[
    {
        "Chapter Introduction": "hello and welcome to chapter 35 pediatric emergencies of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand the anatomy and physiology of the child as compared to the adult you will learn the appropriate assessment and care for all the types of illnesses and injuries affecting children of all ages including patterns based on size and special body systems injuries you will also learn the indicators of abuse and neglect and the medical and legal responsibility of an emt okay so let's get started",
        "Introduction to Pediatric Care": "children differ anatomically physically and emotionally from adults the illness and injuries that children sustained and their responses to them vary based on age and developmental level it's important to remember that children are not just small adults depending on his or her age the child may not be able to tell you what's wrong fear of ems providers and pain can make the child difficult to assess parents or primary caregivers may be stressed frightened or behaving irrationally for these reasons pediatrics the specialized medical practice devoted to the care of young patients can be challenging once you learn how to approach children of different ages and what to expect when caring for them you will find that treating children also offers some very special rewards their innocence and openness can be appealing children often respond to treatment much more rapidly than adults do",
        "Communication With the Patient and the Family": "so first let's start with communicating with the patient and the family caring for an infinite child means that you must care for the patients and caregivers as well family members or caregivers often need emotional support a calm parent usually results in a calm child the parent can often assist you and with the child's care an agitated parent means the child will act the same way which may make the child's care more difficult so remain calm efficient professional and sensitive",
        "Growth and Development": "growth and development many physical and emotional challenges and changes occur during childhood childhood extends from birth to age 18. the thoughts and behaviors of the children as a whole are often grouped into five different stages so first is the infancy and this is the first year of life then there's the toddler and that's ages one to three years then preschool age that is three to six then school age that's age six to twelve and then adolescence from thirteen to eighteen",
        "The Infant": "so first let's talk about the infant the infancy is usually defined as the first year of life first month after birth is called the neonatal or newborn period okay so then we're gonna let's break it down a little bit more so zero to two months infants less than two months spend most of their time sleeping and eating and infants cannot tell the difference between parents and strangers so crying is one of the main modes of expression an unconsolable infant after all obvious needs have been addressed could be a sign of a significant illness their heads have a relatively larger surface area between area which predisposes them to hypothermia all right so ages two to six months they can recognize their parents or caregivers and turn their head towards a loud sound or familiar voice persistent crying irritability or lack of contact contact can be an indicator of a serious illness depressed mental status or a delay in development and then from six to 12 months they become mobile which predisposes them to physical danger they could place things in their mouth which leads to choking or poisoning and they may cry if separated from their parents or caregivers persisting crying or irritability can be a symptom of a serious illness so when we're talking about assessing an infant we begin assessment by observing the infant from a distance we let the caregiver continue to hold the baby during the physical assessment provide as much sensory comfort as possible do any painful procedures at the end of the assessment process complete each procedure efficiently and avoid interruptions explain each procedure to the parent or caregiver before you perform it because the procedure and the infant's reaction may be upsetting",
        "The Toddler": "all right so now let's talk about the toddler after infancy until three years so one year to three years of age a child is called a toddler toddlers experience rapid changes in growth and development from 12 to 18 months because they are explorers by nature and not afraid injuries in this group increase because of the lack of molars they may be they may not be able to fully chew their food and this leads to an increase in choking when we talk about the assessment they may have stranger anxiety they may resist separation from caregiver and demonstrate the assessment on a doll or stuffed animal first if possible may they may be unhappy about being restrained or held for procedures and toddlers can have a hard time describing or localizing pain so use visual cues clues such as the one baker faces pain scale they may be distracted by a toy begin your assessment at the feet or away from the location of pain if possible persistent cries or irritability can be a symptom of a serious injury and previous medical experiences may lead to hesitation towards you if a parent or",
        "The Toddler Continued": "caregiver is unavailable reassure the child using simple words and a calm soothing voice",
        "The Preschool-Age Child": "okay now after the toddlers we're into that preschool aged child and this is ages three to six years old they can have a rich imagination and can be fearful about pain they may believe injury is a result of earlier bad behavior so when i talk about the assessment we can under um they can understand directions and be specific in describing their painful areas despite increased ability to communicate much of the history must still be obtained from the caregivers communicate simple and directly appealing to the child's imagination may help facilitate the examination process do not lie to this patient because it will be hard to regain lost trust the patient may be easily distracted by games or toys or conversation and begin the assessment at the feet and move towards the head use adhesive bandaging to cover the sight of an injection or a small wound and modesty is developing so keep the child covered as much as possible",
        "School-Age Years": "okay so after the toddler and the school age we're gonna move to the school age and this is six to twelve at this stage children begin to understand death is final but their understanding of death it is and why it occurs is still unrealistic assessment begins to be more like an adult to help gain trust talk to the child not just the caregiver the child is probably familiar with the process of a physical exam start with the head and work towards the feet as in with an adult assessment and if possible give the child choices for example ask only the type of questions that let you control the answer allow the child to listen to his or her own heartbeat through the stethoscope these children can understand the difference between physical and emotional pain so give them simple explanations about what is causing their pain and what will be done about it ask the parents or caregivers advice about which distraction will work best",
        "Adolescents": "okay and after that we're gonna get into",
        "Adolescents Continued": "the adolescence and this is ages 13 to 18 physically similar to adults but they are still children on an emotional level and time of um this time they're doing experimentation and taking risk behaviors so adolescents can often understand very complex complex concepts and treatment options so allow adolescents to be involved in their own care an emt of the same gender should perform the physical exam if possible to lessen the stress of the event allow the adolescents to speak openly and ask questions and risk taking behaviors are common at this age",
        "Adolescents Continued Again": "female patients can be pregnant so adolescents also have a clear understanding of the purpose and meaning of pain",
        "Anatomy and Physiology": "so let's start to talk about the anatomy and physiology okay so the body is growing and changing rapidly during childhood you must understand the physical differences between children and adults and alter your patient care accordingly",
        "The Respiratory System": "first we're going to talk about the respiratory system so the anatomy of a pediatric airway differs from adults pediatric airway is smaller in diameter and shorter in length and lungs are smaller the heart is higher in the child's chest opening is higher in position more anteriorly and the neck appears to be non-existent as children develop the neck gets proportionately longer as the vocal cords and epiglottis achieve a correct adult position the occipit is a large it's larger and rounder which requires more careful positioning of the airway the tongue is larger relative to the size of the mouth and in a more anterior location in the mouth a child's tongue can easily block the airway a long flappy u-shaped epiglottis in infants and toddlers is larger than the adults and the rings of cartilage in the trachea are less developed and may easily collapse if the neck is flexed or hyper-extended the upper airway has a narrowing funnel shaped uh compared to the cylinder shape of the of the lower airway okay so the diameter of the trachea and infants is about the same size as a drinking straw so this means that airways can easily become obstructed and also that the infants are they are nose breathers and they may require suctioning and airway maintenance and the respiratory rate is uh from 20 to 60 is newborn uh is uh normal for the newborn so children also have an oxygen demand twice of that of the adult the muscles of the diaphragm dictate the amount of air the child inspires anything that places pressure on the abdomen of a young child can block the movement of the diaphragm and cause respiratory compromise you must make and use caution when applying the straps of a spinal immobilization device because it may hinder the tidal volume gastric distension can interfere with movement of the diaphragm and lead to hypoventilation breast sounds are more easily heard because of their thinner chest walls and less air is exchanged with each breath so detection of poor air movement or complete absent of breast sounds may be more difficult the circulatory system it's important to",
        "The Circulatory System": "know the normal pulse ranges when evaluating children an infant's heart",
        "The Circulatory System Continued": "rate can beat 160 times or more in a minute and children are able to compensate for decreased perfusion by constricting the vessels in the skin signs of vasoconstriction include pallor and that's an or an early sign weak distal pulses in the extremities delayed cap refill and cool hands or feet the table on this slide list responsive pediatric pulse rates",
        "The Nervous System": "all right so let's move on to the nervous system and so the differences are the pediatric nervous system is immature underdeveloped and not well protected head to body ratio of infant and young children is disproportionately larger the occipital region of the head is larger which increases the momentum of the head during the fall the subarachnoid space is relatively smaller leaving less cushing for the brain and the brain tissue and cerebral vasculature are fragile and prone to bleeding from shearing forces the pediatric brain also requires a higher amount of cerebral blood flow oxygen and glucose than does the adult brain tissue and it places them at risk for secondary brain damage from hypotension and hypoxic events spinal cord injuries are less common in pediatric patients if cervical spine is injured it is more likely to be an injury to the ligaments because of a fall for suspected neck injuries perform manual inline stabilization or follow local protocols",
        "The Gastrointestinal System": "the gastrointestinal system okay so abdominal muscles are less developed in pediatric patients this gives them less protection from trauma liver spleen and kidneys are proportionately larger and situated more anteriorly so they are more prone to bleeding and injuries because of minimum direct impact",
        "The Musculoskeletal System": "the muscular skeletal system the child's bones are softer and than those of an adult and open growth plates allow bones to grow during childhood so as a result of open growth plates bones are softer and more flexible making them prone to stress fractures and bone length discrepancies can occur if there is an injury to the growth plate the bones of an infant's head are flexible and soft and soft spots called fontanelles are located at the front and back of the head the fontanels can be used for an assessment tool for such issues as increased intracranial pressure or dehydration the thoracic cage of children is highly elastic and pliable because it is primarily composed of cartilage connective tissue the ribs and vital organs are also less protected by muscle and fat into mega",
        "The Integumentary System": "terry system of the pediatric population differs in a few ways the skin is thinner with less subcutaneous fat composition of the skin is thinner and tends to burn more deeply and easily with less exposure and the higher ratio of body surface area to body mass can lead to a larger fluid loss and heat losses",
        "Scene Size-up": "so let's get into our patient assessment and we're going to start with that scene size up okay so assessment begins at the time of that dispatch remember so prepare mentally for approaching and treating an infant or child plan for pediatric scene size up pediatric equipment and age appropriate patient physical assessments if possible collect the age and gender of the child location of the same scene mechanism of injury or nature of illness and chief complaint from dispatch note the position in which the patient is found the patient may be a safety threat if he or she has an infectious disease so complete an environmental assessment",
        "Primary Assessment": "okay so next um we're going to talk about the p-a-t and the p-a-t is the pediatric assessment triangle and we're gonna um the objective of this primary assessment is to identify and treat in immediate and potential life threats so we're going to use the pediatric assessment triangle to determine if the patient is sick or not sick and it can be performed in less than 30 seconds okay so let's talk about it the p-80 consists of three elements and requires no it uh no equipment and so the first is going to be the appearance and this is the muscle tone or mental status then the work of breathing and then finally the circulation okay so the appearance note the level of consciousness or interactiveness and muscle tone these will provide you with information about the adequacy of the patient's cerebral perfusion and overall function of the central nervous system the pneumonic t-i-c-l-s tickles can also help to determine if the patient is sick or not tickles includes tone interactiveness consult consolability look or gaze and speak speech or cry then is the work of breathing so signs of increased work of breathing often presents with abnormal airway noise accessory muscle use retractions and head bobbing nasal flaring tachypnea and the tripod position okay so the body will attempt to compensate for abnormalities in oxygenation and ventilation and then finally the third is the circulation to the skin so polar of the skin and mucous membranes may be seen in compensated shock it may also be a sign of anemia or hypoxia modeling is another sign of poor perfusion and cyanosis reflects a decreased level of oxygen in the blood from the pat findings you will decide if the pediatric patient is stable and requires urgent care if the patient's unstable assess the xabc's treat any life threats and transport immediately if the patient is stable continue with the remainder of the patient's assessment process perform necessary interventions and discuss transport options with the parents and caregivers hands-on so we're going to really look for do a hands-on assessment and we're going to assess and treat those life threats as we identify them following the x abcs so the x is a signification airway breathing circulation disability and exposure now we're going to talk about those next okay so if the airway is open and the patient can adequately keep it open assess respiratory adequacy if the patient is unresponsive or has difficulty keeping the airway clear ensure that is properly positioned and that it's clear of mucus vomit blood and foreign bodies always position the airway in the neutral sniffing position and establish whether the patient can maintain his or her own airway then breathing so look listen and feel technique we're going to place both hands on the patient's chest to feel for chest rise and fall of the chest wall belly breathing in infants is considered adequate because of the soft pliable bones of the chest and the strong musculature diaphragm comes to circulation we must determine if the patient has a pulse is bleeding origin shock in infants we're going to palpate the brachial pulse or femoral pulse in children older than one year we're going to palpate the carotid pulse strong central pulses indicate that the child is not hypotensive but it does not rule out the possibility of compensation we graphs and peripheral pulses indicates decreased per perfusion and tachycardia may be an early sign of hypoxia or shock or a less serious condition such as a fever anxiety pain or excitement interpret the pulse with in the context of the overall patient history the p-a-t and the primary assessment a trend of an increasing or decreasing pulse rate may suggest worsening hypoxia or shock or improvement after treatment fuel the skin for temperature and moisture and estimate the cap refill time d when it comes to disability we're going to use the av pills avpu score or the pediatric calcoma score to assess level of consciousness we want to check the responsiveness of the pupils and look for symmetrical movement of the extremities pain is present with most types of injuries so assessment of pain must take into consideration the developmental age of the patient and then e is exposure so the hands-on abcs require that the caregiver move remove part of the patient's clothing to allow observation of the face chest wall and skin the pediatric population is more prone to hypothermic events during due to immature system thinner skin and lack of that subcutaneous fat so infants and young children should be kept warm during the during the transport or when the patient is exposed to excessive or reassessing an injury and then d is that transport decision okay so if the pediatric patient is in stable condition obtain a patient history perform a secondary assessment at the scene transport and provide additional treatment as needed okay so rapid transport is indicated if any of the following conditions exist so if there's a significant mechanism of injury if there's a history of capable of or with a serious illness if a physical abnormality is noted during the primary assessment or if a potentially serious um at atomic abnormality or significant pain or an abnormal level of consciousness altered mental status or any signs of or symptoms of shock we want to also consider the following so we want to know the type of clinical problem the expected benefits of advanced life support treatment in the field and local ems systems treatment and transport protocols your comfort level and also the transport time to the hospital if the pediatric patient condition is urgent then immediate transport to the closest facility should be initiated special facilities such as trauma centers or children's hospitals have the training staff and equipment to provide complete care for all levels of pediatric patients so the most appropriate facility is not always the closest so you want to ask yourself can i deliver this pediatric patient to the most appropriate facility without the risk or delay to the pediatric patient if the answer is no you need to transport the patient to the closest facility if patients weigh less than 40 pounds who do not require spinal immobilization you should transport them in a car seat mount a car seat to the stretcher and follow the the seat manufacturer's instructor instructions to secure the car seat to the captain's chair patients younger than two years must be transported in a rear-facing position because of the lack of mature neck muscles for pediatric patients who require spinal immobilization the patient should be immobilized to a long backboard or other suitable spinal immobilization devices pediatric patients in cardiopulmonary arrest should be on a device that can be secured to the stretcher you should not use the pediatric patient's car seat the goal is to secure the and protect the patient for transport in the ambulance okay so history taking your approach to the history will depend on the age of the pediatric patient historical information for the infant toddler or pre-school-aged child will have to be obtained from the parent or caregiver when dealing with adolescent most information will be obtained from the patient sexual activity possibility of pregnancy and drugs or alcohol should be obtained from the patient in private questioning the parents or child about the immediate illness or injury should be based on the child's chief complaint when interviewing the parent caregiver or child about the chief complaint obtain the following you want to know the mechanism of injury or the nature of illness how long the pediatric patient has been sick or injured the key events that led to the injury or illness the presence of fever",
        "History Taking": "effects of the illness of or injury on the pediatric patient's behavior and the pediatric patient's activity level recent eating drinking and urine output change in bowel or bladder habits or the presence of vomiting diarrhea abdominal pain and the presence of rashes you want to obtain the name and phone number of the caregiver if they are not able to come to the hospital with you and then let's talk about the history taking as far as the sample history so it's the same as the adults but you uh the question should be based on the pediatrics patient's age and development stage of life the process for obtaining opqrs t is the same as the children same for the children and as it is the adults so questions should be based on the pediatrics patient's age and developmental stage as well",
        "Secondary Assessment": "okay and then your secondary assessment so a secondary assessment of the entire body should be used when pediatric patients have the potential for hidden illness or injuries okay so it may help identify problems that were not as obvious during the primary assessment but over time the presenting signs and symptoms have become more apparent use the dcap btls pneumonic a focused assessment should be performed on a pediatric patient without life-threatening illness or injuries",
