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Emergency Care
for Children
MODULE 10

Pediatric Anatomy & Physiology

REVIEW

Pediatric Anatomy and Physiology

 Head  Neck and airway

 Little children have very big heads.  Short, stubby necks
 Infant’s head is two-thirds the size it  Airway is much smaller.
will be
 Disproportionately large tongue
in adulthood.
 Cricoid cartilage
 More surface area for heat loss
 More mass relative to the rest of
the body

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Pediatric Anatomy and Physiology

 Chest and lungs  Heart

 Chest wall is thin.  Large right-side forces on the
electrocardiogram
 Less musculature and
subcutaneous fat  ECG axis and voltages shift to
reflect left ventricular dominance.
 Easy to hear heart and lung sounds
 Cardiac output is rate-dependent.
 Rib cage is more compliant.
 Use of diaphragm as a muscle of
respiration

Pediatric Anatomy and Physiology

 Abdomen  Musculoskeletal system

 Abdominal distension  Reaching adult height requires
active bone growth.
 Weak abdominal wall muscles
 Growth plates
 Liver extends below the ribcage in
infants.  Bones are weaker than their
ligaments.

Pediatric Anatomy and Physiology

 Brain and nervous system

 As the brain matures, the infant’s responses to the environment, outside
stimuli, and pain become more organized and purposeful.
 Rapidity of brain development

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Developmental Stages
REVIEW

Developmental Stages (1 of 5)

 Neonate and infant

 Neonates: first month of life.
 By 4 months of age, able to hold their heads up.
 Cannot communicate their feelings or needs verbally
 Assessment in the presence of parent or caregiver

Developmental Stages (2 of 5)

 Toddler
 Ages 1 to 3 years
 “Terrible twos”
 Limited reasoning
 Poorly developed sense of cause and effect
 Language development is rapid.
 Stranger anxiety

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Developmental Stages (3 of 5)

 Preschool-age child
 3 to 6 years
 Becomes more verbal and interactive
 Generally able to tell you what hurts
 Speaks in plain language
 Take advantage of the child’s curiosity and desire
to cooperate.

Developmental Stages (4 of 5)

 School-age child
 6 to 12 years
 More analytic and capable of abstract thought
 Understands cause and effect
 Ask the child about the history and let the child describe
the symptoms.

Developmental Stages (5 of 5)

 Adolescent
 13 to 18 years
 Friends are key support figures.
 Experimentation and risk-taking behaviours
 Address the patient and encourage questions
and involvement.
 Provide accurate information.

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Pediatric Assessment
_________________________________________________________________________________

General Impression

 “Sick or not sick” classification

 Pediatric assessment triangle
 Developed to help paramedics in calls
with pediatric patients
 Standardized approach

Used with permission of the American Academy of Pediatrics,

Pediatric Education for Prehospital Professionals. © American
Academy of Pediatrics, 2000

General Impression

 Appearance
 In many cases, most important factor
 TICLS mnemonic
 Tone
 Interactiveness
 Consolability
 Look or gaze
 Speech or cry

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General Impression

 Appearance (continued)
 Observe the child from
a distance.
 Delay touching the
patient.

General Impression

 Work of breathing
 Oxygenation and
ventilation status
 Reflects the child’s
attempt to
compensate
 Listen for abnormal
airway sounds.

General Impression

 Work of breathing (continued)

 Grunting
 Form of auto-PEEP
 Exhaling against a partially closed
glottis
 Short low-pitched sound
 Suggests moderate to severe
hypoxia
 Reflects poor gas exchange
 Wheezing
 Air forced through constricted or
partially blocked small airways
 Often occurs during exhalation
 During severe asthma attacks
 Often heard only by auscultation

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General Impression

 Work of breathing (continued)

 Sniffing position
 Tripod position

Maternal and Child Health Bureau, Emergency Medical Services

Retractions

Courtesy of Health Resources and Services Administration,



for Children Program.

General Impression

 Circulation
 Determine the adequacy of
cardiac output and core
perfusion.
 Circulation to the skin
reflects the overall status
of core circulation.

