physical changes in the body, which leads to increased modesty in both genders. Breast
development in females, pubic hair growth, and hormonal changes all bring about new emotional
and physical concerns to the adolescent. Cognitively, the adolescent is able to communicate as an
adult and they have an increased ability to reason as they age, which can contradict some
of their actions as they tend to deny that real life tragedies, like death and accidents,
may happen to them. The adolescent will also start to develop morals as they increasingly
find themselves in unique positions involving peers and family.
Because of physical changes, the adolescent is typically self-conscious about body image
as they are forced to become more comfortable with themselves. More relationships and friendships
develop with the opposite gender and adolescents start to develop a better understanding of
who they are and what they believe. If the adolescent is injured, they will be concerned
with their body image and what other people will think. A small cut on an adolescence's
face may appear minor, but can be devastating to the 16 year old. Due to increased freedom
and peer pressure during this age range, the adolescent dabbles in more self-destructive
behaviors such as tobacco use, smoking, alcohol, and illicit drug use. Obtaining a driver’s
license opens up a whole new world of freedom to the adolescent, which is one of the reasons
why motor vehicle accidents claim so many young lives. Given societal and peer pressures,
eating disorders such as anorexia and bulimia are too common in the adolescent population,
especially with females. People in this age group struggle with depression and thoughts
of suicide more than any other age group. Adolescents want to be treated like adults,
but remember they may still share many of the same fears and insecurities of the younger
child. Explain all assessments and treatments clearly and honestly. Give them choices if
appropriate as far as assessments and interventions are concerned. Respect their modesty by trying
to have an EMT of the same gender perform the exam. If possible or needed, assess and
treat the patient away from the parents to obtain a more accurate history and story.
Address the patient’s fears and concerns about lasting effects of their injuries, especially
cosmetic concerns. Be cognizant that adolescence is a time of many hormonal surges, emotions,
and peer pressure. The adolescent is at risk for substance abuse, self-endangerment, pregnancy,
and dangerous sexual practices. The EMT must remain nonjudgmental while providing reassuring
care. Typical vital signs for an adolescent are:
Heart rates range from 55 to 105 beats per minute. Respiratory rates range from 12 to
20 respirations per minute. Systolic blood pressures range from 100 to 120 millimeters
of mercury. Temperatures are close to a normal adult temperature of 98.6 degrees Fahrenheit.
These vital signs are very close to that of an average adult patient.
At this point, we will shift away from looking at specific pediatric age ranges and begin
discussing pediatric anatomy and physiology in general.
For the first several years of life, the child’s head is proportionally larger relative to
their body size. In simple terms, small children have large heads. Because of the weight and
size of the head, there is an increased likelihood of trauma to the head of small child. The
head is heavy and tends to precede the body when falling. Think of the small child’s
head as being similar to an adult’s while wearing a motorcycle helmet; the adult head
wearing a motorcycle helmet is now proportionately similar to the child’s in terms of relative
size and weight to the rest of the body. Unfortunately, the pediatric head obviously lacks the protective
features of that helmet, though. Given their larger head, pediatric patients lying on their
backs can experience airway obstructions because the size of the head causes the neck to flex
forward, which can narrow or even close the child’s airway. This is commonly not a concern
for the adult patient where the head is proportionate to the body. With that in mind, it is important
to make adjustments when opening and securing the airway of the small child. A small towel
or blanket placed under the child between the shoulders will help move the airway in
a more neutral position. On the same note, hyperextending the neck leads to further obstruction
in infants and children as well because the tracheal rings are soft, allowing compression
of the airway. There are also a lot of blood vessels in the head and it is common for patients
to lose tremendous body heat through their head. This is even more pronounced in a pediatric
patient where the head has a proportionally larger surface area than the body.
Soft-spots in the skull (fontanels) are normal in the young child. This is because the newborn
must pass through the mother’s birth canal and a rigid skull would not provide the flexibility
necessary for the birthing process. Fontanels begin to close between the ages of nine and
18 months. Fontanels in younger children can provide important information to the EMT during
assessments. When infants cry, their fontanels tend to bulge out a bit which is a normal
sign. However, when the child appears to be ill and their fontanels are bulging, it may
be from increased intracranial pressure inside the skull. Inversely, if the fontanels appear
sunken, it may an indication of dehydration in the small child.
As discussed several modules ago in the overview of the human body presentation, pediatric
airways are smaller in diameter and shorter in length than an adult airway. Any compromise
such as swelling, fluid, or trauma can be very detrimental in the pediatric patient’s
ability to breathe adequately, more so than in an adult patient. The jaw size is smaller
while the tongue is proportionally larger in the mouth as compared to the adult patient.
This trait becomes important to remember because the tongue is generally one of the most common
obstructions in the pediatric airway. Opening the airway with a jaw thrust maneuver will
help position the tongue in a location to ensure optimal airway patency. Infants are
obligate nose breathers, which allows them to breathe and swallow (nurse) at the same
time. This means that they breathe through their mouths only when crying. Thus, it is
extremely important to clear the nasal airway with a bulb syringe or other appropriate size
suction catheter. Tracheal cartilage is also softer and more collapsible in the small child,
so correct airway manipulation to a neutral position is imperative. In comparison to the
adult patient, the child’s epiglottis is long, floppy, and narrow, which can make it
more of an obstruction when positioning the airway, especially if it is swollen.
Airway care for a pediatric patient includes suctioning both the nares and the mouth. In
the very small infant, suctioning the nares first stimulates the breathing, so whatever
gunk is in the mouth will be inhaled down into the airway. That is the reason EMS providers,
yourself included, are taught to suction and clear an infant’s mouth first, then the
nose. Remember to place the child’s airway in a neutral position with a jaw thrust for
optimal patency. Smaller airways are more easily obstructed
by flexion or hyperextension; particulate matter, including mucus and fluids; and, soft
tissue swelling. Children compensate for airway obstructions
by increasing respiratory rates and effort. Multiple factors make it harder for children
to compensate for airway obstructions than an adult, such as a flexible rib cage, weaker
intercostal muscles, and diaphragmatic or abdominal breathing. Children in respiratory
distress are considered true emergencies as respiratory muscles can fatigue rapidly, leading
to respiratory failure and subsequent arrest with very little warning.
When assessing the chest of a pediatric patient, some important anatomy and physiology considerations
to keep in mind are: the pliability of the ribs given more cartilage in the rib cage
when compared to an adult; there is less overlying muscle and fat to protect the rib cage and
vital organs beneath the ribs; and, ribs move in more of a horizontal fashion primarily
due to weaker intercostal muscles. As a result, small children are predominantly diaphragmatic
breathers; they rely on the diaphragm more than the muscles of the chest wall to breathe.
There are also fewer alveoli present in the lungs during the first year of life, which
does not allow for much collateral ventilation in times of respiratory distress. The chest
wall of the pediatric patient is also thinner than the adult which does make it easier for
an EMT to listen to lung sounds and hear heart tones.
When managing the pediatric patient, it is important to ensure effective movement of
the diaphragm to sustain adequate ventilation. Rib fractures are less common in the pediatric
patient given a higher proportion of cartilage to bone, but any trauma to the chest can cause
significant damage to underlying internal organs because the protection afforded by
a flexible rib cage is less than in an adult patient with a fully developed and rigid rib
cage. Lungs are fragile and prone to tissue damage, pneumothorax, or a collapsed lung.