        "Secondary Assessment Continued": "infants toddlers and pre-school-aged children who do not have life-threatening illness or injuries should be assessed starting at the feet and ending with the head school-aged children and adolescents can be assessed using the head-to-toe approach as with the adult patients okay so when it comes to that physical exam we're going to look at the head bruising decap btls and of course assess the fontanels and infants and with the nose um nasal congestion needs to be cleared because it can cause respiratory distress so you could use a bulb syringe or a suction cap a soft selection cap then the ears you have to look for the drainage in the ears of this indicates the skull fracture just with the the same as adults and the mouth of course we're looking for bleeding or any type anything that could cause an airway obstruction and of course the mouth as with the um adolescent onset or child onset of diabetes we want to note the smell of the breath the neck we're going to look for tracheal deviations same as the adult in the chest decap btls we're going to look listen and feel to the chest area and the clavicles in the back we're going to look for a dcap btls the abdomen we're going to inspect for distension we're going to palpate and note any um guarding or pain or tenderness okay and then of course looking for the seat belt abrasions or bruising and then the extremities we're going to do pms looking for extra um some symmetry and uh and then just rotate to see if there's full range of motion in the extremities vital signs so uh of course these are used uh to assess uh circulatory status and um but they have there is some important limitations when it comes to pediatric patients so normal heart rates vary in age with those pediatric patients and blood pressure is also usually not assessed in pediatric patients younger than three years old and then assessment of the skin is a better indication of the pediatric patient's circulatory status so use appropriately sized equipment when assessing a pediatric patient's vital signs you have to use a cuff that covers two-thirds of the pediatric patient's upper arm all right so when we talk about how to formulate a blood pressure in children 1 through 10 years old we're going to basically just take the child's age in years and multiply it by 2 and then add it to 70. so a systolic blood pressure is a that's a useful tool in determining blood pressure in children um but the cir respiratory rates can also be difficult to interpret so count the respiratory or the respirations for at least 30 seconds and then double it and in infants and children younger than three evaluate respirations by assessing the rise and fall of the abdomen we're going to assess the pulse rate by counting for at least a minute noting quality and regularity okay so normal vital signs in the pediatric patient of course are going to vary with age we want to assess respirations and then pulse and then blood pressure last and we're going to compare the size of the pupils with each other and pulse ox is a valuable tool to measure the oxygen saturation in a pediatric patient with respiratory distress",
        "Reassessment": "and then of course we're going to reassess and uh 15 minutes if they're in stable condition every five if they're in unstable and we of course continually monitor respiratory effort skin color condition and level of consciousness or their interactiveness parents and caregivers may be able to assist you by calming and reassuring that patient down and then of course we have to communicate and document all that info to the emergency department personnel",
        "Respiratory Emergencies and Management": "okay now we're going to get into specific emergencies and management of those types of emergencies okay so specifically to respiratory emergencies it's the leading cause of cardiopulmonary arrest in the pediatric population failure to recognize and treat declining respiratory status will lead to death during respiratory distress the pediatric patient is working harder to breathe and will eventually go into respiratory failure if left untreated in the early stages of respiratory distress you may not know changes in the pediatric patient's behavior such as combativeness restlessness and anxiety signs and symptoms of increased work of breathing include nasal flaring abnormal breath sounds uh accessory muscle use and they might be in the tripod position as the pediatric patient progresses to possibly respiratory failure efforts of uh to breathe decrease the chest rise less with inspiration and the body has used up all its available energy stores and cannot continue to support the extra work of breathing changes in behavior will also occur until the pediatric patient demonstrates an altered level of consciousness patients may also experience periods of apnea as the lack of oxygen becomes more serious the heart muscles become hypoxic and the heart rate slows down respiratory failure does not always indicate airway obstruction it may indicate trauma nervous system problems dehydration or metabolic disturbances a pediatric patient's condition can progress from respiratory distress to respiratory failure at any time a child with an infant or respiratory distress needs supplemental oxygen assist ventilation with a bag valve mask and 100 oxygen if needed allow the patient to remain in a comfortable position okay so airway obstruction children can obstruct their airway with any object that can fit in their mouth in cases of trauma teeth may have been dislodged into the airway",
        "Airway Obstruction": "blood vomit or other secretions can also cause mild or severe airway obstructions infections including pneumonia croup epiglottitis and bacterial tracheitis can also cause airway obstructions infections should be considered if patient has congestion fever drooling and cold symptoms the figure on this slide shows the effects of epiglottitis and this is an infection that can cause an upper airway obstruction in the pediatric patients",
        "Airway Obstruction Continued": "obstructions by a foreign object may involve the upper or lower airway it may be partial or complete signs and symptoms frequently associated with a partial upper airway obstruction include decrease or absent breath sounds and strider signs and symptoms of a lower airway obstruction include wheezing and or crackles the best way to auscultate breast sounds in a pediatric patient is to listen on both sides of the chest and at the armpit level immediately begin treatment of a pediatric patient with an airway obstruction if the patient is conscious and coughing forcefully and someone saw him or her in just a foreign object encourage the child to cough to clear the airway if you see signs of severe airway obstruction attempt to clear the airway immediately if an infant is conscious with a complete airway obstruction we're going to perform up to five back blows and chest thrusts if the child is conscious with the complete airway obstruction we're going to perform abdominal thrusts and this is the heimlich maneuver we need to use a head tilt chin lift and a finger sweep to remove a visible foreign body in an unconscious pediatric patient chest compressions are recommended to relieve a severe airway obstruction in an unconscious pediatric patient okay so let's talk about asthma specific this is a condition in which the similar or the smaller airway passages the bronchioles have become inflamed and they swell and produce excessive mucus which leads to difficulty breathing it's a true emergency if not promptly identified and treated common causes for an asthma attack include upper airway or respiratory infection exercise exposure to cold air or smoke and emotional stress signs and symptoms are wheezing cyanosis respiratory arrest or the tripod position what we want to do is treatment of that pediatric patient with asthma we want to allow the patient to maintain a position of comfort we want to administer supplemental oxygen albuterol alone with ibuproprium via uh mdi or nebulizer and um contact advanced life support and assist ventilations if needed",
        "Pneumonia": "okay that was asthma now let's get into pneumonia pneumonia is a general term that refers to an infection of the lungs often a secondary affection it occurs after a pre-existing infection infections such as a cold and it can also occur from chemical ingestion or direct lung injury or a submersion event children with diseases cause causing immunodeficiency are at an increased risk for developing pneumonia incidence is greatest during fall and winter months presentation in a pediatric patient so unusual rapid breathing or they'll breathe with grunting or wheezing sounds there's also nasal flaring tachypnea hypothermia or fever or unilateral diminished breath sounds or crackles over the affected lung segments so treatment of pneumonia in the pediatric patient will be primary treatment will be supportive we want to administer supplemental oxygen if they need it and administer a bronchodilator it's a chest or if the child's wheezing so diagnosis of the mono pneumonia must be confirmed at the hospital",
        "Croup": "okay and then there's croup",
        "Croup Continued": "so croup is an infection of the airway below the level of the vocal cords and usually caused by a virus typically seen in children between six months and three years it's easily passed between children starts with a cold cough and a low-grade fever it develops over two days the hallmark sign of croup is strider and a seal bark cough it responds well to oxygen or administration of humidified oxygen and bronchiodilators are not indicated for group and can actually make the child worse",
        "Epiglottitis": "and then there's epiglottitis so that's an infection of the soft tissue in the area above the vocal cords it's bacterial infection is the most common cause and since the development of a vaccine against one organism that causes epiglottitis the incident of this disease has dramatically decreased in preschool and school-aged children especially the epiglottitis can swell to two or three times its normal size children with this infection look ill and they report a very sore throat and high fever they will often be found in the tripod position and drooling",
        "Bronchiolitis": "and then um bronchulitis okay so specific viral infections of newborns and toddlers often caused by rsv causes inflammation of the bronchioles rsv is highly contagious and spread through coughing and sneezing and viruses can survive on surfaces and virus tends to spread rapidly through schools and child care centers more common in premature infants and results in copious secretions that may require suctioning okay so it occurs during the first two years of life and is more common in males most widespread in winter and early spring and the bronchioles become inflamed swell and fill with mucus airway of the infants and young children can become easily blocked so you want to look for signs of dehydration shortness of breath and fever how we're going to treat bronchiolitis in pediatric patients is we're going to allow the patient to remain in that position of comfort we need to administer humidified oxygen and consider advanced life support backup",
        "Pertussis": "and then there's pertussis it's a communicable disease caused by a bacterium that is spread through respiratory drop as a result of vaccinations this potentially deadly disease is less common in the united states the typical signs and symptoms are similar to that of a common cold sneezing and a runny nose and as the disease progresses the coughing becomes more severe and characterized by a distinctive whoop sound heard during inspiration infants infecting with pertussis may develop pneumonia or respiratory failure to treat pediatric patients make sure you keep the airway open and transport follow standard precautions including wearing a mask and eye protection let's talk about some airway adjuncts next and",
        "Airway Adjuncts": "these devices that help maintain the airway or assist in providing artificial ventilation include so they're ops and nps bite blocks or bag valve mass devices",
        "Airway Adjuncts Continued": "so the op it's designed to keep the tongue from blocking the airway and make suctioning easier it should be used for pediatric patients who are unconscious and in possible respiratory failure it should not be used in conscious patients or those who have a gag reflex or who have ingested caustic or petroleum-based products",
        "Airway Adjuncts Continued Again": "the nasal pharyngeal it's usually well tolerated and not as likely to cause vomiting it's used in responsive pediatric patients used in association with possible respiratory failure and it's rarely used in infants younger than one year should not be used in pediatric patients with a nasal obstruction or head trauma when it comes to potential problems with airway adjuncts the airway with a small diameter may easily become obstructed with mucus blood vomit or other soft tissues of the pharynx if the airway is too long it may stimulate the vagal nerve and slow the heart rate down or enter the esophagus and that will cause gastric distension so may cause a spasm of the larynx and result in vomiting if inserted into a responsive patient nasopharyngeal airways should not be used when patients pediatric patients have facial trauma because the airway may be soft and the tissues will cause bleeding into the airway",
        "Oxygen Delivery Devices": "so when it comes to oxygen delivery devices treating infants and children who require more than the usual 21 of oxygen that's found in the air um there are several options the blow by technique and this is uh um at six liters provides more than 21 oxygen concentration nasal cannula at one to six liters provides 21 or 24 to 44 non-rebreather at 10 to 15 is up to 95 percent and bag valve mass device is 10 to 15 liters it'll provide nearly 100 percent concentration use of a non-rebreather mask a nasal cannula or a simple face mask is indicated only for pediatric patients who have adequate respirations or tidal volumes children with respirations fewer than 12 breaths a minute or more than 60 an altered level of consciousness or an inadequate title volume should receive assisted ventilations with a bvm device okay so now let's go through these oxygen delivery devices and the blow by method this is not nearly as effective as a face mask or nasal cannula but it it and it also does not deliver that high concentration but it's better than no oxygen then there's the nasal cannula and some pediatric patients prefer the nasal cannula but other fine others find it uncomfortable okay so the figure on this slide shows the blow by technique and the nasal cannula and then there's that non-rebreather and this delivers up to 90 oxygen to that pediatric patient allows them to exhale all the carbon dioxide without rebreathing it then of course the bag valve device this is indicated for pediatric patients who have respirations that are either too slow too fast who are unresponsive or who do not respond in a purposeful way to painful stimulus figures on this slide show a pediatric patient non-rebreather and a one-person bag valve mass ventilation remember there's two-person bag valve mass ventilation and this procedure is similar to that one person except that one rescuer holds the mask on the patient's face and the other maintains the head position while the other ventilates usually more effective in maintaining a tight seal as it provides an open airway dur due to a properly body position",
        "Cardiopulmonary Arrest": "cardiopulmonary arrest so most often associated with respiratory arrest like we said children are affected differently than adults when it comes to decreasing oxygen concentration we want to focus on effective cpr early use of an aed and transport",
        "Shock": "and then shock so shock it develops when the circulatory system is unable to deliver a significant amount of blood to those vital organs it results in organ failure and eventually cardiopulmonary arrest compensated shock in early stages is when the body can still compensate for that loss and decompensated shock is a later stage and this is when the blood pressure is falling pediatric patients the most common cause of shock is it includes traumatic injury dehydration severe infection or neurologic injury",
        "Shock Continued": "a severe allergic reaction anaphylaxis or disease of the heart tension pneumo or blood around the heart pediatric patients respond differently to adults than fluid to fluid loss they may respond by increasing their heart rate increasing respirations and showing signs of pale or blue skin signs of shock in children are tachycardia poor capillary refill time so this is going to be greater than two seconds they could also have a mental status change begin treating shock by assessing the xabcs and intervene when required so if there's an obvious life-threatening external hemorrhage the order becomes cab because bleeding control is the most critical step and if cardiac arrest is suspected the order also becomes cab because chest compressions are essential so pediatric patients in shock often have increased respirations but do not demonstrate a fall in blood pressure until this shock is very severe we want to limit our management to these simple interventions we have to ensure the airways open prepare for artificial ventilation control bleeding and give that supplemental oxygen by mask or blow by we want to keep the patient warm provide rapid transport to the nearest appropriate facility and contact advanced life support backup as needed okay so now let's talk about anaphylaxis um so associated with shock anaphylaxis is all always called anaphylactic shock and it's a life-threatening allergic reaction that involves a generalized multi-system response to an antigen it's characterized by airway swelling and dilation of blood vessels and common causes are insect stings medications or food signs and symptoms are hypoperfusion strider and wheezing increased work of breathing the appearance of restlessness agitation and sometimes the sense of impending doom and hives what how we're going to treat it is we're going to try and keep the patient calm administer oxygen re or assist the parent with administering that prescribed epi auto injector and provide rapid transport",
        "Bleeding Disorders": "okay so then there's some bleeding disorders and hemophilia is a congenital condition in which the patient lacks one or more of the normal clotting factors most forms are hereditary and are severe predominantly found in the male population bleeding may occur spontaneously and all injuries become serious because of blood loss the blood does not clot we have to transport them immediately and we're not going to delay to apply tourniquets for a life threatening hemorrhaging",
        "Altered Mental Status": "neurologic emergencies is what we're going to talk about next and of course we use that mnemonic aeio tips and this reflects the major causes of altered mental status and we just want to understand normal development or age related changes in behavior and listening carefully to the caregiver's opinion signs and symptoms very simple vary from simple confusion to a coma and we want to manage them focusing on that abcs okay",
        "Seizures": "the first one we're going to talk about is seizures and of course this is a",
        "Seizures Continued": "disorganized electrical activity in the brain in in a variety of ways depending on the the age of the child seizures and infants are very subtle consisting only of gay sometimes sucking motion or bicycling movements and older children's seizures are more obvious and typically consist of repetitive muscle contractions and unresponsiveness",
        "Seizures Continued Again": "in this slide shows the common causes of seizures once the seizure shot stops the patient's muscles relax becoming more flaccid or floppy and the breath becomes labored during the post-ictal state okay once the pediatric patient regains a normal level of consciousness the post-dictal state is over seizures that continue every four a few minutes without regaining consciousness in between or lasting longer than 30 minutes is referred to status epileptics this recurring or prolonged seizures should be considered potentially life-threatening if the patient does not regain consciousness or continues to seize protect the patient from harming him or herself and call for advanced life support back up how you manage seizures is you want to make sure that you protect the airway and that's our top priority you want to place the child in the recovery position if they are vomiting and have the suction available and provide 100 oxygen by non-rebreathing mask or blow by method and begin bag mass ventilations if there are no signs of improvement some caregivers will have given the child a rectal volume dose okay and this is prior to our arrival monitor breathing in the level of consciousness carefully and a transport to the appropriate facility",
        "Meningitis": "meningitis meningitis is the inflammation of tissues or meninges that cover the spinal cord and brain they be being able to recognize a pediatric patient with meningitis is very important some are at a greater risk so we have males newborns children with compromised immune systems children who have a history of brain spinal cord or back surgery or children who have head trauma or children who have shunts pins or other foreign bodies within their brain or spinal cord signs and symptoms of meningitis vary depending on the age of the patient fever and altered level of consciousness are common symptoms in all ages children may also experience a seizure which may be the first sign of meningitis in infants younger than two to three months they could have apnea cyanosis fever a distinct high-pitched cry or hypothermia the meningeal irritation or meningeal signs are terms used by doctors to describe the pain that accompanies movement it's often results in characteristic stiff neck one sign of meningitis and an infant is increasing irritability and bulging fontanelle without crying this bacterium that causes a rapid onset of meningitis symptoms often leads to shock and death okay um children with the bacterium typically have small pinpoint cherry red spots or a larger purple black rash on their face or body so the figure on this slide shows the that type of um of rash and typically with the small cherry point spots all pediatric patients with suspected meningitis should be considered contagious you want to follow standard precautions with these patients and follow up to learn the diagnosis because if exposed to the saliva or respiratory secretions you need to receive antibiotics treatment of patients with this suspected meningitis you want to give them oxygen and assist ventilations if needed reassess vital signs frequently during transport to the highest level of service available",
