Section 7: Special Populations

1
Section 7 Special Populations
2
Chapter 30

• Pediatric Outdoor Emergency Care

3
Objectives

• Differentiate the response of the ill or injured
  infant or child (age specific) from that of an
  adult.
• Discuss the field management of the child trauma
  patient.
• Demonstrate an assessment of an infant, toddler,
  and school-aged child.
• Demonstrate oxygen delivery for the infant and
  child.
• Demonstrate the techniques of foreign body airway
  obstruction removal in a child.

4
Airway Differences

• Larger tongue relative to the mouth
• Less well-developed rings of cartilage in the
  trachea
• Head tilt-chin lift may occlude the airway.

5
Breathing Differences

• Infants breathe faster than children or adults.
• Infants depend on diaphragm use when they
  breathe.
• Sustained, labored breathing may lead to
  respiratory failure.

6
Circulation Differences

• The heart rate increases during illness and
  injury.
• Vasoconstriction keeps vital organs nourished,
  ie, pale skin may mean decreased perfusion.
• Constriction of the blood vessels can affect
  blood flow to the extremities.

7
Skeletal Differences

• Growth plates exist at the ends of long bones.
• Bones are weaker and more flexible.
• Bones are prone to fracture with stress.
• Infants have two small openings in the skull
  called fontanels.
• Fontanels close by age 18 months.

8
Growth and Development

• Thoughts and behaviors of children are usually
  grouped into stages
• Infancy
• Toddler years
• Preschool age
• School age
• Adolescence

9
Infant

• Infancy is the first year of life.
• Infants respond mainly to physical stimuli.
• Crying is the infants main avenue of expression.
• Infants may prefer to be with their caregiver.
• If possible, have the caregiver hold the infant
  as you start your examination.

10
Toddler

• 1 to 3 years of age
• Begin to walk and explore the environment
• May resist separation from caregivers
• Make any observations you can before touching a
  toddler.
• They are curious and adventuresome.

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Preschool-Age Child

• 3 to 6 years of age
• Use simple language effectively
• Understand directions
• Identify painful areas when questioned
• Understand what you are going to do from simple
  descriptions
• Can be distracted with toys

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School-Age Child

• 6 to 12 years of age
• Begin to think like adults
• Can be included with the parent when taking
  medical history
• May be familiar with physical exam
• May be able to make choices

13
The Adolescent

• 12 to 18 years of age
• Very concerned about body image
• May have strong feelings about being observed
• Need respect for privacy
• Understand pain
• Explain any procedure that you are doing.

14
Approach to Assessment

• Approach at eye level.
• Note appearance and activity level.
• Note work-of-breathing (WOB).
• Determine responsiveness with AVPU.
• Grade behavior at the stage of development level,
  ie, toddler, infant.
• Maintain normal body temperature.

15
Helpful Hints

• Remain calm and appear confident.
• You are caring for a whole family.
• Honesty is important.
• Inform caregiver and child often.
• Keep the family together.
• Provide hope and reassurance to all.

16
Care of the Pediatric Airway (1 of 2)

• Position the airway in a neutral sniffing
  position.
• If spinal injury suspected, use jaw-thrust
  maneuver to open the airway.

17
Care of the Pediatric Airway (2 of 2)

• Positioning the airway
• Place the patient on a firm surface.
• Fold a small towel under the patients shoulders
  and back.
• Place tape across patients forehead to limit
  head rolling.

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Oropharyngeal Airways

• Determine the appropriately sized airway.
• Place the airway next to the face to confirm
  correct size.
• Position the airway.
• Open the mouth.
• Insert the airway until flange rests against
  lips.
• Reassess airway.

19
Nasopharyngeal Airways (1 of 2)

• Determine the appropriately sized airway.
• Place the airway next to the face to make certain
  length is correct.
• Position the airway.
• Lubricate the airway.

20
Nasopharyngeal Airways (2 of 2)

• Insert the tip into the right naris.
• Carefully move the tip forward until the flange
  rests against the outside of the nostril.
• Reassess the airway.

21
BVM Devices

• Equipment must be the right size.
• Ventilate at the proper rate and volume.
• A BVM device may be used by one or two rescuers.

22
Assessing Ventilation

• Observe chest rise in older children.
• Observe abdominal rise and fall in younger
  children or infants.
• Skin color indicates amount of oxygen getting to
  organs.

23
Airway Obstruction

• Croup
• An infection of the airway below the level of the
  vocal cords, caused by a virus
• Epiglottitis
• Infection of the soft tissue in the area above
  the vocal cords

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Signs and Symptoms

• Decreased or absent breath sounds
• Stridor
• Wheezing
• Rales

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Signs of Complete Airway Obstruction

• Ineffective cough (no sound)
• Inability to cry or speak
• Increasing respiratory difficulty, with stridor
• Cyanosis
• Loss of responsiveness

26
Removing a Foreign Body Airway Obstruction (1 of
5)

• In an unconscious child
• Place the child on a firm, flat surface.
• Inspect the upper airway and remove any visible
  object.
• Attempt rescue breathing.
• If ventilation is unsuccessful after two
  attempts, position your hands on the abdomen.