If rib fractures are present in the pediatric patient, consider the likelihood of significant
energy transmission and evaluate for multi-system trauma in that patient.
Picture yourself sitting in your living room watching a TV ad for a brand name diaper company.
On screen you see a small toddler waddling across your screen smiling and babbling wearing
only a form fitting diaper. How cute is that child? The advertisers really know how to
reach our senses! But back to anatomy. What you see is a small child with a protruding
abdomen or belly, which is actually a normal finding in small pediatric patients. The muscles
of the abdomen are less developed when they are smaller and the internal organs are more
anterior in the body. In the abdominal cavity the liver and spleen are proportionally larger
to the rest of the organs and the soft, pliable ribs offer less protection to the abdominal
organs. When managing pediatric patients with potential illness and injuries, remember that
seemingly insignificant external forces applied to the abdomen can cause serious internal,
multi-organ injuries. Because of their size and location, the liver, spleen, and kidneys
are more frequently injured. When palpating the abdominal quadrants, it
is not normal for the abdomen to be firm or rigid. There should be no pain or tenderness
on palpation. Also, watch for gastric distention from air trapped in the belly and readjust
your ventilation techniques if this occurs during resuscitative efforts. Remember that
children rely heavily on the diaphragm for breathing; chest rise is not as noticeable,
but you will observe more diaphragmatic breathing. If you were to peel back all the muscles,
tissues, and subcutaneous fat from the skeletal system, the bones you find in the pediatric
patient are the same as in the adult patient. As the person transitions into adulthood,
the bones, which were soft and pliable as a child, begin to harden and become stronger.
Children have growth plates, or what is considered to be an area of growing tissue, near the
ends of their long bones. These areas are open and allow for the bones to grow; they
are also weaker than true bone, however. When the body finishes growing, the plates close
and become replaced by solid bone. Injuries to the growth plates can result in bone length
discrepancies. Children and young adults tend to have growth plate injuries in the long
bones adjacent to the wrists, ankles, knees, or feet.
Fractures and dislocations are not always evident in the field and may only be discovered
with x-rays at the hospital, so it is important for EMS to treat signs and symptoms in conjunction
with appreciation for the mechanism of injury. Immobilize the pediatric patient with splinting
techniques similar to those used with adults, but remember to use appropriate sized splinting
equipment. When splinting any injury, it is important to assess the patient’s circulation
(pulse), movement capability, and sensory status before and after splinting a body part.
In the pediatric population, another way to assess circulation status is to check capillary
refill time in a nail bed distal to the injury. Our skin is the largest organ in (or, arguably,
on) the body and it can offer the EMT a lot of information about a patient’s circulation
and perfusion. In the pediatric patient, the skin has a larger surface area in proportion
to body mass when compared to an adult. This can become an issue during the management
of burn and environmental injuries. The skin layers are thinner and can be more easily,
quickly, and deeply burned than adult skin. Given the larger surface area, there is the
potential for greater fluid and heat loss as well. Any resulting hypothermia can then
complicate any treatment and resuscitative efforts for the child.
We already discussed some specific anatomical differences in the pediatric airway structures,
but we also need to point out that there are some specific physiologic differences as well.
In the pediatric patient, there is a higher oxygen demand per kilogram of body weight;
nearly double that of the adult’s, as a matter of fact. With smaller, less developed
lungs, the available oxygen reserves are a lot lower, which can increase the risk of
hypoxia when the child is apneic or is receiving ineffective ventilatory support. When managing
a pediatric patient requiring ventilations, make sure to choose the correct bag-valve-mask
based on the patient’s size and use only enough force to make the chest rise slightly.
Over aggressive bagging will produce gastric distention, possible vomiting, and barotrauma
(including pneumothorax). Ventilations with a bag-valve-mask that is too small in volume
will result in hypoxia and a negative outcome. Undeveloped respiratory accessory muscles
also are more susceptible to early signs of fatigue, so constant monitoring of the work
of breathing is necessary. As the child ages, there will be a continual increase in the
number of alveoli so lung reserves will also increase.
As we now know that that there is a higher relative oxygen demand for the pediatric patient
than there is for the adult patient, our previous discussions regarding vital signs for each
age group should make more sense. Heart rates and respiratory rates are higher in the smaller
child. The demand is there, so the heart and lungs need to work harder and faster to to
circulate blood and deliver oxygen to all the tissues and cells. Over time, capillary
beds become better developed to help in thermoregulation. Any constriction of blood vessels in the pediatric
patient may have a profound effect on the circulation status. The first visible areas
of decreased perfusion would be in the skin and the patient’s mental status. Even though
there is less blood volume circulating in the pediatric patient, there is a proportionally
larger amount of blood circulating in the body when compared to an adult. That is one
reason why children in shock compensate for blood loss early on and then suddenly crash
without a lot of warning. Small amounts of blood loss may have dire consequences for
the pediatric patient. The child’s circulatory status should be monitored carefully and often.
In many instances, if you wait until the child looks like they are in shock to start treating
for shock, it may be too late for that child. As with other pediatric patient body systems,
the nervous system tissue is fragile and lacks the development found in adults. The brain
tissue itself, as well as the vascular system, is more fragile and prone to bleeding after
an injury. Since the subarachnoid space is relatively smaller, it offers less cushioning
when the brain is jarred during an impact. Falls, motor vehicle accidents, and shaken
baby are all mechanisms that can permanently damage brain tissue and the spinal cord given
these factors. In their early years, a child’s brain will reach 90 percent of an adult brain’s
size and weight. Myelination formation increases dramatically, enabling increased transmissions
of nerve impulses that lead to greater cognitive and motor skills development. With all that
growing and developing in the pediatric nervous system, the brain requires two times the amount
of cerebral blood flow than an adult brain. Assessment of the nervous system in an infant
may seem daunting, but simple assessments can yield a good understand of the patient’s
general neurological status. An infant will have a sucking reflex if something is put
to the mouth and will have a intact gag reflex. Acknowledgment of these reflexes is routinely
accomplished by interviewing the caregiver or parents. When assessing the infant at rest,
their arms and legs should naturally be in a semi-flexed position; if they are flaccid
or overextended, this may be an indication of a significant illness or injury to the
nervous system. If the EMT introduces an outside stimulus to the infant, there should be equal
movement of extremities on both sides of the body.
In the prehospital management of the pediatric patient, oxygenation and ventilation play
a large role in maintaining consistent cerebral blood flow to the brain and spinal cord. Any
hypoxia or reduction of circulating volume can cause significant permanent detrimental
effects on the pediatric patient. Ligament injuries are more common than actual spinal
cord injuries. Therefore, management of the head with support and padding where necessary
will help keep the pediatric airway open, which will have an effect on oxygenation.
Glucose is a vital fuel for all age groups. It is an important source of energy for the
body and it is also stored in muscles and the liver for later use. When there are limited
glucose stores in the body, infants and small children may have trouble fueling their bodies
and brains with devastating results. Limited glucose stores are also very common and expected
in babies born to diabetic mothers and premature babies with low birth weights. EMTs in Wisconsin
are able to measure glucose levels in all age ranges, which gives us an opportunity
to treat some blood sugar problems in the prehospital setting.