        "Gastrointestinal Emergencies and Management": "all right so gastrointestinal emergencies never take a complaint of abdominal pain lightly because a large amount of bleeding may occur within the abdominal cavity without any outward signs of shock monitor for signs and symptoms of shock complaints of gastrointestinal origin are common in pediatric patients ingestion of certain foods or unknown substances in some cases the pediatric patient will be experiencing abdominal discomfort with nausea vomiting and diarrhea and remember that vomiting and diarrhea can cause dehydration is also very common and if you suspect appendicitis promptly transport to the hospital for further eval and of course we have to obtain the history from the caregiver and in particular how many wet diapers is the child tolerating liquids how many times has a child had diarrhea and when he or she cries our tears present all right so next we're going to talk about poisoning emergencies and poisonings unfortunately are common in children they can occur by ingesting inhaling injecting or absorbing a toxic substance common sources of poisonings in children are alcohol aspirin cosmetics household cleaning products such as bleach household plants iron prescription medicines illicit drugs or vitamins and the signs and symptoms of poisonings are going to vary widely it's going to depend on the substance and the age and weight of the child they could look normal at first or be confused sleepy or unconsciousness and some substances only take one pill to be lethal in a small child infants may be poisoned as a result of being fed harmful substances by a sibling parent or caregiver so be alert to signs of abuse and may be exposed in a setting in which a harmful substance are being smoked so offer or after you have completed the primary assessment ask the patient or caregiver the following questions what substance was involved the approximately how much of it or how long ago and are there any changes in the behavior or level of consciousness and was there any choking or coughing after the exposure medical control for assistance in identifying poisons in treatment of the poison pediatric patient of course we're going to perform that external decon assess the abcs and monitor breathing provide oxygen and ventilations if necessary and if the child demonstrates signs of shock we want to position them supine keep the child warm and transport properly in some cases give activated charcoal according to medical control or local protocol so dehydration emergencies and management dehydration occurs when fluid loss is greater than fluid intake vomiting and diarrhea are also most common causes of dehydration if left untreated dehydration can lead to shock and death infants and children are at a greater risk than adults for dehydration because their fluid reserves are smaller than those of adults life-threatening dehydration can overcome an infant in a matter of hours signs and symptoms of mild are dry lips decrease saliva or if you wet diapers signs and symptoms of moderate are sunken eyes sleepiness irritability loose skin sunken fontanelles and then severe dehydration is modeled cool clammy skin delayed cap refill and increase respirations treating dehydration and pediatric patients so we need to assess those abcs if dehydration is severe advanced life support backup is necessary okay all patients with moderate or severe dehydration have to be transported all right so fever emergencies is what we're going to talk about next an increase in body temp usually in response to an infection temperatures of a hundred degrees point four or higher are considered abnormal and fever is rarely life-threatening but fever with a rash can be a sign of a serious condition such as meningitis common causes of fever in pediatric patients include infection status epilepsis cancer or drug ingestion such as aspirin arthritis and systemic lupus high environmental temperatures or fever is a result of the internal body mechanism in which heat generation is increased and heat loss is decreased an accurate body temp is an important vital sign a rectal temperature is the most accurate for infants and toddlers depending on the source of that infection the pediatric patient may present with signs and symptoms of respiratory distress shock a stiff neck rash skin that is hot to the touch flushed cheeks seizures and an infant's bulging fontanelles you want to assess for any other signs and symptoms provide rapid transported management and follow standard precautions if you suspect a communicable disease is present when it comes to febrile seizures these are extremely common and in children between six to six months to six years most pediatric seizures are a result of the fever alone which is why they are called febrile seizures they typically occur in the first day of the feveral illness characterized by generalized tonic chronic seizure activity they last fewer than 15 minutes with no or little post uh actual state and they may be a sign of a more serious problem though such as meningitis of course we're just going to um assess the abcs provide those cooling measures and all patients with febrile seizures need to be seen at the hospital okay next we're going to talk about drowning emergencies and this is the second most common cause of unintentional death in children age one to four in the u.s children often fall into the swimming pools and lakes but may drown in the bathtubs and even puddles or buckets of water older adolescent drown when swimming or boating and alcohol can be a cause okay so the principal condition that results from drowning is lack of oxygen even a few minutes without oxygen affects the heart lungs and brain submerging submersion in icy water can lead to hype hypothermia diving into water increases the risk of neck and spinal cord injuries so signs and symptoms are going to vary based on the length and time of submersion and they could be coughing or choking difficulty breathing altered seizure or unresponsive um so you're going to manage them by requesting advanced life support assess the management of abc's administer oxygen or bvm and if trauma suspected have a cervical collar in place and put the patient on the backboard so pediatric trauma emergency these are unintentional injuries are the number one killer of children in the u.s okay so quality of care in the first few minutes after they've been injured is going to have an enormous impact on that child's chances for complete recovery the muscles and bones of children continue to grow well into adolescence and adolescents are prone to fractures of the extremities the fracture of the femur is very rare in pediatric patients but when it occurs it is a source of major blood loss so children's bones and soft tissues are less well-developed than those of an adult and therefore the force of the injury affects these structures differently because a child's head is proportionately larger than the adults it's it exerts greater stress on the neck structures during a deceleration injury children are often injured because of their underdeveloped judgment and their lack of experience so always assume that a child has serious neck or head injuries when it comes to vehicle collisions the exact area that is struck depends on the child's height and the position of the bumper at the time of impact high energy injuries to the head spine or abdomen pelvis or legs when it comes to sport activities children are often injured in organized sports activities so head and neck injuries can occur after high speed collisions remember to mobilize the cervical spine when caring for children with sports related injuries when it comes to head injuries these are common in children once again because of the child's head in relation to the body an infant is also has a softer thinner skull and it could result in injury to the brain tissues the scalp and facial vessels can bleed very easily and may cause a great deal of blood loss if not controlled and then nausea and vomiting are common signs and symptoms of head injuries in children when it comes to mobilization it's necessary for all children who have a possible head injury or spine injury after a traumatic event we can it can be difficult because of the child's body portions so we can mobilize a pediatric patient into a car seat to see the skill drill of 35-6 when it comes to chest injuries it could be a result of blood rather than penetrating trauma in check because the chest is flexible in children it can produce a flailed chest although there are no external signs of injury there may be significant injuries within the chest abdominal injuries are common we have to monitor for shock and if the patient shows signs of shock we need to prevent hypothermia by keeping them warm with blankets and if the patient is has a low pulse we should ventilate and monitor during transport the figure on this slide illustrates the impact of blood loss on the potential for developing shock so a child all children with abdominal injuries should be monitored closely for signs and symptoms of shock burns so they're generally considered more serious than burns to adults infants and children have more surface area to total body mass so children are also more likely to go into shock develop hypothermia and experience airway problems the most common ways that children are burned are exposure to hot substances such as scolding water in the bathtub hot items on the stove exposure to caustic substances such as cleaning solvents or paint thinners and older children are more likely to be burned by flames from the fire infection is also common following a burn injury so sterile techniques should be used in handling the skin of children with burn wounds if possible we want to consider the possibility of abuse in any burn situation and we want to make sure we report any information about suspicions to the appropriate authorities severity of burns there could be minor moderate or severe so minor are partial thickness burns involving less than 20 or 10 percent moderate or partial thickness burns involving 10 to 20 severe is any full thickness burn a partial thickness burn involving more than 20 percent or any burn involving the hands feet face airway or genitalia when it comes to burns um pediatric patients are going to be managed the same as adults injuries to the extremities so children have immature bones with active growth centers and growth of the long bones occur from the ends of the specialized growth plates now the growth plates are potential weak spots incomplete or green stick fractures can occur generally extremely injuries in children are managed in the same way as adults pain management so the first step in pain management is recognizing the patients and pain since some pediatric patients use non-verbal or low limited vocabulary look for visual clues and use the wand baker faces pain skill you are limited to the following pain interventions so positioning ice packs and extremity evaluation those interventions will decrease the pain and swelling to the injury site and then als interventions may be needed another important tool is kindness and providing emotional support okay so next we're gonna stop talk about disaster management use the jumpstart triage system instead of start triage it's jump start and this is intended for patients younger than 8 or who appear to weigh less than 100 pounds there are four triage categories with jumpstart and designated by colors corresponding to different levels of urgency so um we are going to have the green tag and the green is minor not an immediate uh treatment care of treatment and these are people are able to walk except of course for the infants and then there's yellow that's delayed and yellow is they have uh spontaneous breathing they have peripheral pulses and uh they responsive to painful stimuli when it comes to red tag these are the immediate and that is uh apnea and respiratory failure breathing but without a pulse or a proc of inappropriate painful response so apnea and without a pulse or apnea and unresponsive to rescue breathing are black tagged so the figure on the screen illustrates jumpstart triage system all right so child abuse and neglect child abuse means an improper or excessive action that injures or otherwise harms a child or infant this includes physical abuse sexual abuse neglect war and emotional abuse over half a million children are victims of abuse annually many of these children suffer life-threatening conditions and some die if you suspect child abuse and you need to report it and this abuse is likely to happen again perhaps causing permanent injury and even death signs are child abuse occurs in every socio-economic status so you must be aware of the patient's surroundings and document your findings objectively you may be called to testify in abuse cases and it's essential that you record all findings okay you have to ask yourself is the injury typical for the developmental level of the child is the mechanism of injury reported consistent is the pair is the parent or caregiver behaving appropriately is there evidence of drinking or abuse at the scene was there a delay in seeking help for the child and is there a good relationship between the caregiver and the child does the child have multiple injuries at different stages of healing does the child have an unusual mark or bruise that may be caused from cigarettes heating or branding injuries does the child have several types of injuries and does the child have any burns on the hands or feet that involve a glove distribution is there an unexpected decreased level of consciousness is the child clean an appropriate weight for their age is there any rectal or vaginal bleeding and what does the home look like is it clean or dirty is it warm or cold and is there food the mnemonic child abuse may help you remember the points to look for so bruises you want to observe the color and location of the bruises bruises on the back buttocks or face are suspicious and are usually inflicted by a person then burns to a penis testicles or vagina or buttocks are usually also inflicted by someone burns that encircle a hand or foot to look like a glove are usually also inflicted by someone suspect abuse of the child has cigarette burns or grid pattern burns then there's fractures so fractures of the humerus or femor do not normally occur without major trauma falls out of bed are usually not associated with fractures maintain an index of suspicion to an infant or young child who sustains a femur fracture or a complete fracture of any bone shaken baby syndrome so infants may sustain life-threatening head trauma or by being shaken or struck in the head there is bleeding within the head in it damage to the cervical spine resulting from severe shaking and then there's neglect so refusal or failure on the part of the caregiver to provide life necessities children who are neglected are often dirty thin or appear developmentally delayed because of the lack of stimulation symptoms and other indicators of abuse are abused children appear withdrawn fearful or hostile be concerned if a child does not want to discuss how the injury occurred occasionally a parent or caregiver will reveal a history of accidents be alert for conflicting stories or lack of concern from the caregiver the abuser may be a parent caregiver relative or friend of the family emts in all states must report suspected abuse even states or most states have special forms to do so supervisors are generally forbidden to interfere with reporting of suspected abuse law enforcement and child protective surgeries will determine whether there is abuse when it comes to sexual abuse children of all or any age or gender can be victims you want to maintain a high index of suspicion you should the assessment should be limited to determining what type of dressing any injuries need treat the bruises and fractures as well and do not determine if the genitalia of a young child unless there is evidence of bleeding do not allow the emt or the child to wash urinate or defecate ensure the emt or police officer of the same age remains with the child and maintain professional composure the entire time obtain as much information as possible transport all children who are victims and sexual abuse is a crime next we're going to talk about sids so sudden uninspected unif unexpected infant death syndrome and sudden infant death syndrome the sudden and unexpected infant death refers to the sudden unexpected death where the cause is not known until the investigation is conducted and one of the causes of suid is sudden infant death syndrome which is sids which results in death that cannot be explained by another cause about 3 500 infants die of sins annually the american academy of pediatric recommends that a baby be placed on his or her back in a crib that is free of bumpers blankets and toys the csc recommends having a baby sleep in the same room but not the same bed breastfeeding and use of a pacifier are also associated with a lower risk of sids although it is impossible to predict sids risk factor there are some that include a mother younger than 20 mothers who smoke mothers who use alcohol or illicit drugs and a low birth weight death as a result of sids can occur at any time of the day you will face three with three tasks so assessment of the scene assessment and management of the patient and then communication and support of the family you will patient assessment so an infant who has been a victim of sids will be blue and pale not breathing and unresponsive other causes include overwhelming infection child abuse airway obstruction or meningitis accidental poisoning hypoglycemia congenital metabolic deficit defects or begin with the assessment so xabc's you're going to provide interventions as necessary and depending on how much time has passed the child may show signs of postmortem changes if the sign if the child shows these signs call medical control if there is no sign of post-mortem change you want to begin cpr immediately pay special attention to any marks or bruises on the child before you perform these procedures and know any intervention that was not done prior to your arrival you wanna with the scene you need to inspect the environment noting any condition the scene where the infant was found assessed the scene should concentrate on signs of illness including medications humidifiers or thermometers a general condition of the house signs of poor hygiene family interaction and the site where the infant is discovered you have to communicate and support the family after the death of a child the sudden death of an infant is devastating uh event for a family and it tends to evoke strong emotional responses among health care providers follow the family or allow them to express their grief offer the family a high level of empathy and understanding the family may want you to initiate resuscitation efforts which may or may not conflict with your ems protocols always introduce yourself to the child's parents and caregivers and ask about the child's date of birth and medical history do not speculate on the child's cause of death the family should be asked whether you they want to hold the child and say goodbye the following interventions are helpful so learn and use the child's name rather than the impersonal your child speak to the family members at eye level and maintain good contact with them and use the word dead or died when informing the family of the child's death euphemisms such as passed away or gone are ineffective acknowledge the family's feelings offer to call family members keep any instructions short simple and basic and ask each family member individually whether he or she wants to hold the child wrap the child in a blanket and stay with the family members when they hold the child ask them to ask them to not remove tubes or other equipment that is used in an attempted resuscitation each individually in each culture will express grief in a different way some will require intervention most caregivers feel directly responsible for the death of the child and some ems systems arrange for home visits after the child's death so the ems providers and family members can come to some sort of closure you need special training for these visits a child's death can be very stressful take time before going back to the job talk to other ems colleagues be alert for signs of post-traumatic stress in yourself and others and consider the need for professional help if these signs occur apparent life-threatening events so infants who are not breathing or cyanotic and responsive unresponsive when found sometimes resume breathing and color with stimulation this is called an apparent life-threatening event a-l-t-e in addition to cyanosis and apnea an alte or an alt is characteristic by characterized by a distinct change in muscle tone choking or gagging after the event the child may appear healthy and show no signs of illness or distress pay strict attention to airway management assess the infant's history allow caregivers to ride in the back and physicians will have to determine the cause brief result unexplained event so signs and symptoms include brief changes in colors such as pale skin or cyanosis choking absence low or irregular breathing abnormal muscle tone decreased level of consciousness no abdominality found on assessment and transport is required for evaluation okay so this concludes chapter 35 let's see what we've learned by doing the review questions how does a pediatric anatomy differ from adult all right d it's the head that head is proportionately larger when a small child falls from a significant height the blank most often strikes the ground first and we know that's the head it's proportionately larger when assessing a conscious and alert nine-year-old what should we do we want to ask them the questions if they're capable of answering right the purpose of a shunt is to and we know that the purpose of the shunt and a v p shunt is going to be to minimize pressure within the skull which of the following statements regarding febrile seizures is correct all right so we know that febrile seizures are going to be d um and that is uh that usually lasts only 15 minutes and often does not have that postal state okay we respond to a sick child at night the child appears very ill has a high fever it's drooling sitting in that tripod positioning is struggling to breathe all right so the patient's drooling so we think epiglottitis because their apple guys have swollen and they can't swallow treatment for a semi-conscious child who swallowed an unknown quality of pills is gonna be all right if it's semi or unconscious we're going to monitor for vomiting give oxygen and transport fast when using the pneumonic child abuse to assess the child for signs of abuse the d is going to stand for and that's going to stand for delay of seeking care right okay so four-year-old fell from the second-story balcony and landed on her head she's unresponsive slow irregular breathing has a large hematoma to the top of the head and bleeding from her nose oh goodness all right so when somebody has bleeding from their nose we're going to suspect um that she has some type of um of fracture right so head fracture so we got to stabilize our head we're going to jaw thrust put in an airway a jug and then bvm foo what does p stand for and we know that that is painful he is painful all right thank you for joining us with the chapter 35 lecture and we hope you've enjoyed it"
    },
    {
        "Introduction to Neonatal Care": "hello and welcome to chapter 42 neonatal care this chapter reviews the physiologic changes that occur in a newborn during birth the care that should be provided during and immediately after birth and the special needs of premature births and bursts complicated by other factors it also reviews the steps involved in neonatal resuscitation and outlines the process of transporting an infant to a hospital or in between hospitals okay so let's get started a newborn or neonate care must be tailored to meet the needs of the population so a newborn is an infant within the first few hours after birth and a neonate is an infant within the first month after birth so if a newborn needs special support an intervention by trained caregivers parents may feel inadequate supporting the needs of both the newborn and caregiver is important so allow them to be physically close as possible and explain what is being done and provide details for transport plan to the next level of care so skilled care interventions to optimize cardiopulmonary function are routinely required in only about 5 to 10 percent of deliveries approximately eight percent of newborn delivered each year weigh less than 5.5 pounds the most common cause of low birth weight is prematurity and mortality increases as birth weight and gestational age decrease so let's talk about the transition from",
        "The Transition from Fetus to Newborn in Utero": "fetus to newborn in utero the fetus receives oxygen from the placenta and fetal circulation has three major blood flow deviations or shunts from that of an adult so it has the ductus venus the forman oval the ductus arterious and these shunts begin to close off at birth so the figure on the slide shows fetal circulation as a fetus is delivered fetal transition occurs and it enables the newborn to breathe so the first breath is triggered by mild hypoxia and hypercapnia from partial occlusion of the umbilical cord during delivery tactile stimulation and cold stress promote early breathing and pulmonary vasculature resistance drops as the lungs fill with air more blood flows into the lungs picking up oxygen a delay in the decrease of pulmonary pressure leads to delayed transition hypoxia brain injury and death",
        "Gestational Time": "gestational time so when you talk about pre-term that is less than 37 weeks term is 38 to 42 weeks and post-term is more than 42 weeks so let's talk about the arrival of the",
        "Arrival of the Newborn": "newborn next",
        "Patient History": "you want to obtain the patient history and prepare the environment and equipment with any available time okay so key questions to help determine resuscitation and the needed equipment include the woman's age the length of pregnancy presence and frequency of contractions any pregnancy complications if the membranes have ruptured and if so the timing and the makeup of the fluid if they know if they're having multiple fetuses medications that they are taking so 90 to 95 percent of all newborns require no active interventions at birth minimal needs are warm dry blankets and maybe a bulb syringe two small clamps or ties and a pair of clean scissors complications need prompt management if delivered in the ambulance cover the foot of the stretcher with clean warm blankets for the initial stabilized stabilization after confirming adequate airway breathing and pulse rate place a newborn on the mother's chest if more extensive resuscitation is necessary transition the newborn to a second ambulance with a neonatal transport incubator suction the mouth then the nose with a bulb syringe once the head is delivered keep the newborn at the level of the mother after delivery with the head slightly lower than the body clamp the umbilical cord in two places and cut between the clamps if the cord comes out ahead of the newborn the blood supply of the fetus may be cut off so relieve the pressure on the cord by gently moving the newborn's body off the cord and pushing the cord back",