27
Removing a Foreign Body Airway Obstruction (2 of
5)

• Give five abdominal thrusts.
• Open airway again to try and see object.
• Only try to remove object if you see it.

28
Removing a Foreign Body Airway Obstruction (3 of
5)

• Attempt rescue breathing.
• If unsuccessful, reposition head and try again.
• Repeat abdominal thrusts if obstruction persists.

29
Removing a Foreign Body Airway Obstruction (4 of
5)

• In a conscious child
• Kneel behind the child.
• Give the child five abdominal thrusts.
• Repeat the technique until object comes out.

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Removing a Foreign Body Airway Obstruction (5 of
5)

• If the child becomes unconscious, inspect the
  airway.
• Attempt rescue breathing.
• If airway remains obstructed, repeat thrusts.

31
Management of Airway Obstruction in Infants

• Hold the infant face-down.
• Deliver five back blows.
• Bring infant upright on the thigh.
• Give five quick chest thrusts.
• Check airway.
• Repeat cycle as often as necessary.

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Vital Signs by Age

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Vital Signs Respirations

• Abnormal respirations are a common sign of
  illness or injury.
• Count respirations for 30 seconds.
• In children younger than 3 years, count the rise
  and fall of the abdomen.
• Note work of breathing.
• Listen for noises.

34
Vital Signs Pulse

• In infants, feel over the brachial or femoral
  area.
• In older children, use the carotid artery.
• Count for at least 1 minute.
• Note strength of the pulse.

35
Vital Signs Blood Pressure

• Use a cuff that covers two thirds of the arm.
• If scene conditions make it difficult to measure
  blood pressure accurately, do not waste time
  trying.

36
Vital Signs Skin

• Feel for temperature and moisture.
• Estimate capillary refill.

37
Signs and Symptoms of Respiratory Emergencies

• Nasal flaring
• Grunting respirations
• Wheezing, stridor, or abnormal sounds
• Use of accessory muscles
• Retractions of rib cage
• Tripod position in older children

38
Respiratory Emergencies

• Croup viral infection that responds well to
  hydration
• Epiglottitis bacterial infection on the decline
  due to HIB vaccine
• Asthma common, and treated with inhalers, rarely
  epinephrine
• Bronchiolitis, bronchitis, and pneumonia
  infections of lung and lung passages

39
Airway

• Be alert for airway problems in all children with
  trauma.
• Unconscious children breathing on their own are
  at risk for airway obstruction.
• Use jaw-thrust maneuver when necessary.
• Keep suction available.

40
Emergency Care

• Provide supplemental oxygen in the most
  comfortable manner.
• Place child in position of comfort this may be
  in caregivers lap.
• If patient is in respiratory failure, begin
  assisted ventilations immediately.
• Continue to provide supplemental oxygen.

41
Breathing

• Give supplemental oxygen to all children with
  possible
• Head injuries
• Chest injuries
• Abdominal injuries
• Shock
• Use properly sized equipment.

42
Seizures

• Result of disorganized electrical activity in the
  brain
• Types of seizures
• Generalized (grand mal) seizures
• Partial seizures
• Absence (petit mal) seizures
• Usually followed by a postical period
• Status epilepticusa continuous seizure or
  multiple seizures without a return to
  consciousness for 30 minutes or more.

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Febrile Seizures

• Febrile seizures are most common in children from
  6 months to 6 years.
• Febrile seizures are caused by fever.
• They last less than 15 minutes, with tonic-clonic
  activity.
• Postictal period may or may not follow.
• Assess ABCs and begin cooling measures.
• Arrange for prompt transport.

44
Emergency Medical Care of Seizures (1 of 2)

• Perform initial assessment, focusing on the ABCs.
• Securing and protecting the airway is the
  priority.
• Place patient in the recovery position.
• Be ready to suction.

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Emergency Medical Care of Seizures (2 of 2)

• Deliver oxygen by mask, blow-by, or nasal
  cannula.
• Begin BVM ventilations if there are no signs of
  improvement.
• Call ALS for transport if appropriate.

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Altered Level of Responsiveness

• The first step in treatment is to assess the ABCs
  and provide proper care.
• Use the AVPU scale.
• Obtain a brief history from caregivers.
• After initial assessment, secure airway.
• Support patients vital functions.
• Arrange for prompt transport.

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Common Causes A E I O U T I P S

• Alcohol
• Epilepsy, endocrine, or electrolyte imbalance
• Insulin or hypoglycemia
• Opiates or other drugs

• Uremia
• Trauma or temperature
• Infection
• Psychogenic or poison
• Shock, stroke, or shunt obstruction

48
Poisoning

• Poisoning is common in children.
• Care will be based on how awake and alert the
  child appears.
• Focus on the ABCs.
• Do not administer syrup of ipecac unless directed
  by medical control.
• Collect poison containers and vomitus.
• Arrange for prompt transport.
• Childs condition could change at any time.