Small and premature infants are more susceptible to hypothermia due to a large surface area
in proportion to their limited body mass and less inherent body insulation (fat). Infants
may loose heat rapidly if their clothes and diapers are wet, if they are exposed to windy
conditions, or if they are submerged in cold water. Hypothermia could be a factor in both
medical and traumatic situations. The EMT should be cognizant of cool rooms and ambient
temperatures that can reduce an infant’s body temperature. It is important to keep
the infant warm during transport. Covering a patient’s head will help reduce heat loss
at any age, but this is especially true for a pediatric patient. Be aware, however, that
overwarming a newborn too much can worsen neurologic outcomes as well.
Now that we have reviewed some major differences in anatomy and physiology between pediatric
and adult patients, it is time to discuss the pediatric assessment process.
It is common for pediatric emergencies to cause increased stress levels in the EMT because
it is more difficult to assess smaller patients who can not tell us what is bothering them
or what hurts. Communication is often an obstacle given the child’s level of cognitive development
and understanding. Most EMS providers do not routinely see a lot of pediatric patients,
which also increases stress given a lack of familiarity and comfort with pediatric patients.
There are substantial differences in anatomy, physiology, cognitive development, and understanding
between newborns, adolescents, and all age groups in between. Assessment strategies will
need to be modified for each age group as a result.
The utilization of different communication techniques aside, the EMT’s initial goal
in assessing a pediatric patient is to determine whether the child fits into the “sick”
(critical) or “not sick” (stable) category. Classifying a child as “sick” or “not
sick” will help the assessment and interventions stay on the proper course.
It can be important to utilize a parent or caregiver when assessing children, especially
if they are younger. Patients and caregivers can provide important information about the
child’s medical history, signs, possible symptoms, and the events leading up to the
emergency. Parents and caregivers can assist in calming a child to increase his or her
cooperativeness. With that being said, parents can sometimes become part of the problem,
not the solution. Agitated parents can agitate a child, while calm parents typically tend
to relax the child. Caregivers and parents can also help the EMT understand what is “normal”
activity and presentation for the child. Children can change quickly. It is important to continually
assess and reassess interventions and treatments on a regular basis.
The five areas we will review in greater detail pertaining to conducting a pediatric assessment
include: preparation; scene size-up; patient assessment, including the pediatric assessment
triangle; the hands-on approach to airway, breathing, and circulation management; and,
all additional assessments while continuing care. When comparing the adult assessment
to the pediatric assessment process, you will note some modifications and variations in
order, flow, and terminology. These occur in order to complete the pediatric assessment
process in the safest, most efficient manner possible for the patient.
As mentioned earlier, most EMS professionals do not see a large pediatric emergency call
volume. Part of our professional responsibilities and ongoing development is to have an in-depth
understanding of this population’s characteristics, physical attributes, and cognitive development.
There are many resources an EMT can utilize to prepare for pediatric encounters. Visiting,
volunteering, or working at day care facilities and schools; babysitting neighbors, nieces
and nephews; or, spending time with the boy or girl scouts are all excellent ways to prepare
you for your next pediatric patient. Ambulance services in Wisconsin are required to carry
specialized pediatric equipment that should be reviewed on a regular basis; be sure to
practice using the equipment as well. Regular review of normal age appropriate vital signs
and presentations should be part of your continuing education. Many hospitals and service providers
offer in-services and conferences specifically geared to the pediatric population.
Safety for the EMT, the crew, the patient, and bystanders will always be the number one
priority during any assessment. Make sure to review the session on scene size-up (presented
in the Patient Assessment module) for a complete review of the steps and components of an adequate
scene size-up including body substance isolation, personal protective equipment, determining
the mechanism of injury or nature of illness, determining number of patients, and calling
for additional resources. Some additional items or clues from the scene
that become important in the pediatric scene size-up include: evaluating the scene for
alcohol or drug use, either from the patient or bystanders; noting the position and location
in which the patient was found; observing and noting the parents or caregivers’ interactions
with the child; and, whether or not there appears to be any child abuse or neglect given
injuries are inconsistent with the history provided. Are the parents or caregivers appropriately
concerned with the injury or illness? Do the parents show anger or act indifferent? Can
the child be comforted and calmed by the parents or caregivers, or does the child display fearfulness
or withdrawing tendencies? Those behaviors may all be indications of potential abuse.
The Pediatric Assessment Triangle (PAT) provides an effective 15 to 30 second tool for the
rapid assessment of the severity of the pediatric patient’s illness or injury and the need
for life-saving interventions. It is usually done as the EMT enters the scene and approaches
the patient. In many services this is called an “across the room assessment.” There
is no touching necessary, only looking and listening. It is done even before the hands-on
ABCs of the primary assessment. The three components of the PAT are appearance,
work of breathing, and circulation to the skin.
When assessing the appearance of the child, it may be helpful to remember the mnemonic
TICLS, for tone, interactiveness, consolability, look/gaze, and speech/cry. Look at the muscle
tone of the child. Does the child appear normal versus limp, listless, or flaccid? In the
distressed child, muscle tone reflects the energy reserves available. The child who is
struggling to breathe will be working hard with increased muscle tone until he or she
simply tires out from the effort. As the child tires, muscle tone decreases. By the time
full arrest is imminent, the child may appear relaxed and limp (which should be considered
an ominous sign). Observe the interactiveness of the child. Is the child alert, agitated,
or lethargic? With the EMS crew on the scene, the environment should be somewhat exciting
for a child. A lethargic child given the flurry of activity associated with the emergent circumstance
can be a bad sign. Can the parents or caregivers console the child? Watch the child’s eye
contact and follow his or her gaze. Can the child fixate on and follow an object with
his or her eyes, or does the child have a glassy-eyed stare? Lastly, listen when the
child speaks or cries. Is the cry or communication clear, strong, weak, muffled, or hoarse? Appearance
can be one of the most reliable signs when assessing the pediatric patient because infants
and children who are physiologically unstable or critical look sick.
The second side of the PAT is to evaluate the work of breathing. Without a stethoscope,
listen for abnormal breath or airway sounds such as stridor, grunting, wheezing, or crowing.
Observe the child for abnormal body positioning like the tripod position or a refusal to lie
down. Watch for sternal and/or intercostal retractions in the neck and chest wall. Nasal
flaring is a normal physiologic response to hypoxia because it leads to the lowering of
resistance in the airways; keep an eye out for that as well.
The third side of the PAT focuses on circulation to the skin. Remember that the skin is the
largest organ in the human body and it can show a great deal about how our patient is
perfusing. Assess for pallor, mottling, or cyanosis. These are all indicative of an ill
child. Any abnormalities or problems identified in
the first 30 seconds of the pediatric assessment triangle can be from respiratory distress
or failure, cardiovascular shock, cardiopulmonary failure or arrest, isolated head injuries,
ingestion of poisoning, or other central nervous system issues. All of which are significant
emergencies that require rapid and aggressive intervention in the prehospital setting.
The EMT should be able to begin initial triage and make a transport decision based on assessment
of the three components within the pediatric assessment triangle. The pediatric patient
should be categorized as urgent (sick) or stable (not sick). The urgent patient should
receive a rapid ABC assessment, treatment, and transport. If the patient is labeled as
stable, proceed with the ABC assessment, followed by the focused history and complete physical
exam. Begin transport and start potential therapies en route to the receiving facility.
The hands-on ABC assessment step is completed immediately after the 30 second PAT assessment.