        "Primary Survey of the Newborn": "primary survey of the newborn may be done simultaneously with any treatment interventions you need to note the time of the delivery monitor the abcs assess the airway patency and respiratory rate and effort tone pulse rate and color inspect the skin for abnormalities examine the head for symmetry and abnormalities and examine the eyes of the neonate for irregularities a newborn who truly cannot open his or her eyes may have a congenital defect so watch for abnormal eye movement as well examine for any drainage or ocular discharge and inspect the newborn's umbilical cord to detect abnormalities a newborn is at risk for hypothermia so ensure thermoregulation by placing the newborn on pre-warm towels and drying the head and body thoroughly and discarding wet towels and covering with a dry towel and cover the head with a cap position the newborn to ensure the patent airway clear secretions and assess the respiratory effort all babies are cyanotic right after birth so if the newborn stays vigorous and begins to turn pink within five minutes maintain ongoing observation and continue thermoregulation with direct skin contact with the mother while enroute okay so the apgar score helps record the",
        "Apgar Score": "newborns condition in the first five minutes after birth and it helps paramedics determine specific resuscitation measures needed and their effectiveness so the categories of the apgar are appearance pulse rate grimace activity and respiratory effort each sign is given the value of 0 1 or 2. so you want to record record it at 1 and 5 minutes after birth if the 5 minute score is less than 7 an additional score should be done every 5 minutes until about 20 minutes after birth if resuscitation is necessary the apgar score is done by determining the resuscitation results okay so now we're going to talk about",
        "The Algorithm for Neonatal Resuscitation": "the algorithm for neonatal resuscitation if a problem arises follow current natal resuscitation guidelines to optimize the outcome initial steps so there's reevaluation and beginning ventilation should occur within the first 60 seconds follow the initial steps of bulb syringe suctioning the mouth and nose drying and stimulating the newborn if the newborn does not respond further intervention is necessary you want to assess the respiratory rate effort pulse rate and color count the respiratory rate and pulse for 6 seconds then multiply by 10 to determine the per minute rate many newborns have blue hands and feet but are centrally pink meaning they're center core of their body if there is a normal breathing pattern and the pulse rate is greater than 100 beats mean but maintain central cyanosis of the trunk or mucous membranes provide supplemental oxygen if still apneic or has a pulse rate of less than 100 after 30 seconds of drying and stimulates stimulation and oxygen begin positive pressure",
        "Positive Pressure Ventilation": "ventilation buy a newborn size bag valve mask be careful not to squeeze the bag too hard in order to avoid delivering too much volume room air is preferred when resuscitating term infants and the addition of supplemental oxygen might be necessary additional oxygen may be necessary if the neonate is not achieved the target pre-ductal oxygen set for the value of their age if the newborn's pulse rate is less than 100 beats check the chest movement take ventilation corrective steps if needed and insert an et tube or laryngeal mask as appropriate if the newborn's pulse rate is less than 60 begin chest compressions effective chest compressions should result in a palpable pulse use the pulse ox when resuscitation is anticipated and the newborn appear cyanotic if ventilation and chest compressions do not improve the bradycardia administry preferably via an iv line when no sign of life pulse or respiratory effort or present after 10 minutes of resuscitation changes chances of successful recitation resuscitation are low overall outcomes are associated with high early mortality the figure on this slide shows the",
        "Algorithm for Neonatal Resuscitation": "algorithm for neonatal resuscitation so let's talk about drying and stimulation after ensuring airway patency dry and stimulate the newborn nasal suctioning stimulates the newborn to breathe so position the infant on the back or side with the neck in the sniffing position if the airway is not clear suction the head turn to the side suction mouth and nose and flick the soles of the feet or gently rub the back so next we're going to talk about free",
        "Free Flow Oxygen": "flow oxygen so if a newborn is cyanotic or pale provide supplemental oxygen provide oxygen to a pale newborn until a pulse ox reading can give an accurate breathing so if positive pressure ventilation is not indicated oxygen can initially be delivered through an oxygen mask or oxygen tubing cupped and held to the nose of the newborn's nose or mouth so oxygen flow rate should be about five liters a minute do not blow oxygen directly on the newborn's eyes okay so there are oral airways but",
        "Oral Airways": "they're usually rarely used on newborns and there are some conditions that require the oral airways however in all these cases an et tube is inserted down a nostril so keep the mouth open to provide adequate ventilation so the pearl robin sequence is a series of development abnormalities and they include a small chin and posteriorly large physician tongue back valve mask it's indicated when a newborn is apnic and has inadequate respiratory rate has a pulse rate of less than 100 beats per minute airway is cleared of secretions tongue obstruction is relieved and the newborn is dried and stimulated so signs of respiratory",
        "Signs of Respiratory Distress": "distress suggest need for bag valve mass ventilation and they include periodic breathing or intercostal retractions nasal flaring or grunting on expiration",
        "Three Devices To Deliver Bag Valve Mass Ventilations to Newborns": "there are three devices to deliver bag valve mass ventilations to newborns we have self-inflating bag with an oxygen reservoir and that's most likely used in the field and then there's flow inflating bag and that needs a gas source more commonly in surgery and there's a t-piece respirator and that needs a gas source as well usually found in neonatal in intensive care units always use the infant size when available and that's the 240 milliliter bag and um only one tenth of the bags volume will be used for each breast so if a neonatal bag is not available use a bag designed for adults or larger children provided that the delivered breast size is appropriately small and the chest rise is monitored for excessive volume during delivered breaths when administering back valve mass",
        "Back Valve Mass Ventilation": "ventilation with 100 oxygen the face mask should uh provide an airtight seal and um the airway should be patent and the head should be in the sniffing position the first few breaths after birth frequently need higher pressures and subsequent breaths should have enough pressure to deliver a visible but not excessive chest rise a ventilation rate of about 40 to 60 breaths is important because a higher rate can cause hypocapnia air trapping in a pneumo so continue the positive pressure ventilations as long as the pulse rate is less than 100 beats per minute on the or the respiratory effort is ineffective so if more than one minute of positive pressure ventilation is needed hook the system to a pressure manometer so the cause of the ineffective back valve mass ventilation could be an inadequate mass seal in correct head position copious secretions and pneumo or equipment malfunction all right so innovation is indicated when meconium stained fluid is present and the newborn is not vigorous so by that we mean poor muscle tone or bradycardia inadequate ventilation or no respiratory effort at all routine tracheal suction is no longer recommended for a depressed newborn delivered through meconium stained amniotic fluid congenital diaphragmatic",
        "Congenital Diaphragmatic Hernia": "hernia is known and suspected and the respiratory support is necessary so abdominal organs herniate through the opening in the diaphragm into the chest cavity and that's what the congenital diaphragm herme hernia is a prolonged positive pressure ventilation is needed and cranial facial defects impede an inadequate airway so that could be why you need to do innovation the following equipment should be available when you're doing that",
        "Suction Equipment": "innovation so suction equipment the laryngoscope blades they want you to use straight and a shoulder roll adhesive tape an e.t tube and a stylet used by some paramedics must be secured to the top of the et tube of course to properly innovate a newborn you're going to refer to skill drill 42-1 in your book",
        "Complications of the Et2 Placement": "and there are complications of the et2 placement and they include oropharyngeal or tracheal perforation esophageal innovation with subsequent persistent hypoxia and then of course right mainstay main stem integration risk can be minimized by ensuring optimal placement of the laryngoscope blade and noting how far the et tube is advanced and gastric depression so it's indicated if the you're gonna have a prolonged back valve mass ventilation and we consider prolonged more than five to ten minutes abdominal distension is impeding ventilations that could be another reason you're going to do the gastric depression and diaphragmatic hernia and gastrointestinal congenital anomaly so this is when the diaphragm hernias in when you could suspect them are decreased breath sounds on the left side or increased work of breathing to properly insert an oral gastric tube in a newborn you're going to refer to skill drill 42-2 so let's talk about circulation next chest compressions are indicated if the pulse rate remains less than 60 beats per minute despite positioning airway clearing drying and stimulations and 30 seconds of effective positive pressure ventilations two people are needed for effective chest compressions while ventilating there are two different techniques there's a thumb technique and the two finger techniques so the thumb technique is preferred because it generates superior peak systolic and corneal arterial profusion pressure while causing less fatigue on the provider you encircle the torso with both hands with fingers supporting the spines place two thumbs side by side over the lower third of the sternum once the airway is secure or the newborn is innovated chest compressions can be delivered from the head of the bed and allow easier access to the umbilicus then the two finger technique that you place the tips of the index finger and middle fingers of one hand over the lower third of the sternum and the second hand supports the spine the compression depth is one-third of the anterior posterior diaphragm or diameter of the chest the two the thumbs or fingers should be in contact with the chest at all times this allows the chest to completely recoil after each compression chest compressions and artificial ventilation should not be delivered simultaneously you want to coordinate 90 compressions and 30 press so this equals about 120 events per minute and the person doing the compression should count out loud reassess for the presence of a pulse after 60 seconds of well-coordinated chest compressions and ventilations limit the number of pauses in compressions to maximize the chances of achieving return of spontaneous circulation so if the pulse rate is above 60 chest compressions can be stopped if the pulse rate is above 60 chest compressions and positive pressure ventilations check pulse rate after 30 seconds when the pulse rate goes above 100 gradually slow the rate and decrease the positive pressure ventilations",
        "Vascular Access": "so vascular access emergent access is necessary for fluid administration to support circulation and iv resuscitation medication and therapeutic drugs the umbilical vein can be catheterized with an umbilical vein line so you need to clean the cord with an antiseptic drape at the area with sterile towels keeping the stump exposed place a sterile tie firmly around the base of the cord to control bleeding and then cut the cord with the scalpel between the clamp and the cord tie keeping about one to two centimeters from the skin insert the low uv line into the umbilical vein and insert the catheter into the vein for a distance of about 0.75 to 1.5 inches or 2 to 4 centimeters until blood can be aspirated flush the catheter with half a milliliter of normal saline and tape in place a peripheral iv and io can also be used but a smaller needle should be used in newborns okay so medications are rarely needed in newborn resuscitation because they can be resuscitated with effective ventilatory support so medication doses though are based on weight a full term newborn usually weighs about 6.5 to 9 pounds and is about 20 inches long in newborn at 28 weeks of gestation weighs about 2.5 to and is about 14.75 inches long so transport to the nearest facility to provide the next level of care once a newborn is stabilized as much as possible contact the facility for advance regarding care and disposition provide ongoing communication with the family about the current care and do not be specific about survival statistics if you cannot answer questions tell them you will put them in touch with those who can during transport monitor the newborn and frequently assess for status changes and vitals to check are the thermal regulation respiratory effort airway patency skin color and pulse rate and so development of new techniques for newborn care has reduced mortality among high-risk newborns it may be necessary to transfer critically ill newborns to a regional center to get needed treatment",
        "Transport of a High-Risk Newborn": "transport of a high-risk newborn should include the following steps a physician at the referring hospital initiates a request for transport and a mode of transport is chosen depending on the distance availability and weather conditions the transport team is immobilized and the equipment is assembled and of course the ideal team consists of a nurse with special training in neonatal intensive care a respiratory therapist a paramedic with an apprenticeship apprentice shift in neonatal intensive care and a physician could be a part of the team for critically ill patients highly specialized equipment include appropriately designed ventilation and oxygen units and an incubator meeting stringent criteria on arrival at the right referring hospital the transport team continues to stabilize the newborn conditions that should be treated before leaving the referring hospital include hypoxia acidosis hypoglycemia and hypovolemia the team collects information while stabilizing the newborn including a copy of the mother and infant's charts and any radiographic studies of the newborn",
        "Apnea with Newborns": "so let's talk about apnea with newborns and it's common it delivered before 32 weeks of gestation and it's rarely seen in the first 24 hours defined as respiratory pause of greater than 20 seconds and it can lead to hypoxia and bradycardia often follows hypothermia other causes include maternal or infant narcotic exposure or airway or respiratory muscle weakness prolonged or difficult labor or a gastro esophageal reflex or central nervous system abnormalities also there's seizures and metabolic disorders and metabolic disorders are the pathophysiology depends on the underlying ideology so newborns need respiratory support to minimize hypoxic brain damage and other organ damage so assessments you're going to gather the history perform a physical exam and differ differentiate between primary apnea or secondary apnea so primary apnea is after a relatively short period it may have a period of rapid breathing",
        "Bradycardia": "followed by apnea and bradycardia secondary apnea is if hypoxia continues during primary apnea the newborn will gasp and go into secondary phase and the positive pressure ventilation by bag valve mask is gonna be necessary so we talked about apnea now we're gonna talk about bradycardia so the most it most frequently occurs in newborns because of inadequate ventilation so often responds to positive pressure ventilation effectively other causatives are causes are hypothyroidism acidosis maybe congenital heart defect prolonged suctioning or vagal stimulation so morbidity and mortality are determined by underlying cause and how quickly it is correctly corrected you want to assess and manage this and if the heart rate is assessed by auscultation or palpating the base of the umbilical cord the heart rate is less than 100 provide positive pressure ventilations assess the airway if it's less than 60 despite 30 seconds of positive pressure ventilations of course you're going to start chest compressions if less than 60 after 30 seconds of effective ventilation and 30 seconds of chest compressions you want to administer epi the low umbilical vein catheter is the preferred access to administer medications during resuscitation and after about a minute of administering epi you want to check the pulse rate ensure that the et tube is not dislodged and ensure that the chest compressions are be being given at the adequate depth of about one-third focus on maintaining normothermia and transport to the facility that is able to handle high-risk neonates we talked about apnea bradycardia and now we're going to talk about acidosis so suspect metabolic metabolic acidosis if bradycardia persists after ventilation chest compressions and volume expansion consider administering a bolus of normal saline to aid in the improved profusion and clearance of acid the best treatment is to identify and correct the underlying cause of this acidosis okay and then the next we're going to talk about is pneumothorax and it can",
        "Pneumothorax": "occur if the infant inhales meconium or lung is weak by infection and positive pressure ventilation is going to be",
        "Signs of Significant Pneumo": "needed so signs of significant pneumo is severe respiratory distress unilateral breath sounds and shift of heart sounds if the pneumo is on the left side so it's going to push you want to clear the area with alcohol around the second intercostal space mid-clavicular and you're going to",
        "Prepare the Equipment": "prepare the equipment so a 22 gauge through a stopcock and a 20 ml syringe you have to palpate the upper edge of the second rib and insert the needle above it at the same time you're going to pull back on a syringe slowly advancing the needle until the air is recovered if the syringe fills with air turn the stopcock off to the newborn push the air out of the syringe open the stopcock and continue with drawing air remove the needle when there is no more air to be withdrawn if symptomatic ongoing air leak insert the 22 gauge angiocatheter in the similar location and tubing may be taped to the chest and briefly occluded and transport and monitor for re accumulation of the pneumothorax and then of course the next one is going to be meconium and a small percentage of the babies delivered in the presence of meconium stain amniotic fluid may develop meconium aspiration it carries a high risk for mortality and morbidity and it's more common in post term and those small further age newborn stress before",
        "Newborn Stress before or during Delivery": "or during delivery if the newborn passes stool before birth they may inhale the meconium stained amniotic fluid so the airway may become clogged or plugged causing hypoxia so this may um cause a delayed drop in pulmon pulmonary vascular resistance which can cause right to left shunting causing the patient to persistent pulmonary hypertension of the newborn to decrease the risk for this ensure the airways clear keep the newborn warm minimize stimulation and administer supplemental oxygen when necessary if meconium aspiration occurs follow closely for signs of deterioration and you're going to assess the activity level if crying in vigorous use standard",
        "Standard Interventions": "interventions if depressed use of positive pressure ventilation positive pressure ventilation is ineffective than innovating suction may be required to remove any obstructions if the newborn is not responding well to the care outlined in the neonate resuscitation algorithm suspect airway occlusion or pneumo and takes the steps to minimize hypothermia reassess frequently the newborn has prolonged hypoxia after significantly delayed resuscitation the outcome will likely be poor so when transporting stay in communication with the facility support the family and do not discuss chance of survival okay so after meconium the next thing we're going to talk about",
        "Low Blood Volume": "is the low blood volume so fluid resuscitation may be needed if the newborn has significant depletion due to some conditions such as abrupto placenta or twin to twin transfusions or placenta previa or septic shock so signs of hypovolemia occur include pallor persistent low pulse rates weak pulse or no improvement in circulatory status despite efforts a newborn place a a low umbilical line in a neonate who is uh more than a few days old place a peripheral iv or io line consider administering a fluid bolus and multiple boluses may be administered if the patient remains clinically hypovolemic next condition we're going to talk about",
        "Diaphragmatic Hernia": "is a diaphragmatic hernia it's an abnormal opening in the diaphragm that causes the umbilical contents to herniate into the chest cavity causes the heart and the mediastinum to shift to the contralateral side of the hernia so postnatal signs include respiratory distress heart tones which are shifted decreased breath tones bowel sounds heard in the chest an overall survival of infants born with a diaphragmatic hernia is about 67 percent so assessment and management of a newborn may uh demonstrate so they may demonstrate a few or no symptoms severe hypoxia with an increased work of breathing resuscitate with 100 oxygen if hypoxic monitor the heart rate continuously during transport and all ultimately this is going to require surgical interventions so transport to a facility with a neonatal intensive care and pediatric surgery",
        "Respiratory Distress and Cyanosis": "and then there's respiratory distress and cyanosis so it's the single most common cause in the neonate is prematurity so respiratory causes include airway obstruction aspiration pneumonia pneumothorax or congenital diaphragmatic hernia or also immature lungs so other causes are any process resulting in a delay in the drop of pulmonary vascular resistance central nervous system depression septic shock or cardiac abnormalities so assessment and management you want to ensure the airway check the breathing is adequate check to see if the pulse rate is present assess respiratory rate and ask the parents about increased symptoms with feeding when with the feeding attempt so treatment is going to be establishing the airway adequate oxygen delivery effective ventilations and adequate circulation so if resuscitation efforts do not result and improve improvement needle thorough centesis may be necessary respiratory depression secondary to narcotics so administer narcan to the newborn of a drug addicted mother it may participate seizures that can potentially cause death so it's no longer recommended as a first-line drug in resuscitation in the case of a newborn experiencing respiratory depression for the mother's chronic use of narcotics provide ventilatory support and transport immediately and if respiratory depression is a result of the mother being treated acutely with narcotics so without chronic exposure narcan may be administered to the newborn via the iv or im route to reverse the narcotic effects next we're going to talk about premature",