Evaluate
• Primary assessment
• Secondary assessment
• Diagnostic assessement

Intervene

Identify

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Initial Assessment

 Weight  Exposure considerations

 Estimate early in assessment.
 Much of care depends on size.
 Ask a caregiver or make your own
estimate.
 Proper exposure is necessary to
complete the initial assessment.
 Be careful to avoid heat loss.
 Keep the temperature in the
ambulance high.

Initial Assessment

 Airway
 PAT may suggest airway obstruction.
 Check for mucus, blood, or a foreign body.
 Tongue or soft tissue obstruction

http://neoreviews.aappublications.org/content/14/3/e128

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Initial Assessment

 Breathing
 Calculating the respiratory rate
 Auscultating breath sounds
 Checking pulse oximetry for oxygen saturation

Initial Assessment

 Circulation
 Pulse rate and quality, skin CTC, and blood pressure

Initial Assessment

 Mental status

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Initial Assessment
 Assessment
 Health history
 Initially brief; followed by more thorough history when stabilized
 Chief complaint reported by parents or caregiver
 Physical examination
 Rapid cardiopulmonary assessment
 Additional assessments: neurologic, skin and extremity, and pain

Pediatric Emergencies
____________________________________________________________________

Increased Risks for Injury

 Developmental immaturity
 Younger children, because of their size and shape
 Near drowning and poisoning

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Common Medical Treatments

Common Medications
Used

Focused History and Physical

Examination
 Description of the chief complaint
 Determine the MOI or nature of an illness.
 Rapid trauma or medical assessment
 Obtain baseline vital signs.

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Respiratory Emergencies
____________________________________________________________________

Respiratory Emergencies

 Determine the severity of the disease

 Respiratory distress
 Respiratory failure
 Respiratory arrest

Respiratory Emergencies

 Appearance
 Adequacy of CNS oxygenation
 Assess the work of breathing.
 Note the patient’s position of comfort.
 Presence or absence of retractions
 Grunting or flaring
 Pallor or cyanosis

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Upper Airway Emergencies

 Foreign body aspiration or obstruction

 Swallowed foreign bodies
 Tongue
 Initial management
 Position of comfort
 Providing supplemental oxygen
 Transport

Upper Airway Emergencies

© Ansis Klucis/Shutterstock

© Ansis Klucis/Shutterstock

Upper Airway Emergencies

 Anaphylaxis
 Potentially life-threatening allergic reaction
 Food and bee stings are the most common causes.
 “Gold standard” treatment for anaphylaxis is epinephrine.

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Upper Airway Emergencies

 Croup
 Laryngotracheobronchitis
 Viral infection of the upper airway
 Most common cause of upper airway emergencies
in young children
 Transmitted by respiratory secretions
 Hallmark sign of croup is stridor.

Upper Airway Emergencies

 Epiglottitis and bacterial infections

 Inflammation of the supraglottic structures
 Now rare
 Classic presentation
 Symptoms progress rapidly.
 Minimize scene time.

http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?0/44/714

Lower Airway Emergencies

 Asthma
 Most common chronic illness of  Initial management
childhood
 Basic respiratory care
 Most common respiratory  Position of comfort
complaint encountered
 Start supplemental oxygen.
 Ventilation-perfusion mismatch
 Bronchodilators
 Salbutamol
 Ipratropium
 Epinephrine

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Lower Airway Emergencies

 Bronchiolitis
 Inflammation of the small airways in the lower respiratory tract
 Most common source is respiratory syncytial virus.
 Highest frequency during the late fall and winter months
 Primarily affects infants and children younger than
2 years
 Signs and symptoms
 Can be difficult to distinguish from asthma
 Child’s age can be a clue.
 Management is entirely supportive.