Make sure the airway is open (and will stay open) by talking to your patient. If the patient
is unable to maintain his or her own airway, perform a jaw thrust or chin lift to move
the airway into a neutral position. Consider suctioning with a bulb syringe or suction
catheter if secretions are present. If airway adjuncts are needed, choose either a nasal
or oral adjunct based on the patient’s presentation. Assessing breathing and oxygenation requires
the EMT to evaluate respiratory rate and effort; auscultate lung sounds with a stethoscope
and listen for normal or abnormal sounds. If the EMT has the equipment, he or she should
measure oxygenation with a pulse oximeter and consider applying oxygen if necessary
(using a nasal cannula for a low flow and lower concentration, or a non-rebreather mask
for a high flow and higher concentration of oxygen). If the patient needs assistance with
breathing, choose the appropriate size bag-valve-mask (both the masks and the bags are produced
and marketed in different sizes). The child may resist wearing an oxygen mask, so consider
blow by techniques if necessary. Assessment of the patient’s circulation
includes checking the heart rate, both centrally and peripherally. Pulse rates, pulse quality,
and pulse regularity should be assessed. Assessing circulation to the skin includes checking
a general temperature to determine if it is cool, warm, or normal and feeling the condition
of the skin to determine if it is dry, clammy, or diaphoretic. Finally, look at the general
color of the skin to determine if it is normal, pale, flushed, or looks otherwise abnormal.
Capillary refill time (CRT) is commonly used in the younger patient to determine adequacy
of perfusion. As you are assessing the skin, do not forget to look for any uncontrolled
active bleeding. The last part of the circulation assessment would be to obtain a blood pressure
if the child is over the age of three. Assessment of a child’s neurological disability,
if any, includes measuring the level of consciousness by either using the AVPU scale or a modified
version of it for the infant and small patient. If the small child is acting age-appropriate,
you should consider the child to be alert. Disability assessments require you to check
the pupils for equal and appropriate reaction to light, and to test for any neurological
motor deficits by having the patient move all extremities. The last part of the disability
assessment is to check for pain using a standardized pain scale. In adult patients, the standardized
pain scale usually uses the zero to ten scale where zero is no pain and ten is the worst
pain. The pain scale will need to be modified for the pediatric patient in most instances.
Some services actually use little cards with drawings of faces on them showing different
levels of pain/distress, to which a child can point. Check with your local protocols
for pediatric pain scales. The last segment of the hands-on ABC assessment
is exposure. The EMT should remove areas of clothing as necessary and examine for additional
injuries and abnormalities. Remember that heat loss is a major concern with the pediatric
patient, so promptly re-cover to prevent hypothermic states.
After completing the hands-on ABC assessment for the pediatric patient, you should have
an idea as to what facility would be the most appropriate transport destination. The next
assessments may take place on scene if there is no transport urgency or while en route
to the receiving facility. The order of these assessments may be different than that presented
based on patient presentation and available resources.
The SAMPLE history will help the EMT determine the signs and symptoms from which the patient
is suffering. Allergies to food, environmental, or medicines are important to determine. Ask
whether the patient is currently taking any prescribed medications and, if so, what the
medications are. (If you are unfamiliar with a particular medication, look it up or ask
why the patient is taking the medication.) Ask about over-the-counter and prescribed
medications as well as herbal supplements. The older your pediatric patient, the more
important it is to ask about illicit drug and alcohol use (it may be necessary to separate
the pediatric patient from his or her parents to increase the likelihood of an honest, affirmative
answer). The patient’s past medical history may yield needed clues in the assessment.
Investigate any past pertinent medical problems by asking follow-up questions and also explore
any key events that precipitated the current illness or injury.
Every patient needs some type of physical exam. The EMT should look at the mechanism
of injury and/or nature of illness, the PAT, and the ABCs to determine if a head-to-toe
or a focused physical exam is necessary. If a secondary assessment is performed to the
head, look for any bruising or swelling, and examine the quality of the fontanels in the
small infant. Look in the nose for drainage or anything that has the ability to obstruct
breathing through the nose. Suction any secretions with bulb syringe or suction catheter. Look
in the ears for any drainage or blood and check the mouth for loose teeth, identifiable
odors, or bleeding. When assessing the neck of a pediatric patient, check for abnormal
bruising or swelling. If the patient has a fever, also determine whether or not the patient
is able to move the head by bending and turning the neck. An assessment of the torso includes
both the anterior chest and the posterior back. Look for bruises, injuries, or rashes.
In the abdomen, assess for distention, tenderness, seat-belt abrasions, or bruising. The extremities
should be checked for deformities, swelling, or pain on movement.
In critical patients a head-to-toe order is suggested. If the child is stable, the EMT
might choose a toes-to-head assessment, based on the child’s chief complaint. In young,
stable children, it may be best to begin the secondary assessment at the torso, proceeding
to the extremities, concluding with the head. This approach helps alleviate anxiety for
the young pediatric patient. In the event of a specific non-life threatening injury
to a particular area of the body, a focused physical examination is also warranted. Such
an assessment commonly looks for deformities, contusions, abrasions, penetrations, burns,
tenderness, lacerations, and swelling. During transport, reassessment of vital signs,
the PAT, and ABCs should be completed at appropriate intervals. All interventions should also be
rechecked. If the patient is critical, reassessment should be done every five minutes. If the
patient is stable, reassessment may be performed every 15 minutes.
Respiratory distress is the most common medical problem in infants and young children. In
pediatric children, cardiac arrest is usually preceded and caused by respiratory arrest.
Pediatric patients are predisposed to airway obstructions and respiratory distress for
multiple reasons. We have already discussed anatomic and physiologic differences in pediatric
versus adult airways, so it should not be surprising that the small pediatric airway
is easily obstructed by foreign bodies, fluid, or swelling. Any respiratory illness affecting
the lower airway has a much more pronounced effect on younger children as well. Additionally,
other non-respiratory conditions or medical emergencies may be life-threatening because
of their effect on the airway and breathing. Some of those other conditions include seizures,
head injuries, and any state of altered mental status. All of these may result in the obstruction
of the pediatric airway because the tongue can fall back to the posterior and obstruct
airflow. Over the next few slides we will review several
medical emergencies that also can effect the patency of the pediatric airway. Before we
do that, however, it is important for the EMT to recognize the various signs and symptoms
associated with respiratory distress, respiratory failure, and respiratory arrest.
Respiratory distress is a sliding scale and the EMT must determine what specific interventions
are needed depending on where the patient is within that range.
In early stages of respiratory distress, the patient is still alert and can talk. The patient
may exhibit slight changes in his or her mental status, such as anxiousness and restlessness.
At this point, the body recognizes there is some distress and hypoxia, so the body starts
to compensate by trying to increase the amount of air (and, thus, oxygen) being exchanged
in the lungs. Respiratory rates and heart rates will increase and abnormal sounds resembling
wheezing, grunting, or crackling may be heard. The patient is usually sitting in a tripod
position and speaking in short sentences or word strings. Nasal flaring might be present
in the infant or young child. An increase in accessory muscle use along with retractions
may be visible. In the respiratory distress stage, there is still a lot of fight left
in the patient, so to speak. Management of the respiratory distress patient varies depending
on cause of distress, but oxygen administration via a nasal cannula, a non-rebreather mask,
or blow by oxygen is commonly warranted to treat the patient’s developing hypoxia.