        "Premature and Low Birth Weight Infants": "and low birth weight infants so",
        "Premature Newborns": "premature newborns are delivered before 37 weeks and if idiopathic but maternal conditions associated with preborn labor and delivery include maternal infection or maternal illness leading to dehydration placental insufficiency preeclampsia and pregnancy-induced hypertension in addition to increased mortality and number of morbidities are associated with prematurity including respiratory distress syndrome respiratory suppression and apnea hypothermia sepsis and central nervous system compromise low birth weight newborns weighing less than 5.5 pounds the most common etiology is prematurity",
        "Factors Contributing to Premature Delivery": "and factors contributing to premature delivery include genetic factors infection abruption multiple gestations previous delivery of premature infants drug use and trauma other chronic factors um contributing to low birth weight include um maternal hypoten or hypertension placenta abnormalities and smoking also chromosomal abnormalities morbidity and mortality rate are related to the degree of prematurity so those born at 24 weeks of gestation are likely unlikely to survive and those born after 32 weeks of gestation or weight at least three pounds who receive cardiopulmonary support survive long term assessment and management of course to determine prematurity rely on the physical features so the maturity of the skin size of the infant and the degree of the respiratory distress information from family about the gestational date and information related to maternal and fetal complications to optimize survival of the newborn delivered prematurely in the field provide cpr and provide thermo-neutral environment use only minimal pressures necessary to move chest when providing the positive pressure because the risk of retinopathy of prematurity worsened by long-term oxygen exposure you want to manage you want to focus on clearing the airway gentle stimulation administering supplemental to providing chest compressions if effective ventilation does not result in adequate heart rate increase and then maintain a warm environment there's also the risk of seizures in the",
        "Risk of Seizures in the Newborn": "newborn and it strongly suggests the presence of a neurologic disorder most common and premature newborns the following are often mistaken for",
        "Seizures": "seizures though so normal movements when a newborn is drowsy or sleep and jitteriness so that's most common seen in hypoglycemia or drug withdrawal seizures are usually related to an underlying abnormality and seizures may interfere with cardiopulmonary function feeding metabolic function and prolonged seizures may cause brain injury so there's types of seizures there's subtle seizures and they are characterized by eye deviation blinking chewing mouthing or apnea there's clonic seizures or focal or multifocal and then",
        "Tonic Seizures": "there's tonic seizures and that's characterized by focal or generalized spasms um that could be a single brief sun movement resulting in a tick or a jerk or mono monoclonic seizures and that's focal monofocal or generalized and it could be just a flexation of an arm or generalized and bilateral jerking or flexation of arms or legs there are causes and it could be hypoglycemia or another metabolic disturbance and metabolic abnormalities include disturbances in levels of glucose calcium magnesium or other electrolytes amino acids blood ammonia or certain toxins so assessment and management you want to evaluate pre prenatal and birth history perform a careful physical exam hypoglycemia must be recognized and treated promptly so blood glucose",
        "Blood Glucose Measurement and Dextrose Administration": "measurement and dextrose administration should occur obtain baseline vital signs and provide oxygen assist ventilation blood pressure evaluation and iv access is necessary if blood glucose is less than 40 give iv bullish of 10 dextrose solution and recheck in 30 minutes iv administration of dexter should uh often needs to be followed by a 10 glucose infusion before giving an anticoagul convulsive medication consult medical control because benzodiazepines are commonly used to terminate neonatal seizures and may be administered regularly or intravenously monitor respiratory status and oxygen saturation carefully and maintain normal body temperature and then of course keep the family informed as you transport okay so we just talked about seizures which can be caused by hypoglycemia",
        "Hypoglycemia": "but now we're going to talk about hypoglycemia itself and it's considered a blood glucose level of less than 45 milligrams uh in full term or pre-term newborns and an imbalance between glucose supply and utilization with low glucose levels due to inadequate intake or increased glucose utilization so now remember that most newborns are asymptomatic until glucose levels fall below 20 and then they may result in seizures or severe permanent brain damage",
        "Assessment and Management of Symptoms": "assessment and management of symptoms may be non-specific but including cyanosis apnea irritability poor sucking or feeding limpnessness irregular respirations or eye rolling symptoms may be associated with lethargy tremors or seizures coma tachycardia tachypnea or vomiting so check blood glucose levels in all sick newborns and evaluate vital signs manage hypoglycemia after establishing good oxygenation ventilation and circulation and establish an iv medical control may order dextrose solution if the newborn's blood glucose is less than 40 and it may be followed by an iv infusion of dextrose based on the newborn's gestational age recheck the blood glucose about every 30 minutes and maintain normal body temperature okay so we just talked about hypoglycemia",
        "Vomiting": "now we're going to talk about vomiting and it's common in newborns it ranges from spit up to severe bloody or projectile vomiting so persistent vomiting is a warning sign though and can cause excessive fluid loss dehydration and electrolyte imbalances so persistent vomiting in the first 24 hours may be may indicate upper digestive tract obstruction or increase intracranial pressure so vomitus with dark red blood indicates gut bleeding and this may be life-threatening and then vomitous aspiration may cause respiratory insufficiency or airway obstruction",
        "Common Causes in Newborns": "so there are common causes in newborns they seen with excessive frothing soon after birth or possible choking when trying to feed gastroesophageal reflux it may vomit either immediately or a few hours after feeding so in infants and young children it persists as typical and or atypical crying apnea poor appetite it could be wheezing strider weight loss or poor growth so sun and unexpected and forceful vomiting may occur in conjunction with um asphyxia or meningitis or hydrocephalus so meningitis and hydrocephalus may be associated with increased intracranial pressure or icp there are also withdrawal symptoms in an addicted mom can include vomiting so assessment and",
        "Assessment and Management": "management you wanna the stomach may be distended due to vomiting and suspect infection if the newborn has a fever it may also indicate temperature instability apnea or abdominal tenderness or guarding or minimal or absent bowel sounds you want to start management with the",
        "The Abcs": "abcs of course the airway keep the face turned on the side to prevent aspiration suction the airway with a catheter or suction bulb consider a nasogastric or oral gastric tube to depress the stomach do not administer antibiotics in the field the newborn may need fluid resuscitation of normal saline the signs point to dehydration",
        "Dehydration": "and some of those uh signs of dehydration include dry mucosa tachycardia or sunken fontanelles place a newborn on the sign when transporting to a facility that can manage a high-risk newborn and then of course diarrhea so five to six stools a day is normal especially when breastfeeding and diarrhea is excessive loss of electrolytes and fluid in the stool it can cause acute causes are infection or poisoning gastroenteritis or lactose intolerance neonatal abstinence syndrome or cystic fibrosis severe causes can cause dehydration and electrolyte balances and of course a poor this will show with poor vital signs or cap refill delayed dry mucous membranes or absenteers assessment and management you're going to estimate the number and volume of the loose stools decrease urinary output in the great you're trying to get the degree of dehydration based on the skin trigger presence of salt sunken eyelids and the mucous membranes and patient management begins with the abcs of course you have to ensure the adequate oxygen and ventilation cpr if needed and fluid therapy may be necessary okay now we're going to talk about neonatal",
        "Neonatal Jaundice": "jaundice the results from immaturity of the liver to get rid of the bilirubin in the first week it's considered pathologic when clinically visible in the first 24 hours and basically clinical jaundice persists for more than one week in full term infants or more than two weeks in preterm and it can result in red blood cells disorders or excessive bruising and severe hyper bilirubin anemia can lead to kern etritus it's a form of developmental delay from the death deposition of bilirubin in the neurological tissues so assessment and management you want to transport is essential for bilirubin measurements at the hospital then additional assessment not available in the field so start iv fluids if the neonate shows significant clinical jaundice communicate with medical control about the newborn with jaundice okay so next we're going to talk about",
        "The Thermoregulation": "the thermoregulation and it's limited in newborn but average normal temperature of a newborn is 99.5 degrees it ranges between about 97.9 and 99 degrees and the production of heat by metabolism is the newborn's primary source of heat production so brown fat is unique in newborns and heat loss occurs when the heat is lost to the environment and uh",
        "Fever": "of course we're gonna talk about fever next fever is a rectal temperature greater than a hundred point four degrees fahrenheit or an oral temp of one fahrenheit lower than a rectal temp on average auxiliary temp is a 1.1 degrees celsius or 2 degrees lower than rectal temp a newborn may not always present with a fever in the illness or infection because of the immaturity of its temperature regulation system so no matter the pres presenting signs or symptoms it is imperative to identify serious bacterial infection in newborns so they can be treated fever may be caused by overheating or dehydration then there's a limited ability to control their temperature within newborns they don't sweat when they're hot and they do not shiver to raise temperatures so signs and symptoms are irritability decreased feeding or warmth to the touch",
        "Assessment of Management": "assessment of management so you're going to examine for the presence of rashes especially petechiae or pinpoint pink or red lesions obtain a careful history and note increased respiratory rate and work of breathing obtain the vital signs and provide free flow supplemental oxygen and chest compressions if necessary and anti-pyritic agents are controversial in the field so do not give them anything and then to cool remove just layers of clothing to improve ventilation hypothermia is a drop in body temperature less than 95 degrees fahrenheit it's more common during the winter months moderate hypothermia is linked with increased risk of death in low birth weight newborns and newborns have increased surface area to ratio volume ratio and are sensitive sensitive to environmental conditions especially when wet after delivery if a newborn is hypothermic investigate for the infections",
        "Assessment": "assessment okay so you're gonna hypothermic newborns may be cool to the touch or pale may present with decreased respiratory effort apnea bradycardia cyanosis weak cry or lethargic",
        "Preventative Measures": "preventative measures include warming your hands before you touch them drying thoroughly after birth placing a pre-warmed cap on the head and placing the newborn skin to skin with the mom if the newborn is hypoglycemic administer d10 um warm fluids can assist in rewarming once stabilized it is ideal if possible to place a critically ill newborn in a pre-warmed incubator okay so let's talk about common birth",
        "Common Birth Injuries in the Newborn": "injuries in the newborn so birth trauma comes from injuries resulting in mechanical forces during the delivery process most are self-limiting with a favorable outcome so newborn injuries can occur because of the newborn size or the position during the labor and delivery conditions associated with a difficult birth include the first pregnancy prolonged labor or prolonged rapid labor abnormal presentation large size or the shoulder dystocia prematurity or low birth weight",
        "Trauma Injuries": "birth trauma injuries include those that can involve instruments used during delivery so abrasions or lacerations or bruising or subcutaneous fat necrosis excessive molding of the head and overriding parental bones also linear skull fractures avoid pressure to involved areas and displaced fractures need neurosurgical intervention um",
        "Brachial Plexus Injuries": "you could have brachial plexus injuries and they typically occur in deliveries complicated by shoulder injuries the facial nerve pla palsy and the findings include asymmetric faces when crying in dif phragmatic paralysis so that may occur from cervical root injury or brachial plexus injury the newborn may experience respiratory distress or acidosis and laryngeal nerve injury resulting from intrauterine posture or spinal cord injury resulting from excessive traction or rotation and torsion clavicle is the most frequently fractured bone in the newborn most often an unpredictable and unavoidable complication risk factors are large size or mid forceps delivery and may present in some type of paralysis to minimize the pain examination will show crepitus or a bony um palpable irregularity so possible lack of arm movement as well long bone fractures may present with loss of spontaneous arm and leg movement treatment includes splinting and check for signs of radial nerve injury with humorous fractures intra-abdominal injuries is uncommon in newborns and bleeding either catastrophic um is usually uncommon so consider in every newborn though presenting with shock or abdominal distension and hypoxia and shock should or could be caused by birth trauma okay so next we're going to talk a little bit about congenital heart diseases and the pathophysiology of that most common birth defect occurring in eight out of one one thousand live bursts approximately one-fourth are critical it's a leading cause of death among children and with congenital malformations and it can vary there are varying degrees of cardiopulmonary and cardiorespiratory compromise depending on the particular cardiac legion in neonates and infants typically it presents in a neonatal period with increasing respiratory distress per perfusion cyanosis or cardiovascular collapse in early recognition stabilization and transport to an appropriate cardiac care center is critical visual detection of cyanosis is difficult painless non-invasive methods include measuring pulse ox or monitoring oxygen set best outcomes are fine when a physical exam is paired with pulse ox screening for about 24 hours the american academy of pediatrics recommends pulse ox screening for full-term healthy newborns an effort made to diagnose congenital heart defects early in the neonatal period okay and then there's a non-cyanotic disease pink effects and that's oxygenated blood is shunted from the left side of the heart to the right side it's called left to right shunt",
        "Atrial Septal Defects": "atrial septal defects this is an abnormal opening or hole that exists in the wall of the septum separating the atrial chambers of the heart it allows some of the oxygenated blood from the left atrium to flow into a hole to the right atrium and it's usually asymptomatic in infants and children it presents a characteristic murmur patients are at risk for atrial dysrhythmias then there's ventricular",
        "Ventricular Septal Septal Defects": "septal septal defects and that's an abnormal opening that exists in the wall separating the right and left ventricles and it allows for oxygenated blood to flow from the left ventricle to the right its cardiac output is usually affected in in small openings patients are usually asymptomatic and growth and development are unaffected in moderate to large openings patients often experience delayed growth decrease exercise tolerance and repeated pulmonary infections infants and children with a ventricular septal defect are at high risk for bacterial endocarditis in moderate and large defects may require surgical closure closure so um",
        "Ductus Arteriosus": "patient ductus arteriosus it exists when the ducks ductus arteriosus fails to close after birth persistence of the ductus beyond 10 days of life is considered abnormal oxygen blood traveling through the aorta is shunted from the aorta across the duct to the pulmonary aorta where it maximizes or mixes with the deoxygenated blood symptoms depend on the size of the duct and ductus and how much blood flow is carrying and signs and symptoms associated with the large shunt may include fatigue or failure to thrive if poor feeding or consistent permanent characteristic murmur or increased workable breathing so then you have a condition of the narrowing of the aorta the of course the aorta is the largest oxygen carrying artery in the body it forces the left ventricle to work harder resulting in increased blood pressure proximal to the defect and decreased blood flow distal may be associated with other cardiac defects typically involves involving the left side of the heart asymmetric in most patients until later in childhood it may include the following physical",
        "Physical Findings": "findings so dypsnia poor feeding poor weight gain high blood pressure low blood pressure chest pain muscle weakness or heart failure in some infants and hypertension in older children there's a thing called a cyanotic disease and this is deoxygenated blood from the right side of the heart mixes with the left side it's a right to left shunt and then pulmonary stenosis that's a pulmonic valve near the right ventricle becomes damaged patients will have a decrease in blood flow to the lungs and will persist with jvd cyanosis or right ventricular hypertrophy it's um typically associated with chd but can also result from rheumatic heart disease",
        "Trunctus Arteriosus": "then there's trunctus arteriosus so pulmonary aorta arteries are combined as one vessel greatly increases blood flow to the lungs causing congestive heart failure patients will have slightly lower oxygen levels later in life eventually resulting in cyanosis and of course surgical invention is necessary and then tricuspid atresis that's the tricuspid valve is missing it results in an undersized or absent right ventricle it will have a significantly decreased blood flow to the lungs leading to severe hypoxia and death and then hypoplastic left heart syndrome this is the left side of the heart is uh completely underdeveloped the left side of the heart is unstable to or unable to fill the circulation needs patients present with a murmur or cyanosis heart transplant may be needed if a surgical procedure cannot be performed or fails okay the next one we're going to talk",
        "Tetralogy": "about is tetralogy and it's just what it sounds like it's four four of the heart defects and so it's ventricular septal the pulmonary stenosis right ventricular hypertrophy and an overriding aorta most of these infants are pink at birth because they usually have that patent ductus arteriosus that provides additional pulmonary blood flow so as the ductus closes and the first hours or days of life the cyanosis may develop or become more severe and of course this is going to require open heart surgery next one we're going to",
        "Transposition of the Great Arteries": "talk about is transposition of the great arteries and that's known as tga and it's positions of the pulmonary artery and they order are reversed so blood gas uh blood goes to the lungs for oxygenation then returns to lungs while blood from the body um to the heart goes back to the body without becoming oxygenated so cyanosis",
        "Cyanosis": "is usually present soon after birth patients present with shortness of breath or finger and toe clubbing while and of course it's going to require surgical intervention total omulus pulmonary venous return so that's the four pulmonary veins connect to the right atrium instead of to the left atrium results in diminished oxygenation and increased load on the right ventricle patients will present with signs and symptoms shortly after birth so general assessment and management of the so critical chd presents in the neonatal period and rapid detection and transport are mandatory and communication with medical control is critical to have adequate services available on arrival at the emergency facility okay so that concludes the neonatal care chapter 42 lecture thank you for joining me"
    },
    {
        "Introduction to Pediatric Emergencies": "chapter 36 pediatric emergencies pediatric emergencies represent a relatively small proportion of an EMS system's overall call volume however the assessment management of infants and children present distinct challenges that differ significantly from adult care it's not uncommon for healthc care providers to experience heightened anxiety when responding to Pediatric calls due to these complexities one of the primary challenges is that pediatric patients particularly infants and young children are often unable to provide the medical history that is typically more accessible in adult patients this lack of verbal communication requires a greater Reliance on observational assessment caregiver information and clinical findings to guide the management of pediatric emergencies in pediatric emergencies it's important to be prepared to interact with patients or caregivers as they can either provide valuable information regarding the child's medical history and current condition or may be of limited assistance depending on the situation it's also critical to recognize that children are not simply small adults they have unique physiological and developmental characteristics that necessitate tailored assessment and management strategies this requires a thorough understanding of pediatric specific approaches to ensure appropriate care and intervention when managing pediatric emergencies it's important to recognize that you may have multiple patients to treat including not only the child but also the family members or caregivers who may require emotional support patients or caregivers can sometimes become angry or demanding especially in stressful situations which can further complicate patient care maintaining clear and effective communication with the family is vital as a calm parent typically contributes to a calm child while an agitated or distressed parent is likely to cause the child to exhibit similar Behavior as a result part of your role is to help manage the emotional state of the caregivers which in turn can Aid in the successful treatment of the Pediatric patient it's important to remain compassionate calm and professional when communicating with both the Pediatric patient and their caregivers as your demeanor directly impacts the Dynamics of the situation when appropriate involving patients or caregivers in the child's care can be beneficial as it helps calm them and gives them a sense of contribution to the child's well-being this participation can also alleviate some of the stress they may feel for children who are not in immediate critical condition allowing them to remain on a parent or caregiver's lap during assessment can further reduce anxiety and promote a sense of security during assessment and treatment.",