Management of Respiratory
Emergencies
 Airway management
 Check for obstruction.
 Position the airway.
 Airway adjunct if
necessary
 Nasal or oral airway
Courtesy of AAOS

Pharmacology: Respiratory
Emergencies
Salbutamol - 1.25-2.5 mg Nebulized prn
Ipratropium Bromide - 250 – 500 mcg nebulized (mixed with 2.5-5 mg
salbutamol) q 20 min, max 3 doses; 5 puffs MDI
Epinephrine - 1:1000 - 0.01 mg/kg
Diphenhydramine - Child 6-12 yr: PO/IM/IV – 5 mg/kg/day divided into
4 doses, max 300 mg/day
Dexamethasone - 0.5mg/kg to a max dose of 8mg IM/IV/IO/PO
Prednisone - 2mg/kg PO to a single max dose of 60mg

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Cardiovascular Emergencies
____________________________________________________________________

Cardiovascular Emergencies
 PAT and initial assessment
 Overview of perfusion, oxygenation, ventilation,
and neurological status
 Tachypnea
 Congestive heart failure
 Pallor, cyanosis, or mottling

 For suspected cardiovascular compromise

 Start with airway and breathing.
 Provide supportive prehospital care as needed.
 Assess circulation.
 If stable enough to continue assessment on site
 SAMPLE history
 Focused physical examination

Shock
 Compensated shock
 Critical abnormalities countered by the body’s physiological response
 Shunts blood from the periphery
 Increases the heart rate
 Increasing vascular tone
 Decompensated shock
 Body’s mechanisms to improve perfusion are no longer sufficient.
 Hypotensive
 Tachycardic and poor peripheral perfusion
 Altered appearance
 Hypotension is a late and ominous sign in an infant
or young child.

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Hypovolemic Shock

 Hypovolemia
 Most common cause of shock in infants and young children
 Excessive fluid loss and poor intake
 Medical shock
 Position of comfort

Hypovolemic Shock

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Distributive Shock

 Decreased vascular tone

 Resulting in vasodilation and increased vascular permeability
 Drop in effective blood volume and functional hypovolemia
 May be due to sepsis, anaphylaxis, or spinal cord injury
 Fever is a key finding in septic shock.
 Neurological deficits in shock due to spinal cord injury
 Frontline treatment is volume resuscitation.
 Anaphylactic shock should be treated immediately with SQ or IM
epinephrine.

Cardiogenic Shock

 Pump failure
 Intravascular volume is normal; myocardial function
is poor.
 Circulation will be impaired.
 Consider establishing IV access en route to the receiving facility.

Arrhythmias

 Rhythm disturbances
 Classified based on rate
 Signs and symptoms are often nonspecific.
 ECG or rhythm strip to identify the underlying rhythm

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Bradyarrhythmias

 Most often secondary to hypoxia

 Airway management, supplemental oxygen,
and assisted ventilation
 Treat any underlying respiratory problem.
 Initiate ECG monitoring.
 If asymptomatic
 If pulse rate is lower than normal for age
and oxygenation

Tachyarrhythmias
 Sinus tachycardia is common in children.
 Subdivided into two types based on the width
of the QRS complex

Narrow complex tachycardia Wide complex tachycardia

-Supraventricular tachycardia (SVT)
is the most frequent.
-Absent or abnormal P waves, pulse
rate, and history
-Treatment geared toward the
underlying cause
-Synchronized cardioversion
-VT
-May reflect underlying cardiac
pathology
-Antiarrhythmic medication
Amiodarone is the drug of
choice.
-Synchronized cardioversion

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Pulseless Arrest

 Cardiopulmonary arrest
 Usually a secondary event (profound hypoxemia
and acidosis)
 Asystole is the most common arrest rhythm.
 Survival rate is poor.
 Provide high quality BLS care.
 Confirm unresponsiveness, pulselessness,
and apnea.
 Begin CPR if not immediately available.
 Apply pads

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Pharmacology: Cardiovascular
Emergencies
 Epinephrine – 0.01mg/kg (0.1ml/kg)
 Amiodarone – 5 mg/kg
 Lidocaine – 1 mg/kg loading dose; maintenance 20-50 mcg/kg/min
 Atropine – 0.02 mg/kg – min. dose 0.1mg max. single dose 0.5 mg
 Adenosine – 1st dose 0.1 mg/kg (max. 6mg); 2 nd dose 0.2 mg/kg (max. 12mg)
 Dopamine – 2-20 mg/kg/min

The End
NEXT MODULE: HEALTH DISORDERS – PART A

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