Administration of medications may also be an option depending on the cause of the distress
(and whether or not the warranted medication falls within the EMS provider’s scope of
practice). As the patient moves into respiratory failure,
the body starts to experience fatigue and the child’s efforts to breathe start to
wane. Cyanosis might develop in nail beds and around the patient’s lips, changing
the color of those areas to resemble a bluish tint. Changes in behavior are evident and
the patient may become increasingly agitated before they slip into an altered mental state.
At this point, the heart is also starved for oxygen and the patient’s pulse rate decreases
to a very ominous bradycardia. These patients may still have some energy reserve left, but
they are clearly headed “down the tubes” and need immediate, aggressive intervention
by the EMT. This state is dangerous because these patients may go from the unstable respiratory
failure state to the critical respiratory arrest stage without warning.
Respiratory arrest occurs when breathing stops. Immediate positive pressure ventilations with
a bag-valve-mask and high flow oxygen is required. Respiratory arrest can stem from a progression
of a medical condition, a foreign body obstruction, or a traumatic event. Depending on the nature
of illness or injury, this may be a gradual or a sudden process. Regardless, the pediatric
patient in respiratory arrest will die if aggressive interventions are not started immediately.
One of the most common causes of respiratory problems in pediatric patients is an airway
obstruction. In discussing airway obstructions, it is common to identify which part of the
airway is primarily affected. Thus airway obstructions are commonly denoted as being
either upper or lower airway obstructions. Common upper airway obstructions include croup,
foreign body aspiration, bacterial tracheitis, epiglottitis, and tracheostomy dysfunction.
General lower airway obstructions, commonly caused by reactive diseases, include asthma,
bronchiolitis, pneumonia, foreign bodies, and pertussis. While many of these pathologies
impact adults as well, we will take a little time to discuss these obstructions as they
specifically impact pediatric patients. Croup is a viral infection that results in
swelling and inflammation of the lining in the upper airway structure. It occurs more
commonly in the winter months. Signs and symptoms vary by the type of infection, but they are
generally more evident either at night when the child is sleeping or when the child is
upset or crying. One distinct sign that makes croup easier to identify from other respiratory
difficulties is the loud cough that sounds like a seal bark. Other signs and symptoms
may include grunting, wheezing, stridor, cold-like symptoms, pale/cyanotic, retractions, or nasal
flaring. Grunting is commonly heard at the end of respiration.
It is a later sign produced by the body’s efforts to open blocked airways.
Wheezing is a high-pitched whistling sound created by the narrowing of the airway structure
and is heard prominently during expiration because air becomes trapped. Inspiratory sounds
usually suggest a foreign body or other cause of obstruction in the trachea or upper airway,
but a child with croup may have both inspiratory and expiratory wheezing associated with their
illness. Stridor is a sign of an upper airway obstruction.
It is heard on inspiration due to swelling or obstruction around the vocal cords. Aside
from foreign-body aspiration, congenital airway abnormalities such as an extremely large tongue
or developed airway abnormalities such as a cyst or tumor could also result in stridor.
It can also be heard with infections such as croup, upper airway edema, or trauma.
Based on how hypoxic the child is, skin color changes such as pallor or cyanosis may be
visible. Intercostal retractions are easy to identify
in the pediatric patient having respiratory distress. Retractions are the visible “sinking
in” of the soft tissues of the chest between and around the firmer tissues of the bones
and cartilage of the ribs. Finally, nasal flaring is the involuntary
reaction of the body attempting to keep airway passages open.
Patient management includes monitoring the ABCs and administering oxygen through a nasal
cannula, non-rebreather mask, or by utilizing a blow by technique. Make sure the patient
is in a position of comfort and transport. Depending on the patient’s level of respiratory
difficulty, you may want to consider calling for an ALS intercept, if available.
As we learned earlier, young children tend to put almost anything into their mouths.
They are naturally curious and do not understand the potential negative consequences of their
actions. A foreign body can lodge in any part of the airway structure causing either a partial
or a complete obstruction. With a partial airway obstruction, the patient is still able
to ventilate and exchange air into and out of the lungs. If the foreign body partially
obstructs the airway, monitor the ABCs closely and encourage the patient to cough; do not
intervene with back slaps or abdominal thrusts. At this point, the child is still exchanging
air and receiving oxygen; external interventions could shift the foreign body resulting in
a complete obstruction. It is best for the patient to clear their own airway in those
instances. If the airway is completely obstructed, however, interventions are required. Be sure
to follow the current American Heart Association guidelines for the management of foreign body
airway obstructions. As we learned earlier, young children tend
to put almost anything into their mouths. They are naturally curious and do not understand
the potential negative consequences of their actions. A foreign body can lodge in any part
of the airway structure causing either a partial or a complete obstruction. With a partial
airway obstruction, the patient is still able to ventilate and exchange air into and out
of the lungs. If the foreign body partially obstructs the airway, monitor the ABCs closely
and encourage the patient to cough; do not intervene with back slaps or abdominal thrusts.
At this point, the child is still exchanging air and receiving oxygen; external interventions
could shift the foreign body resulting in a complete obstruction. It is best for the
patient to clear their own airway in those instances. If the airway is completely obstructed,
however, interventions are required. Be sure to follow the current American Heart Association
guidelines for the management of foreign body airway obstructions.
The patient suffering from epiglottitis may resemble one suffering from croup, but epiglottitis
is a true emergency with devastating effects if not treated immediately. Epiglottitis is
caused by a bacterial infection of the epiglottis. When the epiglottis becomes infected, it inflames
and swells closing off the air passage down to the lungs. In the past, it was somewhat
common to see epiglottitis in children. With current vaccinations, however, these cases
are now considered to be rare. In fact, in some areas, epiglottitis is actually observed
with more frequency in the adult population. A patient with epiglottitis will commonly
experience a rapid onset of signs and symptoms. By comparison, croup patients tend to have
cold-like symptoms for a few days before it starts to become worse. Epiglottitis patients
have a sudden onset of high fever and a sore throat that makes it difficult to swallow,
which in turn usually causes excessive drooling. Stridor is heard due to the swelling and narrowing
of the airway. The patient experiences hoarseness from the swelling and may experience chills
and cyanosis due to the low levels of oxygen in the blood stream. The patient may appear
to sit very still, but the muscles of breathing are working hard. When managing this patient,
be reassuring with gentle and calm actions. The EMT should not introduce any agitating
stimuli to the patient. Do not suction, examine, or place anything in the mouth or pharynx.
This patient warrants a rapid transport with consideration of ALS.
EMS providers are exposed to many patients with special needs. (More information on that
special population of patients is discussed in a different module.) Many of these special
needs patients include patients with a tracheostomy tube for breathing. Any type of dysfunction
with the tube or area surrounding the tube will cause respiratory distress in the patient.
These dysfunctions may include foreign body obstructions, bleeding in or around tube,
air leaking around tube, infection, or a dislodged tube. Management of the patient with a tracheostomy
tube starts the same as with all other respiratory distress patients by checking the ABCs. Your
first job is to maintain an open airway. That may include suctioning the proximal end of
the tube, repositioning the patient, or assisting the patient with steps to clean and clear
the tube. Additional treatment and interventions may be performed at the hospital.