        "Infant Development and Assessment": "to understand the unique characteristics of pediatric patients it's important to review the stages of growth and development as outlined in chapter nine on lifespan development during infancy which encompasses the first year of life the neonatal or newborn period specifically refers to the first month following birth infants between 0 and 2 months of age spend the majority of their time either sleeping or eating often sleeping up to 18 hours per day at this stage they primarily respond to physical stimuli such as light warmth hunger and sound as their sensory and motor development is still in its early phases infants between 0 and two months should be easily aroused from sleep failure to do so may indicate an emergency and requires immediate evaluation at this stage infants possess a strong sucking reflex for feeding but their head control remains limited they can turn their heads and focus on faces though their motor skills are still developing due to their immature Thermo regulation they are prone to hypothermia crying is their primary means of communication typically signaling hunger or other unmet needs if an infant is inconsolable despite having all basic needs being addressed such as being fed dry and comfortable this may be indicative of significant illness at this stage infants cannot distinguish between parents and strangers and they rely on caregivers to meet their basic needs including being warm dry and fed physical Comfort through holding cuddling or rocking often soothes them additionally hearing is welldeveloped and calm reassuring speech can be effective in calming the infant between 2 to 6 months of age infants begin to spend more time awake and become increasingly active and social during this period they start to recognize their caregivers and May respond with voluntary smiles and increased eye contact their motor development progresses allowing them to start rolling over and by around 4 months of age they typically gain enough neck strength to hold their heads up independently this stage marks significant growth in both physical and social abilities as they engage more with their environment and the people around them healthy infants in this age range typically exhibit a strong sucking reflex active movement of their extremities and a vigorous cry they begin to visually track bright lights or toys and will often turn their heads in response to loud sounds or the voices of their caregivers their increasing awareness of their surroundings allows them to use both hands to explore and examine objects persistent crying and irritability at this stage May indicate a serious illness while a lack of eye contact can be a concerning sign possibly indicating significant illness a depressed mental status or developmental delays between 6 to 12 months of age infants typically achieve significant motor Milestones such as sitting unsupported reaching for objects and beginning to crawl and in some cases take their first steps their awareness of their surroundings increases and they begin to explore their own bodies and the environment more actively this stage is also marked by teething which leads infants to place objects in their mouths frequently making them much more susceptible to F body aspiration and accidental poisonings close supervision and careful management of their environment are crucial during this developmental phase to prevent such incidents during the six to 12-month period infants typically begin to develop teeth and transition to eating soft foods babbling becomes more common and by around 12 months many infants will learn their first word separation anxiety often emerges during the stage with infants crying when separated from their parents or caregivers as they become more emotionally attached however persistent crying or irritability should not be dismissed as it can be a sign of serious illness requiring further evaluation when assessing an infant the Pediatric assessment triangle is used to evaluate three key components the child's appearance work of breathing and circulation this rapid structured assessment helps to quickly identify the severity of the child's condition additionally it's important to respect and consider a caregiver's perception if they express that something is wrong as they are often more sensitive to subtle changes in the infant's Behavior or condition that may not be immediately apparent to the clinician this can especially be true of parents or caregivers of children who have chronic or terminal issues these caregivers and parents know more about their child's illness than you ever will think of them as a clinical partner and not as somebody who's trying to tell you what to do when assessing an infant if all obvious reasons for crying such as hunger or discomfort have been addressed then persistent crying can indicate a significant illness although infants spend a substantial amount of time sleeping they should be easily aroused and any failure to do so should be treated as an emergency by 6 months of age infants should be able to make eye contact and a lack of eye contact could signal significant illness depressed mental status or developmental delays infants approaching 12 months are particularly at risk for foreign body aspiration and poisoning as their Mobility through crawling or walking exposes them to More Physical dangers when performing a primary survey it's important to consider the best location for the infant as older infants may feel more comfortable in a parents arms during the assessment additionally ensure your hands and stethoscope are warm to provide Comfort during the exam and reduce the infant's distress when examining an infant it's important to be opportunistic in your approach if the infant is quiet Begin by listening to the heart and lungs possibly over their clothes to minimize disruption if a young infant starts crying offering a pacifier or allowing them to suck on a glove finger can help calm them for older infants distractions such as jingling keys or a pin light may be useful in capturing their attention and reducing distress additionally always explain each procedure to the parent or caregiver before performing it to ensure they understand the process and feel comfortable with the care being provided this helps maintain trust and cooperation during the assessment.",
        "Toddler Development and Assessment": "toddlers ranging from 1 to 3 years of age undergo significant developmental changes between 12 to 18 months they begin walking and exploring their surroundings becoming increasingly mobile and curious this newfound Independence allows them to open doors drawers boxes and Bottles which increases their risk of injury due to their exploratory nature and lack of fear toddlers also begin to imitate the behaviors of older children and adults showing interest in mimicking daily activities at this stage they can identify major body parts when pointed out and may have a vocabulary of 4 to six words however they're still developing the ability to fully chew their food which places them at a higher risk for aspiration and choking between 18 to 24 months a toddler's cognitive development accelerates significantly by the age of two most toddlers are able to pronounce approximately 100 Words and can identify common objects when pointed out they also begin to grasp the concept of cause and effect which further enhances their understanding of their environment during this period their balance and gate improve rapidly enabling them to run and climb with increasing confidence however toddlers often remain emotionally attached to their parents or caregivers Clan to them for security many also have a comforting object such as a blanket or toy that help ease separation anxiety during times of distress when assessing a toddler Begin by observing their interactions with their caregiver vocalizations and Mobility using the Pediatric assessment triangle as a guide this approach allows for a quick evaluation of the child's overall condition persistent crying or irritability in toddlers should be regarded as a potential symptom of serious illness and warrants further investigation additionally their increased Mobility at this stage exposes them to a higher risk of physical dangers and injuries making it crucial to consider the possibility of trauma during the assessment when examining a toddler in stable Condition it's often helpful to conduct the assessment while the child remains on the patient's lap allowing them to hold familiar or comforting objects this approach can reduce anxiety and make the child feel more secure additionally positioning yourself at the child's eye level by sitting or squatting during the examination can help establish Rapport and make the process less intimidating for the toddler when examining a toddler with stranger anxiety it's important to be creative and flexible in your approach you can involve the parent in the assessment by asking them to lift the child's shirt so you can observe respiratory rate or have them press on the child's abdomen to assess for pain play into distraction techniques are also effective for reducing anxiety toddlers may become upset when restrained for procedures so it's helpful to offer limited choices to give them a sense of control avoid asking yes or no questions as their default response is often no additionally todders May struggle to describe or localize pain so patients and careful observation are needed whenever possible perform the more upsetting parts of the exam last to maintain the child's cooperation be aware that some toddlers May resist a full body exam so flexibility is key lastly for Airway management toddlers at this stage no longer require shoulder rolls to limit neck flexation during bag Mass ventilation or Advanced Airway procedures.",
        "Preschool and School-Age Children Development and Assessment": "preschool children between 3 to 6 years old shows significant cognitive and communication development at this stage they are capable of understanding directions and can be much more specific in describing their Sensations they are also able to identify painful areas when asked which AIDS in their assessment however despite their growing awareness the risk of foreign body aspiration remains high due to their continued tendency to explore their environment and occasionally Place objects in their mouths when assessing a preschool-aged child leverage their Natural Curiosity and willingness to cooperate If the child is medically stable you can engage them by offering to take turns listening to each other's hearts and lungs allowing them to hold or play with safe medical equipment it's important to respect the child's modesty only exposing areas of the body as needed for the examination providing simple choices helps the child feel involved in in control and always explain what you doing before performing any procedure avoid asking yes or no questions as they may not provide helpful responses If the child acts out set clear behavioral limits by this age most preschoolers can be talked through a complete orderly full body exam which can be done with cooperation if approached thoughtfully schoolage children between 6 and 12 years old begin to display behaviors and thinking patterns more similar to adults they're able to think in concrete terms respond sensibly to questions and actively participate in their own care this developmental stage allows them to communicate more effectively and follow instructions which can greatly Aid in their assessment and treatment these children are generally more cooperative and capable of understanding the the procedures being performed making them easier to manage in medical settings compared to younger children when assessing a schoolage child it's important to recognize that they can differentiate between emotional and physical pain and may have concerns about the meaning of their pain offering simple clear explanations about the cause and the Planned interventions helps to ease their anxiety whenever possible provide the child with appropriate choices and a sense of control over their care respect their modesty by keeping them covered as much as possible during the exam engaging the child in games or conversation can serve as an eff of distraction and offering a reward after the completion of a procedure can further encourage cooperation and reduce stress during future medical encounters.",
        "Adolescent Development and Assessment": "adolescents are typically aged between 12 and 18 years and are capable of abstract thinking and are able to actively participate in decision making regarding their care this period marks the onset of puberty which can be challenging times as they negotiate issues related to Independence body image sexuality and peer pressure these factors May contribute to heightened emotional responses and anxiety especially in medical settings understanding the complexities of adolescents is critical When approaching their care as they may require sensitivity and support when discussing health and personal matters when assessing an adolescent it's important to treat them as an adult by addressing them directly encourage them to ask questions and actively involve them in decisions regarding their care providing clear and accurate information it's also essential to acknowledge and address their concerns and fears particularly regarding the potential long-term effects of injuries including cosmetic issues which may be especially important to them engaging to adolescent by finding out their interests and encouraging them to talk about those topics can also help build rapport and ease anxiety during the assessment process as with other children it's important to to respect their privacy and modesty particularly when discussing sensitive topics whenever possible conduct the assessment without a caregiver present to allow the patient to speak more openly about personal concerns if friends are present at the scene they may prefer for them to stay during the assessment allow the patient to have as much control over the situation as is appropriate while maintaining professional boundaries and following the law despite a accommodating their preferences providers should always remain Vigilant about seeing safety and do not compromise it in any way nor place yourself in any type of compromising position.",
        "Anatomical and Physiological Differences in Children": "during childhood the body undergo rapid growth and changes that significantly affect anatomy and physiology these changes along with the anatomical and physiological differences between children and adults can present challenges in assessment and treatment if not fully understood recognizing these developmental variations is important for accurate evaluation and appropriate management of pediatric patients as they directly impact how children respond to illness injury and medical interventions the Pediatric respiratory system presents several key anatomical differences compared to adults the airway in children is smaller in diameter and Sher in length which increases the risk of obstruction the tongue occupies more space in the Ora ferx and can easily block the airway especially in cases of altered Consciousness Additionally the epiglottis in children is larger floppy and u-shaped making Airway management more challenging the LX is positioned higher and more anterior and the trachea is smaller in diameter contributing to increased Airway resistance during respiratory distress in cases of respiratory distress tracheal tugging where the trachea visibly pulls inward toward the neck can be observed and is a sign of significant respiratory effort infants primarily rely on their diaphragms rather than their chest muscles for inspiration as a result any pressure on the abdomen can restrict diaphragm movement potentially leading to respiratory compromise additionally young children are prone to muscle fatigue more quickly than adults and this fatigue can lead to respiratory failure if not promptly addressed this Reliance on diaphragmatic breathing and their limited endurance must be considered during assessment and treatment to prevent further respiratory distress in pediatric patients the lung tissues are more fragile and the ribs are primarily calines offering less protection to the thoracic organs as a result substantial chest compressions or trauma can cause significant injury to vital intrathoracic organs even if external signs of trauma are minimal The Fragile lung parena also makes children more susceptible to barot trauma particularly during mechanical ventilation or improper bag mask ventilation Additionally the respiratory muscles in children are less developed and fatigue more quickly than those of adults increasing the risk of respiratory failure during prolonged distress the media stinum is more mobile which can complicate the response to thoracic trauma lastly children have a smaller functional residual capacity meaning their oxygen Reserve are proportionally lower making them more vulnerable to hypoxia in situations of respiratory compromise gastric distension in children can lead to hypoventilation and increases the risk of regurgitation which may result in aspiration further complicating respiratory management infants up to approximately 4 to 6 months of age are obligate nasal breathers meaning they primarily breathe through their nose for this reason it's important to keep the nasal passages clear in infants younger than 6 months additionally hyperextension of the neck should be avoided during Airway management as it can compromise the airway ensure the airway is kept clear of all secretions and exercise caution when managing the airway to prevent trauma or further compromise particularly given the unique anatomical and physiological features of infants and young children infants and children are particularly vulnerable to hypoxia due to several factors including decreased oxygen reserves higher oxygen demand and respiratory muscles that fatigue quickly these factors make rapid identification and intervention in respiratory distress critical when ventilating a pediatric patient it is advisable to use a larger bag to ensure adequate title volume however care must be taken to apply only enough pressure to produce visible chest rise as excessive pressure can lead to barot trauma or further complications this graph shows hemoglobin oxygen saturation over time for different patient populations including a normal 10 kgam child normal and moderately ill adults and an obese adult the key concept Illustrated here is hemoglobin desaturation which refers to the rate at which blood oxygen levels decrease when a patient is not ventilating meaning there's no gas exchange that's occurring the initial fraction of inspired oxygen or fi2 is 0.87 meaning the patients start with oxygen enriched Air at roughly 99 to 100% spo2 levels for Pediatric patients the the graph indicates that a 10 kg child will desaturate more rapidly than an adult when no gas exchange is occurring this is clinically significant because children have higher metabolic rates and lower functional residual capacity compared to adults the faster decline in oxygen saturation in pediatric patients means that when respiratory compromise occurs such as in an airway obstruction or apnea intervention must be swift to prevent hypoxia in emergency situations this rapid desaturation requires immediate attention often necessitating the use of advanced Airway management techniques including Rapid sequence intubation or providing supplemental oxygen via bag valve mask in addition clinicians must recognize that pediatric patients can experience severe hypoxemia much faster than adults demanding quicker action during respiratory distress or during procedures like sedation or intubation this graph serves as a reminder that respiratory assessment in children must be proactive ensuring early detection of hypoxemia and emphasizes The Importance of Being prepared for Airway management and oxygenation in pediatric emergency care in the Pediatric population it's important to be familiar with the normal pulse ranges for each age group when evaluating cardiovascular status unlike adults children primarily rely on their heart rate to maintain adequate cardiac output for example an infant's heart can accelerate to 200 beats per minute or more in response to injury or illness as a compensatory mechanism this Reliance on heart rate underscores the need for prompt recognition of tacac cardia as a potential sign of underlying distress or compromise in the Pediatric patient children have a higher circulating blood volume relative to their body weight in infants and children the circulating blood volume is approximately 70 to 80 MLS per kg of body weight while in adults it's about 60 to 70 MLS per kg this means that pound per pound children have more blood relative to their body weight than adults do however in absolute terms an adult has a significantly higher total blood volume due to their larger size this difference is important in clinical settings especially during resuscitation or when managing trauma or dehydration in pediatric patients as even small amounts of blood loss can have a proportionally greater impact on children due to their relatively larger blood volume per kilogram despite having a smaller absolute blood volume their ability to Vaso constrict effectively helps maintain profusion to vital organs even during periods of distress or injury injured children can sustain their blood pressure longer than adults even in shock meaning a proportionally larger volume of blood loss must occur before hypotension develops as a result the onset of hypotension in pediatric patients is often a late sign of shock therefore the presence of tacac cardia in an infant or child should raise suspicion for shock even in the absence of hypotension and prompt early intervention is critical brto cardia is frequently associated with severe hypoxia reflecting the body's attempt to compensate for inadequate oxygenation hypotension on the other hand often signifies impending cardiopulmonary arrest indicating a critical decrease in profusion pressure that may lead to loss of consciousness and respiratory failure clinically signs of Vaso constriction can manifest as weak peripheral pulses which may indicate compromised blood flow and delayed capillary refill time particularly in children younger than 6 years serving as a vital indicator of circulatory status Additionally the presence of pale cool extremities can further suggest systemic Vaso constriction as the body prioritizes blood flow to vital organs the nervous system comprising the brain and spinal cord exhibits less protection compared to other anatomical structures neural tissue and its Associated vasculature are inherently fragile rendering them susceptible to damage and Hemorrhage following injury notably the subarachnoid space in pediatric patients is smaller than that in adults which can influence the Dynamics of intracranial pressure and cerebral spinal fluid distribution additionally bruising and damage to the brain can occur as a consequence of head momentum highlighting the importance of understanding mechanisms of injury in clinic iCal assessment and management the Pediatric brain necessitates nearly twice the cerebral blood flow compared to the adult brain to support its metabolic demands and developmental processes head injuries in children are significantly worsened by hypoxia and hypotension which contribute to ongoing neuronal damage and complicate recovery in contrast spinal cord injuries are less less common in pediatric patients although they can still occur and may lead to severe functional impairments the muscular skeletal system in pediatric patients is characterized by softer and more porous bones until adolescents which increases the likelihood of incomplete fractures such as green sticks given this vulnerability it's important to treat any sprain or strain with the same caution as a potential fracture immobilizing the injury appropriately to prevent further damage additionally injury to the epical plate during the development or puncture of the growth plate during in ocus canulation can lead to abnormalities in normal bone growth and development this underscores the importance of careful assessment and management of muscular skeletal injuries in this