BLS Management of the Peds Patient

1. BLS Management of the Peds Patient By Daniel B. Green II, NREMT-P, CCP

2. Objectives • Review developmental milestones of children • Use the pediatric assessment triangle to assess pediatric patients • Discuss modifications to patient assessment based on age • Review common pediatric illnessess and treatments

3. Pediatric Development

4. Pediatric Development

5. Age and Weight • Important to be able to estimate ages and weights for pediatric patients • Affects treatment decisions, particularly for AED and CPR

6. Age and Weight

7. Age and Weight

8. Developmental Characteristics • Children have different behaviors at different ages • Tailor your assessment

9. Newborns and InfantsBirth to 1 Year • Do not like cold • Do not like separation from primary caregivers • Let parent or caregiver hold child during assessment • Ask caregiver to expose areas for examination • Warm stethoscope bell before placing on child

10. Newborns and InfantsBirth to 1 Year • Ask caregiver to comfort crying child • Try distraction: pen or toy • Check fontanels • Bulging indicates possible increased intracranial pressure • Sunken may indicate dehydration

11. Toddlers 1–3 Years • Sense of independence but unable to communicate complex ideas • Do not like strangers or separation from parents • Require assurance • May consider illness or separation from family as punishment

12. Toddlers 1–3 Years • Place bell of stethoscope under shirt, rather than taking off clothing • Consider demonstrating procedure such as chest auscultation on stuffed toy before using on child • May not tolerate oxygen mask • Use blow-by oxygen

13. Preschoolers 3–6 Years • More developed concrete thinking skills • Ask for their version of events and feelings • Frightened of potential pain, blood, injury • Reassure, provide simple explanations • Allow parent or caregiver to remain • Protect modesty

14. School Aged Children6–12 Years • Have basic idea of body and its functions • Very literal • Aware of and afraid of dying, pain, deformity, permanent injury • Use reassurance and include them in discussions of care

15. Adolescents 12–18 Years • More thorough understanding of A&P • Able to process and express complex ideas • Good risk takers, poor judges of consequence • Sense of immortality • Speak respectfully • Protect privacy

16. The Pediatric Airway • Head • Proportionally larger and heavier than body • Tongue • Larger in proportion to lower jaw • Falls back, occluding airway • Trachea • Thinner, more elastic • May close off with hyperextension

17. Breathing • Infants breath primarily through nose • Nose may be blocked with secretions • Infant and child have higher respiratory rate • Abdominal breathers • Tire quickly when stressed

18. Pediatric Assessment Triangle

19. Pediatric Assessment • Elements of the pediatric assessment triangle • Appearance and environment • Work of breathing • Circulation

20. Appearance and Environment • Key questions • Is scene safe? • Is there an obvious mechanism of injury? • Is environment safe for a child? • Is child active and attentive? • Can child make eye contact, respond to parent’s voice?

21. Work of Breathing • Look for symmetrical chest movement • Note respiratory rate • Primary causes of cardiac arrest in children are respiratory disorders

22. Abnormal Findings • Stridor • Harsh, high pitched sound during inhalation or exhalation • Indicates partial upper airway obstruction • Retraction of chest wall muscles • Muscles pulling in between ribs, above sternum with inspiration • Nasal flaring • Extended opening or flaring of nostrils • Wheezing • High pitched sounds created by air moving through narrowed air passages in lungs

23. Assessing Circulation • Central perfusion • Supply of oxygen to and removal of wastes from central circulation • Asses with brachial and femoral pulse checks • Check capillary refill • Assess skin temperature, color, and moisture

24. Assessing Circulation • BP difficult to obtain below 3 years of age • Rely on mental status, quality of pulses, and capillary refill • Children 3 • Ensure right size BP cuff • Be aware of variation of vital signs with age

25. Compensating/Decompensating • Children will compensate for poor respirations and circulation • However, decompensation may develop quickly

26. Respiratory Emergencies in Infants and Children • Respiratory distress • Respiratory failure • Respiratory arrest • Airway management • Airway adjuncts • Oxygen therapy • Assisted artificial ventilations • Shock

27. Respiratory Distress • Most common cause in pediatric patients is asthma • Also includes • Chronic lung disease • Airway obstruction • Congenital heart disease • Foreign body aspiration • Chest wall trauma