49
Shock

• Circulatory system is unable to deliver
  sufficient blood to organs.
• Shock has many different causes.
• Patients may have increased heart rate and
  respirations, and pale or blue skin.
• Children do not show decreased blood pressure
  until shock is severe.

50
Assessing Circulation

• Pulse greater than 160 beats/min suggests shock
• Skin signs assess temperature and moisture
• Capillary refill is it delayed or are the
  fingers just cold?
• Color is skin pink, pale, ashen, or blue?

51
Emergency Medical Carefor Shock

• Ensure airway.
• Support ventilations with supplemental oxygen.
• Control bleeding.
• Elevate feet and maintain body temperature.
• Arrange for immediate transport.
• Monitor vital signs.
• Arrange for ALS backup as needed.
• Ensure that caregiver accompanies patient.

52
Dehydration

• Determine if child is vomiting and/or has
  diarrhea and for how long.
• Watch for clues
• Dry lips and gums
• Fewer wet diapers
• Shrunken eyes
• Irritable or sleepy
• Poor skin turgor
• Cool, clammy skin

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Other Emergencies

• Hyperthermia watch for overdressing and infants
  left in vehicles
• Hypothermia newborns are especially susceptible
• Sepsis usually follows a history of upper
  respiratory infection
• Sports-related injuries seen in activities with
  high speed or contact

54
Head Injuries

• Nausea and vomiting are common signs and
  symptoms.
• The most important step is to ensure the airway
  is open.
• Respiratory arrest can occur be prepared.
• Avoid hyperventilating the patient until normal
  ventilations with a BVM device have been
  established for a few minutes.

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Immobilization

• Any child with a head or back injury should be
  immobilized.
• Young children may need padding beneath their
  torso.
• Children may need padding along the sides of the
  backboard.

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Chest Injuries

• Most chest injuries in children result from blunt
  trauma.
• Children have soft, flexible ribs.
• The absence of obvious trauma does not exclude
  the likelihood of serious internal injuries.

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Abdominal Injuries

• Abdominal injuries are very common in children.
• Children compensate for blood loss better than
  adults but go into shock more quickly.
• Children involved in trauma tend to swallow air,
  creating stomach distention.

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Injuries to the Extremities

• A childs bones bend more easily than an adults.
• Incomplete fractures can occur.
• Growth plates are susceptible to fracture.
• Treat fractures in the same manner as in adults,
  but do not use adult splints unless the child is
  large enough to fit the device.

59
Burns

• Most common burns involve exposure to hot
  substances, items, or caustic materials.
• Suspect internal injuries from chemical ingestion
  when burns are present around lips and mouth.
• Infection is a common problem with burns.
• Consider the possibility of child abuse.

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Submersion Injury

• Drowning or near drowning
• Second most common cause of unintentional death
  of children in the U.S.
• Assessment and reassessment of ABCs are critical.
• Patient may be in respiratory or cardiac arrest.

61
Family Matters

• When children are injured, rescuers will have to
  deal with caregivers as well.
• Calm parents calm children
• Keep caregiver with child.
• Support and inform family often.
• Act calm, confident, and professional.

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Child Abuse

• Child abuse refers to any improper or excessive
  action that injures or harms a child or infant.
• This includes physical abuse, sexual abuse,
  neglect, and emotional abuse.
• More than 2 million cases are reported annually.
• Be aware of signs of child abuse and report it to
  authorities.

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Considerations Regarding Signs of Abuse (1 of 4)

• Is the injury typical for the childs
  developmental stage?
• Is reported method of injury consistent with
  injuries?
• Is the caregiver behaving appropriately?
• Is there evidence of drinking or drug abuse?

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Considerations Regarding Signs of Abuse (2 of 4)

• Was there a delay in seeking care for the child?
• Is there a good relationship between child and
  caregiver?
• Does the child have multiple injuries at various
  stages of healing?
• Does the child have any unusual marks or bruises?

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Considerations Regarding Signs of Abuse (3 of 4)

• Does the child have several types of injuries?
• Does the child have burns on the hands or feet
  that look like gloves or socks?
• Is there an unexplained decreased level of
  consciousness?

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Considerations Regarding Signs of Abuse (4 of 4)

• Is the child clean and an appropriate weight?
• Is there any rectal or vaginal bleeding?
• What does the home look like? Clean or dirty?
  Warm or cold? Is there food?

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Emergency Medical Care

• Take care of ABCs.
• Treat all injuries.
• Arrange for transport if you suspect abuse.
• Do not make accusations.
• Law enforcement and child protective services
  must investigate all reports of abuse.

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Response to Pediatric Emergencies

• Providers may experience a wide range of emotions
  after dealing with a child or infant.
• You may feel anxious if you have limited
  experience with children therefore, practice is
  necessary.
• After difficult incidents, a debriefing may be
  helpful.