population in pediatric patients the head is proportionately larger than in adults which can predispose infants to excessive heat loss due to the higher surface to area volume ratio during infancy the anterior and posterior font Nails remain open providing flexibility during child birth and accommodating brain growth these font Nails typically close by approximately 18 months of age furthermore infants and young children are particularly susceptible to head trauma necessitating Vigilant assessment and protective measures to mitigate the risk of injury when managing a child's Airway Special Care must be taken in positioning to ensure optimal ventilation in children younger than 3 years it's advisable to place a thin layer of padding under the shoulders and or the back to achieve a neutral alignment of the airway for seriously ill children older than 3 years a thin layer of padding should be positioned under the oxop put accompanied by a thicker layer of padding under the shoulders Andor upper back facilitating a sniffing position that promotes Airway patency and enhances respiratory function font Nails serve as an important indicator of a child's neurological and hydration status a bulging font nail suggests increased inter cranial pressure which may be indicative of conditions such as menitis or hydris conversely a sunken font nail often points to dehydration reflecting inadequate fluid volume in the body monitoring these features is essential in the assessment of our pediatric patients the gastro intestinal system in pediatric patients is characterized by Immature abdominal musculature which provides less protection to solid vascular organs such as the spleen and liver both of which are proportionally larger and more vascular in children Additionally the proximity of abdominal organs in this age group increases the likelihood of injury as a result pediatric patients are at a heightened risk for splenic and hepatic injuries compared to adults multiple organ injuries are more prevalent in children which necessitates careful evaluation and management in cases of abdominal trauma the integumentary system in infants and children features thinner and more elastic skin along with a larger body surface area to body mass ratio and less subcutaneous fatty tissue these characteristics contribute to an increased risk of injuries resulting from exposure to temperature extremes as well as a heightened vulnerability to hypothermia and dehydration both of which can complicate recitative efforts Additionally the severity of burns is often greater in pediatric patients many Burns that would be classified as minor or moderate in adults may be considered severe in children highlighting the need for careful assessment in management metabolic differences in infants and children include limited stores of glycogen and glucose which can be rapidly depleted following injury or illness this vulnerability makes them particularly susceptible to hypothermia a risk that is exacerbated by their larger body surface area to mass ratio furthermore infants and young children lack the ability to shiver which further impairs their Thermo regulation and increases the likelihood of hypothermic complications significant hypovolemia and electrolyte derangements are more common in pediatric patients due to severe vomiting and diarrhea necessitating Vigilant monitoring and management during transport keep the child warm to prevent loss of body heat this includes covering the child's head to minimize heat loss however caution must be exercised with newborns as overheating can just as easily adversely affect their neurological outcomes highlighting the importance of maintaining an appropriate body temperature during care and transport.",
        "Respiratory Emergencies in Children": "in the assessment and management of respiratory emergencies it's important to recognize that infants have limited capacity to compensate for Respiratory insults many infants and children experiencing respiratory conditions present with signs of respiratory distress if a child in respiratory arrest can be resuscitated prior to the onset of cardiac arrest the likelihood of survival with the return of full function is significantly increased when confronted with a respiratory emergency the first step is to determine the severity of the disease respiratory distress is characterized by an increased work of breathing necessary to maintain adequate oxygenation Andor ventilation signs of respiratory distress in pediatric patients can manifest in various ways poor or modeled skin color may be observed along with signs of irritability anxiety or restlessness the rest Ator rate is often faster than normal for the child's age and physical findings may include retractions in the super sternal intercostal or subcostal areas as well as abdominal breathing other indicators include nasal flaring inspiratory Strider and grunting which can signify increased efforts to breathe mild tacac cardia may also be present reflecting the body's response to respiratory compromise a patient experiencing respiratory failure is in a state where the respiratory system can no longer meet the body's demands for oxygen or eliminate carbon dioxide effectively despite compensatory mechanisms such as an increased respiratory rate or effort initially patients in respiratory distress may attempt to compensate through an increased work of breathing which will manifest itself as to kipa nasal flaring and retractions or visible sinking of the skin around the chest wall muscles during inhalation this indicates that acccessory muscles are being recruited to Aid in breathing as respiratory failure progresses the patient's ability to sustain this increased effort diminishes leading to a decline in respiratory muscle function and fatigue when retractions decrease or become absent this can be a critical sign that the patient is no longer able to compensate the reduction in retractions suggests that the respiratory muscles are failing and the patient is losing the ability to generate adequate tidal volumes to maintain oxygenation and carbon dioxide elimination additional signs of impending respiratory failure include an altered mental status cyanosis bradia or even apnea if left untreated this can lead to complete respiratory arrest early recognition of these signs is vital for prompt Intervention which may include non-invasive ventilation support such as a CPAP or BiPAP intubation and mechanical ventilation depending on the severity of the failure this immediate action is needed to prevent hypoxia hypercat AA and subsequent organ failure in pediatric patients these signs can be even more subtle and develop more quickly than adults due to their smaller functional Reserve making the early identification and management of respiratory failure particularly important in this population if respiratory failure is not corrected the patient will enter respiratory arrest and the immediate initiation a bag mask ventilation with supplemental oxygen should begin as this is aimed at preventing further deterioration into cardiopulmonary arrest during respiratory restr the patient is unable to effectively breathe leading to insufficient oxygen delivery and accumulation of carbon dioxide both of which can rapidly result in hypoxia and cardiac arrest if not addressed promptly the administration of bag m mask ventilation delivers positive pressure ventilation helping maintain Airway patency improving oxygenation and supporting carbon dioxide elimination supplementing this ventilation with oxygen increases the fraction of inspired oxygen or F2 further optimizing oxygen delivery to the tissues in pediatric patients early and effective respiratory intervention often leads to positive outcomes as many instances of pediatric cardiopulmonary arrest are initially triggered by respiratory failure by addressing the respiratory component early through effective ventilation progression to cardiopulmonary rest can often be avoided however if a child does progress to cardiopulmonary arrest the outcomes are more variable and often worse due to the significant hypoxia that may have already occurred this makes rapid and aggressive respiratory management the priority in pediatric emergencies obtaining a sample history is important in guiding treatment as this information can help identify potential causes of the respiratory arrest such as an allergic reaction foreign body aspiration or a chronic condition such as asthma administering supplemental oxygen can further enhance oxygenation particularly in children exhibiting mild respiratory distress or early signs of hypoxemia for younger children particularly toddlers who may resist the use of an oxygen mask Blow by oxygen where oxygen is delivered close to the child's face without direct contact can still be an effective alternative especially if a caregiver is involved in administering the oxygen this can keep the child calm which of course is beneficial as crying and agitation can worsen respiratory distress continuous electronic monitoring of key Vital Signs such as pulse rate respiratory rate and oxygen levels is critical in assessing the child's status monitoring allows for the timely identification of any deterioration and helps evaluate the response to interventions oxygen saturation levels provide real-time feedback on the child's oxygen status while pulse rate and respiratory rate can signal early signs of compensation or failure ECG monitoring should be performed if there are no signs of clinical Improvement after addressing the respiratory distress and the provider should establish intervenous access particularly if there are concerns regarding dehydration frequent reassessment is necessary to ensure the interventions such as bag mask ventilation or oxygen Administration ation are affected adjustments may need to be made based on the child's clinical presentation and response to treatment the ultimate goal is to stabilize the patient's respiratory function and prevent the progression into cardiopulmonary arrest.",
        "Upper Airway Emergencies": "upper Airway emergencies can present with specific signs and symptoms including decreased or absent breath sounds and strider for body aspiration or obstruction is a common concern as children can obstruct their Airway with any object that fits into their mouth in cases of trauma dislodged teeth may also pose a risk of Airway obstruction additionally blood vomitus or other secretions can contribute to Airway blockage necessitating prompt identification and management to ensure Airway patency and adequate ventilation in the treatment of upper Airway emergencies involving forign body obstruction if the patient is responsive and coughing forcefully it's important to encourage the child to continue coughing to clear the airway if the material in the airway does not completely block air flow the patient may be able to breathe adequately without immediate intervention in such cases refrain from any interventions other than providing supplemental oxygen allow the patient to remain in the position that is most comfortable for them and continuously monitor their condition during transport to ensure safety and effectiveness of care the airway should be cleared immediately if any of the following signs are present ineffective cough inability to speak or cry increasing respiratory difficulty accompanied by Strider cyanosis or loss of consciousness in cases where an infant is responsive but it experiencing complete Airway obstruction the appropriate intervention is to perform up to five back blows followed by five chest thrusts this sequence is critical for effectively relieving the obstruction and restoring Airway patency if a child older than one year is responsive and has a complete Airway obstruction abdominal thrusts also known as the himlet maneuver should be performed to dislodge the object object in the case of an unresponsive child with a suspected form body obstruction and no suspected spinal injuries the airway should be opened using the head tilt chin lift maneuver it is important to look inside the mouth to determine if the obstructing object is visible however finger sweeps should never be employed if the object is not seen as a matter of fact you shouldn't stick your finger in the patient's mouth at all as you're most likely just going to push the object object farther down into the airway in situations where the patient is unresponsive chest compressions are recommended to relieve a sever obstruction as they create increased pressure in the chest functioning as an artificial cough that may expel the farm body from the airway anaphylaxis is a potentially life-threatening allergic reaction triggered by exposure to an antigen upon exposure the antigen stimulates the release of histamine and other vasoactive chemical mediators from white blood cells leading to a rapid onset of symptoms that typically occurs immediately a child experiencing severe anaphylaxis may present in respiratory failure and shock by the time medical personnel arrive the Pediatric assessment triangle May reveal an anxious child highlighting the urgency of the situation and the need for prompt intervention the primary survey in cases of anaphylaxis typically reveals signs such as hives swelling of the lips and oral mucosa and Strider Andor wheezing as well as diminished pulses obtaining a sample history may help uncover recent contact with or ingestion of the potentially offending agent which is needed for effective management the gold standard treatment for an aaxis is epinephrine as it decreases Airway edema through Vaso constriction and improve circulation by increasing peripheral vascular resistance additionally badril or Dien hydramine is indicated for its anti-histamine effect providing further relief from allergy symptoms please see our chapter on immunological emergencies for more information about anaphylaxis cro is an infection of the upper Airway that occurs below the level of the vocal cords most commonly caused by the para influenza virus this condition primarily affects children between 6 months to 3 years of age with the majority of cases occurring during the fall and winter months croo leads to edema and Progressive Airway obstruction which can result in characteristic symptoms such as a barking cough Strider and respiratory distress Strider is the Hallmark sign of croo the Pediatric assessment triangle will typically reveal an alert infant or toddler who exhibits audible Strider particularly with activity or agitation however significant concern for critical Airway obstruction arises if a child with the history of consistent group appears sleepy obtunded or exhibits significant respiratory distress or cyanosis while breath sounds are likely to be clear over the lung Fields Strider may still be heard indicating the presence of upper Airway obstruction in managing cou it's important to allow the child to assume a position of comfort and to avoid any actions that may agitate them the administration of humidified oxygen can be beneficial as it helps soothe the airway and improve oxygenation if nebulized epinephrine is required early activation of paramedic backup is essential for timely Advanced Care in cases of respiratory failure assisted ventilation with a BVM can often be effective in overcoming upper Airway obstruction igitis is characterized by inflammation of the super glottic structures due to bacterial infection since the introduction of the vaccine against hemophilus influenza type B this condition has become rare in children the classic presentation of epiglottitis can easily be distinguished using the Pediatric assessment triangle these patients typically appear ill and anxious exhibiting increased work of breathing with poor or cyanosis potentially evident patients will typically be sitting in a tripod position in drooling obtaining a sample history often reveals a sudden onset of high fever and sore throat symptoms of epiglotis can progress rapidly making timely intervention critical it's important to inquire about the child's immunization history particularly regarding the hemophilus influenza type B vaccine the primary go goal in managing a child with suspected epiglotis is to ensure they are transported to an appropriate hospital where a maintainable Airway can be established allowing the patient to assume a position of comfort is essential and supplemental oxygen should be provided only if it's tolerated providers should not attempt to look in the mouth or establish intervenous access as these actions May provoke further distress or Airway compromise be prepared with the BVM in case of complete obstruction and the need for assisted ventilation additionally alert Personnel at the receiving facility about the child's condition to ensure prompt and appropriate care upon arrival many hospitals will treat the epiglotis patient as a potential failed Airway.",
        "Lower Airway Emergencies": "lower airway emergencies often present with signs and symptoms such as wheezing and or crackles the best approach to osculate breath sounds in a pediatric patient is to listen on both sides of the chest at the level of the armpit ensuring accurate assessment of Airway conditions and guiding further management asthma is characterized by acute spasm and inflammation of the bronchioles in the lungs often associated with excessive mucus production it's commonly encountered in children with the pre-existing history of the disease between asthma attacks the child is usually asymptomatic various triggers can provoke an asthma episode including upper respiratory infections allergies changes in environmental temperature smoke exposure physical exertion and emotional stress during an acute asthma attack hyperactive bronchioles become narrowed leading to a reduction in air flow the immune system's response triggers the release of histamines which contribute to inflammation in Bronco constriction as the attack progresses expiratory air flow becomes increasingly restricted making it difficult for the patient to breathe effectively signs and symptoms of an acute asthma attack can vary but may include the child sitting in a preferential position to to aid breathing along with evident respiratory distress a prolonged expiratory phase is often noted and wheezing may be present in severe cases wheezing can even be heard without the use of a stethoscope additional indicators include tacac cardia Topia and agitation all of which signal the need for immediate assessment and intervention in man in an acute asthma attack administer oxygen using the method that is most tolerated by the child it's important to determine whether the patient has been prescribed a metered dose inhaler containing a beta 2 Agonist or another medication you may assist the child with their medication or administer a nebulized updraft of a beta 2 Agonist as directed by medical control additionally inquire if the patient has ever been intubated or admitted to intensive care for asthma as this information can guide management if the patient has been intubated once before the chances are extremely high that they may need to be intubated again the primary pharmacologic agent used for asthma is a beta 2 Agonist without butol being the most commonly administered Bronco dilator other medications may be U utilized based on local protocols and the specific needs for the patient albuterol is typically administered through a nebulizer to provide effective Bronco dilation always contact medical control prior to administering any medication to ensure appropriate guidance and compliance with protocols If the child exhibits signs of respiratory failure initiate assisted ventilations using a BVM in with 100% oxygen if necessary Bronco dilator therapy can be administered during positive pressure ventilations using a small volume inline nebulizer in cases where intubation may be required call early for paramedic backup to facilitate a timely and advanced Airway management prompt action in these situations can significantly impact patient outcomes additional treatment for a child experiencing an asthma attack includes monitoring oxygen saturation levels and ensuring prompt transport to a medical facility if the child's condition permits it's important to avoid separating them from their parent or caregiver as this can provide comfort and reassurance a prolonged unrelieved asthma attack May progress into status asthmaticus which is characterized by minimal air movement and presenting a DI higher emergency in such cases treatment becomes more aggressive and must be initiated in route to the hospital to mitigate the risks associated with this severe condition status asthmaticus is a severe life-threatening exacerbation of asthma that does not respond to ster treatments such as Broncho dilators and corticosteroids in this condition Airway obstruction worses progressively leading to significant rest distress and the potential for Rapid deterioration if not managed properly let's look at some of the common symptoms of status asthmaticus as the Airways become increasingly constricted due to bronchospasm inflammation and mucus plugging the child's ability to move air effectively is severely compromised this results in inadequate oxygen intake and carbon dioxide elimination the body initially compensates with increased respiratory rate and effort but over time this compensation fails leading to respiratory failure due to the inability to adequately ventilate oxygen levels in the blood drop resulting in hypoxia this can manifest a cyanosis altered mental status agitation or confusion hypoxia is particularly dangerous in pediatric patients as children can deteriorate quickly once oxygen levels fall increasing the risk of hypoxic injury to vital organs as ventilation becomes inadequate the body's ability to eliminate carbon dioxide is impaired leading to a buildup of CO2 in the blood this contributes to respiratory acidosis where the pH of the blood becomes more acidic metabolic acidosis can also occur as a result of tissue hypoxia leading to Anor robic metabolism and lack acid production both respiratory and metabolic acidosis can exacerbate the child's clinical condition causing further deterioration in the early stages of status asthmaticus the patient typically exhibits signs of severe respiratory effort including retractions the use of accessory muscles nasal flaring and grunting however as the condition progresses the patient may become physically exhausted from the prolonged effort to breathe this exhaustion is particularly dangerous as it can lead to decreased respiratory drive worsening hypoventilation and ultimately respiratory arrest immediate intervention is critical in managing status asthmaticus this often includes high flow oxygen to maintain adequate oxygenation continuous nebulization of bronco dilators and systemic corticosteroids to reduce Airway inflammation in severe cases intervenous medications such as magnesium sulfate or epinephrine may be administered to relax the Airways and improve air flow if these treatments fail to reverse the symptoms the patient may require assisted ventilations with a BVM to ensure adequate oxygenation in ventilation in cases where the patient continues to deteriorate or exhibit signs of impending respiratory arrest Advanced Airway management including intubation and mechanical ventilation may be necessary this is a challenging decision in status asthmaticus as intubation can worsen Airway resistance and increase the risk of barot trauma or ventilator induced lung injury that being said it may be the only option to maintain oxygenation and prevent further acidosis and organ failure recognizing the symptoms of status asthmaticus and responding promptly is essential to prevent life-threatening complications in pediatric patients the window for intervention is often narrow making early identification and aggressive management critical a well-coordinated approach that includes respiratory support pharmacologic treatment and continuous monitoring of oxygenation and ventilation status is necessary in order to stabilize the child and prevent further deterioration pneumonia is a common disease that infects the lower airway and lungs and it can occur at any age though it's frequently seen in infants Toddlers and preschoolers from one to 5 years of age the condition is usually caused by a virus but as children grow older the incidence of bacterial pneumonia does increase a recent history of call