Some lower airway or reactive airway diseases we will be discussing momentarily include
asthma, bronchiolitis, pneumonia, foreign body airway obstructions, pertussis (whooping
cough), and cystic fibrosis. While there are many more diseases that can negatively impact
a patient’s respiratory status, these are some of the more common diseases you will
experience as an EMS provider. With that being said, it is important for you to continue
your learning beyond this initial course offering to acquire even greater familiarity with these
and other diseases that impact a patient’s respiratory health.
Asthma is a lower reactive airway disease (RAD) that occurs in acute episodes after
being trigged by an exposure to an irritant or other stimulant such as cold air, dust,
strong fumes, exercise, inhaled irritants, emotional upsets, or smoke. Acute asthma episodes
involve inflammation and swelling of the airway passage, spasms and tightening of the muscles
surrounding the bronchi and bronchioles, and extra production of mucus; all of which make
it increasingly difficult for the patient to breathe.
Signs and symptoms of an acute asthma episode will vary by patient and his or her sensitivity
to the irritant or stimulus. Due to the inflammation, swelling, and bronchoconstriction of the airway
passages, wheezing lung sounds are a common sign in the asthma patient. Wheezing can be
heard on inspiration and expiration. Due to the passive nature of exhalation, air tends
to be trapped in the narrowed passageways causing wheezing to be more distinct on exhalation.
Because the muscles surrounding the airways are constricting and in a state of spasm,
the patient may also experience some chest tightness and shortness of breath, which creates
additional anxiety. The patient may only be able to talk in short sentences or short word
strings and probably will be sitting in a tripod position with pursed lip-breathing.
The patient may also become fatigued because of all the extra work the accessory muscles
are doing to move the air in or out. If the airways tighten or swell too much, the EMT
may hear what is defined as a silent chest. The patient may be conscious and trying to
talk, but there is not enough air movement to create any sounds in the lungs. This is
a true emergency and needs immediate intervention. Patient management for an acute asthma patient
includes monitoring the ABCs, administering oxygen, placing in position of comfort, administering
respiratory medication based on local protocol, and rapid transport. ALS units do have the
ability to provide even more interventions for an asthmatic patient. If available, the
EMT may want to consider calling for ALS. Bronchiolitis is a viral illness that typically
occurs in newborns and toddlers. It is often caused by a respiratory syncytial virus (RSV),
which causes inflammation of the bronchioles. Bronchiolitis is more common in the winter
months and early spring. Signs and symptoms of bronchiolitis may include
shortness of breath; a runny, stuffy nose; wheezing; and, a slight fever. Depending on
the level of distress, you may also notice nasal flaring, accessory muscle use, some
cyanosis, and lethargy in the patient. Management includes monitoring the ABCs; administering
humidified oxygen, if possible; and, transporting. As with other respiratory emergencies, the
EMT may also want to consider ALS assistance. Pneumonia is a lower airway disease that results
from an inflammation of the lungs caused by either a bacteria or a viral infection. Pneumonia
is usually triggered by a simple upper respiratory tract infection or by the flu. It commonly
presents with a fever, cough, and an excess production of sputum. Excess fluid accumulation
will eventually separate alveoli from the surrounding capillary beds, thus inhibiting
gas exchange and causing some respiratory distress.
As with many of these lower respiratory diseases, signs and symptoms for the pediatric patient
exhibiting pneumonia can vary from patient to patient. Some of the more common signs
and symptoms include dyspnea (difficulty breathing), abnormal breath sounds from the excessive
fluid production, increased respiratory and heart rates, a low grade fever, the chills,
pale or cyanotic skin, coughing up sputum, and general malaise or fatigue. In the more
advanced stages of pneumonia, the patient may exhibit an altered level of consciousness.
Patient management includes monitoring the ABCs; administering oxygen; suctioning mucus,
if necessary; and, transport with the consideration of an ALS intercept.
Pertussis is a communicable airborne bacterial infection that affects mostly infants and
young children. It is highly contagious through droplet transmission. The irritating spastic
cough becomes increasingly worse over a few weeks and is usually followed by a “whooping”
sound on inspiration. It is recommended EMTs are vaccinated with DPT (diphtheria, pertussis,
and tetanus) to protect themselves from being infected as well. Be sure to review the management
of communicable diseases for specific treatments and interventions. As a reminder, good hand
washing and routine cleaning of the ambulance and your equipment should always be part of
the EMT’s regular roles and responsibilities. Some common signs and symptoms of whooping
cough are shortness of breath; a “whoop” sound on inspiration; cold-like symptoms,
including a runny nose and sneezing; a long-lasting, irritating coughing attack; changes in skin
color and tone; loss of appetite; dehydration; and, thick secretions. The patient may also
vomit. To manage this highly contagious patient,
monitor the ABCs, administer oxygen by non-rebreather mask to help contain the air particulates,
wear appropriate personal protective equipment based on your local protocols, and transport.
Make sure to follow your local guidelines on transport considerations. Some receiving
facilities have special negative pressure rooms for patients with potentially communicable
diseases. Cystic fibrosis is a chronic genetic disorder
caused by a defective gene that leads to dysfunctions in the endocrine system. It primarily affects
the respiratory and digestive systems. Excessive secretions in the lungs can cause shortness
of breath and provide a breeding ground for infections. CF is a fatal disease where few
patients live beyond their teens. The patient may present with a persistent, productive
cough; wheezing; and, thick, salty secretions. Management of this patient includes monitoring
the ABCs, administering oxygen, suction if needed, monitor for dehydration, and transport.
Depending on the patient’s level of discomfort, the EMT may want to consider calling for ALS
interventions. When dealing with a pediatric patient in shock,
it is important to remember the anatomic and physiological differences between the different
age ranges. Shock is progressive and is divided into three stages: compensated, decompensated,
and irreversible. Please review the module on shock for further information covering
stages, signs and symptoms, assessment parameters, management, and treatments for shock patients
in every age range. Causes of an altered mental status in children
can be numerous. Some of the more specific conditions we will be reviewing for the pediatric
patient include meningitis, seizures, and closed head injuries. One of the mnemonics
that should be considered during the assessment of any altered patient is AEIOU TIPS. This
mnemonic, which we will discuss momentarily, lists numerous causes of an altered mental
status. Additional information about the AEIOU TIPS mnemonic is also available in both the
medical and trauma modules of this course. The A, in AEIOU TIPS, is for alcohol, apnea,
arrhythmia, or anaphylaxis. Alcohol is a depressant that replaces sugar in the brain, resulting
in an altered mental status. Apnea (not breathing) or being hypoxic can impact a child’s level
of response, as can a cardiac arrhythmia. Anaphylaxis is an exaggerated immune response
that impacts multiple body systems, including the neurological system.
E is for epilepsy or environmental factors. While epilepsy is responsible for causing
seizures, any seizure activity, if if not due to epilepsy, will cause central nervous
system dysfunction. Environmental conditions can alter a person’s thermoregulatory functions
and too high or too low of a body temperature can affect a person’s responsiveness.