28. Definitions • Respiratory distress • Abnormal physiologic process that prevents adequate gas exchange • Respiratory failure • Inability of respirations to maintain adequate oxygenation and ventilation • Respiratory arrest • Absence of breathing

29. Upper Airway Obstruction • Partial obstruction • Stridor on inspiration • Complete obstruction • No crying, no speaking, no coughing • Cyanosis

30. Lower Airway Obstruction • Wheezing • Prolonged, labored exhalations • Rapid respiratory rate • No stridor

31. Altered mental status Flared nostrils Pale or cyanotic lips or mouth Noisy respirations (stridor, grunting, gasping, wheezing) Respiratory rate greater than 60 Retractions Use of abdominal muscles for breathing (see-saw breathing) Poor peripheral perfusion Decreased heart rate Signs of Respiratory Distress in Children

32. Decreased mental status Poor eye contact No response to verbal stimuli Pale, cyanotic skin Delayed capillary refill, weak pulses Fatigue, floppy, head bobbing Signs of Respiratory Failure

33. Continuing Respiratory Failure • Without immediate intervention, child will continue to deteriorate • Respiratory rate 10/min • Unresponsive, limp • Decreasing heart rate • Eventual respiratory and cardiac arrest

34. Airway Management • Airway is primary concern for children • Modify head tilt/chin lift to maintain neutral position • Avoid hyperextension or flexion • Consider placing towel under body to maintain neutral airway position

35. Suctioning Secretions and Vomit • Use bulb-type suction device for suctioning nose and mouth of infant • For larger children, use thin flexible plastic catheter • Use rigid catheter for removing thick secretions and vomit

36. Principles of Suctioning • Administer oxygen prior to suctioning • Suction for maximum of 5 seconds at a time • Do not touch the back of the throat • May slow heart rate and cause soft-tissue damage

37. Partial Airway Obstruction • Alert • Noisy respirations • Increased work of breathing • Retractions around ribs and sternum • Pink mucous membranes • Good peripheral pulses

38. Managing Partial Airway Obstruction • Place child in position of comfort • Likely sitting up • Calm child • Allow child to sit with parent or caregiver • Provide oxygen by mask or blow-by technique • Let child or caregiver hold oxygen device

39. Management of Airway Obstruction • Intervene if following signs are noted • Absence of speaking or crying • Ineffective cough • Altered mental status • Respiratory arrest

40. Children Under 1 Year of Age • If ventilation is ineffective or impossible, clear airway • 5 back blows • 5 chest thrusts • If object is visible, remove • Continue until effective

41. Children Over 1 Year of Age • If ventilation is ineffective or impossible, clear airway • Perform chest compressions • Do not perform blind finger sweeps

42. Shock • Causes in children • Vomiting • Diarrhea • Infection • Trauma • Blood loss • Less common • Allergic reactions • Poisoning

43. Cardiac Causes of Shock • Very rare in children • Occasionally may have child with congenital or chronic heart disease

44. Rapid heart rate Rapid respiratory rate Cool extremities Pale skin, dry mucous membranes Delayed capillary fill time Weak central pulse Weak or absent distal pulse Decreased response to environment “Floppy” muscle tone Signs and Symptoms of Shock

45. Questions to Ask Caregiver • Has child been vomiting or had diarrhea? • How many wet diapers in the past 24 hours?

46. Management of Shock in Children • Child showing signs of shock is very sick • Children tend to compensate well, then decompensate quickly

47. Emergency Care for Shock • BSI and scene safety • Ensure adequate ABCs • Control obvious bleeding • Administer high flow oxygen • Keep patient warm • Elevate legs, if possible • Expedite transport/call for ALS backup

48. Trauma in Children • Leading cause of death in infants and children • Head injuries • Chest injuries • Abdominal injuries • Injuries to the extremities • Burn injuries

49. Common Mechanisms of Injury • Motor vehicle crash • Motor vehicle versus bicycle • Pedestrian versus motor vehicle • Fall from height • Diving into shallow water • Others • Burns, sports injuries, child abuse

50. Motor Vehicle Crashes • Most common cause of blunt trauma • Unrestrained child • Injuries to head and neck • Restrained child • Abdominal and lower spine injuries