I is for insulin, referring to diabetes. If an individual does not have enough sugar in
the blood (hypoglycemia) or too much sugar (hyperglycemia) unresponsiveness or a depressed
responsiveness are possible. O Is for overdose. This can include both prescribed
medications as well as non-prescribed medications (such as those belonging to the child’s
mom or dad) and street drugs. Drugs can impact the body’s sympathetic and parasympathetic
nervous systems, as well as impact other body systems that may eventually impact a child’s
mental status. Such overdoses, which can also include taking medication not prescribed to
the child, can be accidental or intentional. U is for uremia, which refers to an electrolyte,
hormone, fluid, or other metabolic imbalance in the body. Whenever there is such a metabolic
imbalance in the body, mentation can be affected. Renal patients and any degenerative disease
of the brain can affect the metabolic state of the body, resulting in an altered mental
status. T is for toxins or trauma. Toxins can be injected,
ingested, absorbed, or inhaled. While the signs and symptoms vary depending on the chemical
compounds involved, an altered level of consciousness tends to be a common denominator. Trauma from
head injuries often cause direct or indirect injuries to the brain, which affects mentation.
I is for infection. The body can experience sepsis from an overwhelming infection of bacteria
in the blood stream. Cellular deficit (caused by toxin) inhibits the ability of the cell
to utilize oxygen in the body for fuel. Meningitis is a common ailment in children and teens
that can impact their neurological status. P is for psychological disorders and poisoning.
Poisoning can include an overdose or toxic exposure, as defined previously. A psychological
disorder could cause an altered state, but the EMT should always look for another possible
underlying cause of the altered mental status. S is for shock or stroke. Shock is the inability
of the body to perfuse, to provide oxygen to the cells. If that hypoxia impacts the
brain, an altered level of consciousness will result. While strokes are commonly associated
with the elderly, this topic can also refer to increased pressure, a clot, or a bleed
in the brain, which can occur due to trauma, infection, or congenital problems. Such occurrences
will impact the supply of oxygen to the brain, resulting in an altered mental state.
The brain and spinal cord are protected by three layers of tissue known as the meninges.
Meningitis is the inflammation or infection of those layers. Meningitis can be caused
by a bacteria or virus. Viral meningitis is rarely life-threatening, whereas bacterial
meningitis is often fatal. There is no possible way to know what type of meningitis a patient
may have in the field, so EMS providers need to be cautious and vigilantly use standardized
respiratory precautions during assessment and treatment. Signs and symptoms vary based
on the type of infection and the child’s age. Some common signs and symptoms include
fever, poor feedings, lethargy, neck stiffness or pain, irritability, headaches, and possible
bulging fontanels in the infant. To manage this potentially contagious patient, monitor
the ABCs, administer oxygen by non-rebreather mask to help contain the air particulates,
wear appropriate personal protective equipment based on your local protocols, and transport.
Be sure to follow your local guidelines on transport considerations given a communicable
disease. Some receiving facilities have special negative pressure rooms for patients with
potentially communicable diseases such as meningitis
A seizure is a sudden, brief disruption of normal functioning in the brain. Seizures
are caused by abnormal electrical discharges within the brain. Some nerve cells fire without
stopping and those disruptions can spread to or involve other nerve cells. Seizure activity
commonly creates a surge of energy through the brain, resulting in altered levels of
consciousness and the involuntary contraction of skeletal muscles.
Signs and symptoms of a seizure vary given the type of seizure the patient is experiencing.
Such signs and symptoms can include: staring; falling; repetitive motions; disorientation;
convulsions; and involuntary, unorganized movements.
Seizures are grouped into three areas: generalized seizures, partial seizures, or Status Epilepticus.
There are four types of generalized seizures: tonic-clonic, absence, atonic, and myoclonic.
Tonic-clonic seizures are what used to be known as grand mal seizures. They are the
most commonly known and recognized of all seizure activity in which there is stiffening
of the limbs (the tonic phase) followed by jerking of the limbs and or face (the clonic
phase). Absence seizures were formally known as petit mal seizures. These are short lapses
of awareness during which the patient sometimes appears to be staring. These seizures begin
abruptly, only last a few seconds, and end just as abruptly. There is typically no warning
or after-effect from an absence seizure. The patient’s ability to communicate and interact
with his or her surroundings usually returns quickly. Absence seizures are more common
in children than adults. Atonic seizures, also referred to as drop attacks, result in
an abrupt loss of muscle tone. The patient’s head may suddenly drop, they may have a loss
of posture, or sudden full-body collapse. This also is abrupt without warning and can
lead to traumatic injuries, especially to the head and face. As in absence seizures,
the patient’s ability to communicate and interact with his or her surroundings returns
quickly. Myoclonic seizures are defined as rapid, brief muscle contractions that usually
occur at the same time on both sides of the body. Occasionally, the person will move one
arm or leg at a time. Witnesses usually think of these actions as a sudden jerks or clumsiness.
Partial seizures are categorized as either simple partial or complex partial. These seizures
are actually the most common type of seizure. The electrical disturbance of the brain is
limited to a specific area, which may eventually spread to cause a generalized seizure. Virtually
any symptom can occur with a partial seizure. The difference between the two partial seizures
is the patient’s mental status during the seizure. Consciousness is usually retained
during a simple partial seizure, where a complex partial seizure results in impaired or lost
consciousness. If seizures are prolonged, or occur in a series,
there is an increased risk of Status Epilepticus, which is a continuous state of seizure activity.
This type of seizure can be potentially life-threatening, especially in children. Utilization of prehospital
ALS, if available, is important to administer medications that can stop the seizure activity.
Some key points to remember during assessment and treatment of a patient exhibiting the
signs and symptoms of a seizure include: protecting the patient by moving furniture or other objects
that could harm the patient, placing a small pad under the patient’s head, and not forcibly
restraining the person from having a seizure. Also, do not try to insert anything into the
patient’s mouth. The wives tale that someone having a seizure will swallow their tongue
is a fallacy, as you should now already realize, the tongue is attached to other structures
in the head; it cannot be swallowed. Trying to insert a bite stick or some other object
into a seizing person’s mouth can actually make things worse by introducing facial and
mouth trauma, potentially introducing a foreign body that can be swallowed or inhaled, or
by placing the rescuer in harm’s way while trying to open the seizing person’s mouth.
If possible, try to gather information from witnesses to determine when and how the episode
began, how long it lasted, and what they observed. If a patient has a seizure while eating, it
could lead to aspiration of the food or an airway obstruction. It is also common for
the patient to experience incontinence during a seizure. Make sure to protect the dignity
of the patient as you are assessing and treating him or her. Airway management should be a
priority during your care. Suction if needed and think about oxygenation. Try to determine
the cause of the seizure, if you can. Go through the AEIOU TIPS mnemonic to rule in or rule
out possibilities. Always measure a blood sugar for seizure patients. Watching a seizure
can be a terrifying experience for bystanders and witnesses, so be sure to calmly reassure
the patient, the family, and any witnesses to the event.
After some seizures, the patient may be in what is called a postictal state. This is
the state where the patient may be conscious, but with a lethargic and/or confused mentation.
The recovery time may only be a few minutes or it might last up to an hour. If the patient
has any drugs or alcohol in his or her system, it may take longer to become fully alert and
orientated. Most seizures resolve safely and do not result in death or serious injury.
Just be aware that suffocation could occur if the seizure is during sleep. Generalized
tonic-clonic seizures can place a substantial strain on the cardiovascular system, but this
is less of a concern for the pediatric population, which typically has a more robust cardiovascular
system than an adult. There are a number of things that can cause
the sudden, brief disruption of normal functioning in the brain. Refer back to your AEIOU TIPS.
Of increased significance is trauma to the brain. Anytime there is trauma, scarring may
occur, which can cause a patient to seize. Sometimes a first seizure is a precursor to
the discovery of a brain tumor. Medical conditions and medications can cause seizures. Infections
in the body will change the chemical makeup in the systems and, if there is an infection
that impacts the brain, a seizure is possible. Seizures can also be caused by drugs and alcohol.
Common pediatric seizures are febrile seizures that occur when the child’s body temperature
rises too quickly, typically due to infection or some other illness. If no cause is determined
for a seizure, it is labeled as an idiopathic seizure.
We already discussed the anatomic and physiologic differences between the pediatric and adult
gastrointestinal systems. Aside from a greater likelihood of traumatic injury to abdominal
organs, of special concern for the EMS provider is pediatric vomiting and diarrhea. This is
a concern because pediatric patients dehydrate quicker than their adult counterparts. Children
with vomiting and diarrhea lose a lot of fluid and, along with those fluids, essential electrolytes.
Because the child is probably ill, resulting in the vomiting or diarrhea, the last thing
he or she wants to do is drink fluids to replace those being lost. An additional concern with
vomiting is aspiration if the child also has a decreased mental status.
When assessing gastrointestinal problems, it is important to find out how often and
how much the child is eating or drinking. Is the child still producing wet diapers?
If not, it may be indicative of dehydration. What color and consistency are the child’s
stools? Be sure to examine the abdomen. Look at it for signs of bruising or trauma; palpate
for tenderness or guarding. If the child has pain and is old enough to communicate effectively,
ask him or her the same questions you would ask an adult. Do they have pain? Does it radiate?
How would they describe it? Is it sharp, dull, localized, diffuse, or otherwise? When did
the problems start? Does anything make it better or worse. If vomiting, when did it
start? Is there anything unusual about it, such as projectile vomiting?
Depending on the nature of the gastrointestinal complaint, there may not be much for EMS to
do but transport in a position of comfort. If dehydration is a concern, the child continues
to vomit, or the child appears to be in significant distress for what should be a simple bout
of abdominal discomfort, consider ALS intervention to start fluid therapy or have an antiemetic
administered. Anatomic and physiologic differences play
an important role when discussing pediatric toxicology pathophysiology. The patient’s
weight and age range commonly play a part in determining the effect of the substances
taken and the type of interventions required. Unfortunately, poisoning can be very common
in children. Luckily, fatalities are less frequent since the introduction of “child-proof”
medication packaging. Infants and toddlers put almost anything into their mouths and
they are also inherently curious. The medicine cabinet, grandma’s purse, the shelf in the
basement or garage, the cabinet under the sink, and other areas where medications are
stored by adults are all readily accessible to the average infant or toddler. Teens and
adolescents are at an increased risk for attempted suicides due to pressure, stress, and hormone
changes associated with their age range, in conjunction with a lack of life experience
and maturity. If possible, try to identify the substances
to aid in treatment of the patient. Try to bring containers with you to the hospital,
if possible. Depending on the substance, the patient’s mental status may change rapidly
from alert and responsive to comatose and unresponsive, with the loss of protective
airway reflexes such as a cough and gag reflex. These patients are proverbial “time bombs”
because they can suddenly become apneic, vomit and aspirate, or seize without any prior warning.
Responding EMS providers should monitor the ABCs, administer oxygen, be prepared to ventilate,
be prepared to suction, look for possible injuries, try to identify the substances,
contact medical control for further interventions, and transport. ALS should be considered for
poisoning patients, if available. Sudden Infant Death Syndrome (SIDS) is defined
as a sudden, unexplained death of an infant less than one year old. EMTs are not able
to diagnose SIDS in the field; that diagnosis is made only after a complete autopsy with
clinical history. SIDS occurs while the infant is sleeping, typically striking between two
to four months of age. The number of incidents have decreased dramatically since emphasis
has been placed on lying babies on their back to sleep, along with the removal of extra
bedding and blankets within the crib. If involved on a SIDS call, it is important
to remember that the scene will be investigated by law enforcement, so observation, attention
to scene detail, and proper documentation will be crucial to assist in the investigation.
Try to remember and document everything you see, touch, and hear. Do not disturb any evidence
if it can be avoided. Some cases of suspected SIDS deaths turn out to be child abuse related,
so gathering the story, timeline, signs, and symptoms is absolutely vital. Document the
position of the patient at first discovery, the surface on which the infant was sleeping,
the position of the patient upon EMS arrival, any caretaker resuscitation attempts, temperature
of room, what the infant was wearing, and if there have been any recent illnesses or
medication changes. The choice to perform CPR in a SIDS case may
be a difficult one. In CPR, you learned that obvious signs of death included rigor mortis,
lividity, tissue decomposition, and injuries incompatible with life. CPR started with any
one of these signs will prove to be unsuccessful and can do more harm than good for the surviving
family. The infant SIDS case can present a unique challenge, however. You may understand
that CPR will not have an effect on the child, but it may help the grieving process for the
parents. Typically parents want everything possible tried to save their child. The decision
to start CPR or not start CPR may be an ethical choice for you and your crew, or it may be
defined by a local protocol. Actions that are performed on scene may help limit the
“what if” questions that come up during the grieving process. It helps give families
solace that “everything possible was done.” On the other hand, your resuscitation attempts
and subsequent transport will simply delay the inevitable, result in a greater financial
burden for the parents or guardians, place the public at risk during transport of a nonviable
patient, and possibly delay the start of the grievance process by giving them a false hope.
Ultimately, each call is unique and the circumstances may dictate a different plan. Follow your
local protocols and do not hesitate to contact medical control for guidance.
Trauma is the leading cause of death in children over the age of one year old. Of the different
mechanisms of trauma, blunt trauma is the most common in the pediatric population. Anatomical
and physiological differences in the pediatric population drive what type of assessment and
interventions should be completed, while also playing a major role in what equipment is
used in the prehospital setting. Please review pediatric considerations within the trauma
module of this course for additional information. Given your completion of this module, you
should now be able to: Explain why pediatric patients need varying
approaches to assessment and care. Identify the developmental considerations
for the following age groups: infants, toddlers, pre-school, middle childhood, and adolescent.
Consider the metabolic differences in providing care to the pediatric patient.
Identify the anatomical and physiological differences to consider in the care of the
pediatric patient in the following areas: head, airway, chest, lung, abdomen, extremities,
integumentary system, respiratory system, circulatory system, nervous system, and spinal
column. Summarize the components of the pediatric
assessment triangle (PAT). Describe the hands-on assessment of the ABCs.
Identify the additional assessment techniques utilized in a SAMPLE history and secondary
assessment. Predict the emotional reaction an EMT may
have during and after a pediatric emergency. Describe general considerations of the assessment
process utilized for the pediatric patient. List specific pathophysiology, assessment,
and management of the following emergencies encountered in the pediatric patient: respiratory
distress, shock, neurological, gastrointestinal, toxicology, SIDS, and trauma.
Explain the importance of including family members in the assessment and management of
a pediatric patient. Explain the rationale for having knowledge
and skills appropriate for dealing with a pediatric patient.
Attend to the feelings of the family when dealing with an ill or injured pediatric patient.
Understand the provider’s own emotional response in caring for pediatric patients.
You should also be able to conduct a pediatric patient interview and demonstrate the assessment
of a pediatric patient. That concludes this module on pediatric patients.
Please do not hesitate to contact your instructor with any questions.
This presentation was created by Waukesha County Technical College with grant funding
from the Wisconsin Technical College System.