for cold or a lower airway effect is often noted in affected individuals additionally pneumonia can result from direct lung injuries further complicating the clinical picture pneumonia in pediatric patients typically presents with rapid breathing often accompanied by abnormal respiratory sounds such as grunting or wheezing which are indicative of lower airway involvement and difficulty in maintaining adequate gas exchange additional physical signs include nasal flaring which reflects increased work of breathing and crackles or rails heard upon oscilation which signify fluid accumulation in the Alvi other findings may include fever or in some cases hypothermia which is particularly concerning in young infants unilateral diminished breath sounds may suggest a localized area of lung consolidation or collapse pointing to a severe or more advanced infection infants especially younger ones may exhibit a more pronounced respiratory compromise with pneumonia compared to older children and adults they may show increased accessory muscle use such as intercostal and subcostal retractions indicating significant respiratory effort due to their smaller lung capacity and less developed immune systems infants are at a greater risk for hypoxemia and Rapid clinical deterioration therefore early recognition and treatment are critical in managing pneumonia in this vulnerable population and clinicians should be vigilant in monitoring for signs of respiratory distress that could lead to respiratory failure if not addressed promptly the treatment of pneumonia is primarily supportive it involves monitoring the patient's airweight and breathing status closely and administering supplemental oxygen as needed to ensure adequate oxygenation If the child presents with wheezing a Bronco dilator may be administered to relieve Broncos spasm generally vascular access is not indicated however if the condition warrants medication therapy IV or IO access should be established in route to the hospital final diagnosis is confirmed through a chest radiograph after which antibiotics are administered as the primary treatment to address bacterial infections when present bronch elitis is a viral infection that leads to inflammation and constriction of the bronchioles significantly affecting air flow it's often caused by respiratory synctial virus and typically occurs during the first 2 years of life with a higher incidence in males this condition is particularly widespread during the winter and early spring months in bronchiolitis the bronchioles become inflamed swell and fill with mucus which can easily obstruct the Airways of infants and young children due to their smaller Airway size it's important to monitor for signs of dehydration as the condition can exacerbate fluid loss patients may also exhibit shortness of breath and fever which are common symptoms associated with this viral infection treatment for bronchitis involves maintaining a calm demeanor to help reduce anxiety in the patient allowing the child to assume a position of comfort can Aid in their breathing address any Airway and breathing problems as needed and if available administer humidified oxygen to assist with oxygenation be prepared to assist with ventilations If the child shows signs of respiratory distress and make sure to call for early paramedic backup if you determine that advanced Airway management is necessary pertusus commonly known as whooping cough is a potentially deadly disease caused by the bacterium bordatella puses which spreads through respiratory droplets due to widespread vaccination efforts the incidence of prusis has decreased in the United States initial signs and symptoms often resemble those of a common cold including coughing sneezing and a runny nose however as the disease progresses characteristic severe cing fits May develop making early recognition and intervention important for Effective management as the disease progresses the coughing becomes more severe and is characterized by the distinctive whoop sound during the inspiratory phase indicating significant Airway irritation maintaining a patent Airway is critical and prompt transport to a medical facility is essential for further evaluation and management given that pusis is highly contagious it's important to follow standard precautions including wearing a mask and eye protection in order to prevent the spread of the infection during patient care in the general assessment and management of respiratory emergencies Airway adjuncts are vital for maintaining a patent Airway in children with inadequate ventilation the provider should choose appropriately sized equipment to ensure effectiveness and minimize potential harm if an airway adjunct is not the correct size it may cause more harm than good potentially leading to further Airway obstruction or injury therefore careful selection and application of Airway adjuncts are needed for optimal patient outcomes the Oro fareno Airway is indicated for use in patients who were unresponsive and in respiratory failure should not be used in responsive patients or those with a gag reflex as this could induce vomiting and further cause Airway compromise additionally it's contraindicated in children who have ingested acostic or petroleum based product due to the risk of Airway injury the correct insertion of an Opa in a pediatric patient involves several key steps first gather the necessary equipment including the appropriately sized PA and ensure suction is available in a safe environment position the child in a suine position possibly using a small pillow or rolled towel to elevate the shoulders and align the airway assess the patient responsiveness to confirm they are unresponsive and in respiratory failure ensuring there is no gag reflex present select an Opa that is the appropriate size by measuring from the corner of the mouth to the angle of the jaw or earlobe open the mouth using the crossed finger technique or a Bite Block to move the tongue out of the way starting at the corner of the mouth insert the OPA with the curved side facing the top of the mouth and continue inserting along the natural curvature of the airway until the OPA rests securely against the lips with no resistance at this point the provider should check for improved Airway patency to observe for adequate ventilation continuously monitor the patient's respiratory status and be prepared to suction the airway if secretions obstruct ventilation finally document the procedure including the size of the OPA used the patient response and any additional interventions provided the naso faral airway or MPA is indicated for use in responsive pediatric patients experiencing respiratory failure although it is rarely used in infants younger than one year it should not be utilized in patients with nasal obstruction facial trauma or moderate to severe head trauma due to the risk of complications Begin by gathering the necessary equipment ensuring that you have the appropriately ized MPA for the child's age and size position the patient comfortably typically in a suine position to facilitate the procedure assess the patient's responsiveness to confirm their alert and in respiratory failure ensuring there are no contraindications such as those outlined above if you are inserting the airway into the left nare hold the mpa with the tip facing upwards and insert it upside down with the bevel pointing towards the septum gently Advance the mpa until it reaches the orax ensuring it is properly positioned after insertion reassess the airway to confirm effective ventilation and the proper function of the mpa all ill or injured infants and children should receive supplemental oxygen to support their respiratory needs the method of oxygen delivery will be determined by the adequacy of the patient's breathing and tital volume this assessment is critical in selecting the appropriate device whether it be a nasal canula simple face mask or other oxygen delivery symptoms in order to ensure optimal oxygenation and ventilation based on the child's condition devices and techniques for delivering sub Al oxygen to Pediatric patients includes several options based on the patient's needs the blowby technique can be utilized at a flow rate of 6 L per minute which is particularly useful for infants or children who may not tolerate masks a nasal canula is appropriate for delivering oxygen at flow rates of 1 to 6 L per minute offering a comfortable option for patients who can breathe independently for those requiring higher concentrations of oxygen a non-rebreathing mask should be used as a flow rate of 10 to 15 L per minute in order to ensure adequate oxygen delivery in cases where assisted ventilation is necessary a BVM equipped with an oxygen Reservoir can be used at a flow rate of 15 L per minute or above to provide effective oxygenation while managing ventilation the use of a non-ar breathing mask or the blowby technique is indicated only for patients who have adequate respiratory rates and tital volumes when administering Blow by it's important to note that it does not deliver a high concentration of oxygen however it can be a suitable option for children who will not tolerate a nonr breathing mask ensure that the airway is patent and maintain proper head position which may require assistance from a parent or caregiver to administer blowby place the oxygen tubing through a small small hole in the bottom of an 8 O cup and connect the tubing to an oxygen source set at 6 L per minute hold the cup approximately 1 to 2 in away from the child's nose and mouth to provide effective oxygen delivery for some patients a nasal canula may be preferred as it offers a more comfortable option for delivering oxygen at flow rates of 1 to 6 L per minute however individual preferences may vary with some children finding the nasal Cula uncomfortable therefore assessing each child's comfort and tolerance is essential and selecting the most appropriate method for oxygen delivery the non-ar breathing mask is designed to deliver up to 95% oxygen to the patient while allowing for the exhalation of carbon dioxide without rebreathing it it makes it an effective choice for patients requiring high flow oxygen the bag MK device is indicated for patients with respirations that are too slow or too fast those who are unresponsive or those who do not respond purposefully with painful stimuli it's important to note that errors in technique can lead to complications such as gastric distension or pneuma thorax common errors include providing too much volume with each breath squeezing the bag too forcefully or ventilating at too rapid of a rate additionally patients May regurgitate posing a risk of aspiration of stomach contents two rescuer bag mask device ventilation requires two providers to effectively manage the airway this approach is usually more effective in maintaining a Tight Seal around the mask which is crucial for delivering adequate ventilation additionally ventilating a trauma patient is a two-person skill allowing one rescuer to provide effective ventilation while the other maintains the mass position and ensures proper head alignment this teamwork enhances the overall efficacy of the ventilation process improving patient outcomes.",
        "Cardiopulmonary Arrest and Shock in Children": "cardiopulmonary arrest in pediatric patients is most often associated with respiratory failure and arrest as children become hypoxic their heart rates may slow leading to brto cardia and eventually pea the overall survival rate from cardiac arrest in the prehospital setting for children is low and many survivors may experience permanent brain injury as a result of the arrest to mitigate the risk of progressing to Cardiac Arrest ventilate with high concentrations of oxygen early in the course of treatment shock develops when the circulatory system is unable to deliver a sufficient amount of blood to the body potentially leading to pediatric cardiac arrest early recognition and prompt intervention are crucial as they can prevent permanent disability or death children are capable of compensating for shock for longer periods than adults primarily due to their ability to undergo Vaso constriction however hypotension can occur quickly and unpredictably in pediatric patients which may result in Rapid deterioration to cardiopulmonary rest common causes of shock in pediatric patients include hypovolemia sepsis allergic reactions and poisonings with shock resulting from a primary cardiac event being rare loss of greater than 25% of blood volume significantly increases the risk of developing shock signs of shock typically include teoc cardia poor capillary re refill time and changes in mental status treatment should begin by assessing the ABCs intervening immediately as required if cardiac aress is suspected the assessment order shifts to cab it's important to note that patients may not demonstrate a decrease in blood pressure until shock has reached a severe State underscoring the need for Vigilant monitoring and early intervention in assessing circulation during a shock evaluation it's important to pay particular attention to key indicators first evaluate the pulse a rate exceeding 160 beats per minute suggests shock skin signs capillary refill time and overall color are also factors to consider changes in pulse rate skin color and capillary refill time provide important Clues indicating the presence shock measuring blood pressure in pediatric patients can be challenging as it requires using a cuff that's the proper size ideally 2/3 the length of the upper arm normal blood pressure values are age specific and it's important to remember that blood pressure May remain normal in compensated shock that being said low blood pressure is a clear sign of decompensated shock indicating a more critical State requiring IM immediate intervention when assessing a child in shock the provider should determine when signs and symptoms first appeared and whether any of the following has occurred a decrease in urine output absence of Tears even when the child is crying a sunken or depressed fontel or changes in level of Consciousness and behavior time should not be wasted performing extensive field procedures in instead limit management to the following critical actions ensuring the airway is open and preparing for artificial ventilation if necessary the control of any bleeding providing supplemental oxygen and continuously monitoring the airway and breathing position the patient in a position of comfort as dictated by local protocol and keep them warm to help maintain body temperature unless you absolutely need to time can consuming procedures should be performed in route to the hospital to ensure that prompt and efficient care is provided without delaying transport as discussed earlier anaphylactic shock is a severe and potentially lifethreatening reaction characterized by generalized multi-stem response to an antigen common triggers include insect stings medications and certain foods this type of shock requires immediate recognition and intervention as it can rapidly progress to respiratory failure and cardiovascular collapse the early administration of epinephrine is the current standard of care in managing anaphylaxis and mitigating its effects signs and symptoms include obvious hypo profusion along with Airway involvement either upper or lower patients May exhibit an increased work of breathing and an altered appearance often displaying restlessness agitation and sometimes a sense of impending doom additionally hives could be present mainly on the trunk or globally indicating a skin response to the allergic reaction the treatment of anaphylactic shock involves several steps first maintain the airway and administer oxygen to ensure adequate ventilation in stable patients allow the parent or caregiver to assist with positioning the patient delivering oxygen and keeping the patient calm as this can help reduce anxiety if available and accorded to local protocol assists with the use of an epinephrine auto injector prompt transport to a medical facility is essential epinephrine should be administered subcutaneously or via an Auto ejector to counteract the allergic reaction additionally obtain IV or IO access and administer 20 MLS per kg of an isotonic crystalloid solution to help maintain profusion it's also important to call early for paramedic backup to facilitate timely Advanced Care.",
        "Bleeding Disorders and Vascular Access": "bleeding disorders such as hemophilia are congenital conditions characterized by a deficiency in one or more normal clotting factors in the blood this condition is hereditary and is predominantly found in males because all injuries in individuals with hemophilia are potentially serious these patients should be transported immediately to a medical facility for evaluation and treatment in cases of life-threatening Hemorrhage don't delay the application of a tourniquet as prompt action is necessary to control severe bleeding in and prevent complications IV access is performed less frequently in children compared to adults however the techniques indications and contraindications remain the same the same IV Solutions and equipment used for adults can also be applied in pediatric cases when establishing IV access in children it's vital to ensure proper technique and to carefully assess the patient condition as these patients may have different responses to IV Therapy compared to adults When selecting catheters for Pediatric patients 20 22 24 and 26 gauge catheters are generally the most suitable for insertion butterfly catheters can also be beneficial as they can be placed in the same locations as over the needle catheters and are particularly useful for assessing visible scalp veins and INF however we should note that butterfly catheters have a higher rate of infiltration compared to other types so careful monitoring is necessary to ensure proper placement and function when administering IV fluids to Pediatric patients providers should keep in mind that fluid control is necessary to ensure accurate delivery A specialized micro drip set known as a volu troll or bu trol is often recommended for this purpose as it allows for precise fluid management If a volue troll is not available a regular micr drip Administration set can be used effectively proper selection and use of these Administration sets help prevent fluid overload and ensure the safe administration of IV therapy and children when establishing IV access from Pediatric patients hand veins are commonly chosen as the location of starting at the peripheral IV despite being painful and difficult to manage in younger children once the IV site has been established it's important to protect it to prevent accidental dislodgment or infiltration using a pin light can help illuminate the veins on the back of the hand making them easier to visualize and access in some cases an anti the cubicle vein may still be the best choice for IV insertion especially if the hand veins are not suitable or simply not accessible IO access is utilized for emergency vascular access when immediate IV access is difficult or impossible when placed correctly the io needle rests in the medullary Canal allowing for Effective fluid and medication administration IO access should be attempted if IV access cannot be obtained within three attempts or 90 seconds in a critically ill or injured pediatric patient as permitted by local protocol often these children are in life-threatening situations making timely ineffective access critical for their survival and treatment IO infusion is contraindicated if a secure IV line is already available or if there's a possible fracture in the bone where the io needle is to be inserted the needle is typically inserted in the proxil malul tibia and various products such as the fast one easy IO and Bone injection gun or big can be used for this procedure the most commonly used IO catheter is the jam sheety needle which features a double needle design a solid board needle inside a sharp sharpened Hollow needle this is pushed into the bone using a screwing and twisting action once the needle penetrates the bone the solid needle is removed leaving the hollow steel needle in place to which standard IV tubing is in attached anything that can be administered intravenously can also be delivered through the io line these lines should be fully and carefully stabilized similar to how one would stabilize an impaled object potential complications of IO access include several serious conditions compartment syndrome can occur due to increased pressure within the muscle compartment potentially compromising blood flow there's also risk of failed infusion where fluids or medications do not adequately enter the circulation additionally IO access can lead to growth plate injuries particularly in pediatric patients which may affect bone development osteitis an infection of the bone and skin infections are also possible complications finally there's a risk of causing a bony fracture during the insertion of the io needle careful technique and monitoring are essential to minimize these risks and ensure patient safety food resuscitation is a component of managing pediatric patients in shock or those requiring intervenous therapy appropriate fluid administration ensures adequate profusion and supports the patient clinical condition IV fluids must be administered based on the specific clinical circumstances taking into account factors such as the patients age weight and underlying health issues however caution is necessary as administering too much fluid can lead to overload potentially resulting in complications such as pulmonary edema or heart failure careful monitoring and adjustment of fluid volumes are vital to achieve optimal outcomes if the fluid volume is insufficient it will be ineffective in treating the child's condition emphasizing the importance of accurate fluid management for hypovolemic shock fluid resuscitation typically begins with an initial bolus of 20 ml per kg of an isotonic crystalloid solution after this initial Administration careful reassessment is needed to evaluate the child's response and adjust a treatment plan accordingly monitoring Vital Signs capillary refill and mental status helps to ensure that the resuscitation efforts are effectively addressing the child's needs.",
        "Altered Mental Status and Seizures": "altered mental status in pediatric patients can arise from several common causes including hypoglycemia hypoxia seizures and drug or alcohol ingestion each of these factors can significantly impact neurological function and overall well-being prompt identification and management of the underlying calls are essential to stabilize the patient and prevent further complications recognizing the signs and symptoms associated with each cause can facilitate timely intervention and appropriate care altered mentation in pediatric patients may be exhibited in various ways including a lack of response to vocal commands and pain combed Behavior confusion thrashing about drifting in and out of an altered state and changes in the pitch and nature of the cry to help remember the major causes of alter mental status the memonic aeiou tips can be used this memonic encapsulates important factors to consider when assessing a patient facilitating a comprehensive evaluation and timely intervention to address the underlying issues contributing to the altered mental state signs and symptoms of altered mental status can vary widely ranging from simple confusion to Coma management focuses on the ABCs impr prompt transport to a medical facility if the child's level of Consciousness is low they may be unable to protect their Airway necessitating immediate action to ensure patent Airway and adequate breathing providers should assess and secure the airway while providing necessary support followed by transporting the patient to a hospital for further evaluation and treatment seizures in pediatric patients can arise from a variety of common causes including child abuse electrolyte imbalances fever hypoglycemia infections ingestion of substances hypoxia medications poisoning indwelling seizure disorders recreational drug use head trauma and idiopathic factors identifying the underlying cause of a seizure is crucial for Effective management and treatment prompt evaluation and intervention ition can help mitigate potential complications and provide appropriate care for the child who's experiencing a seizure seizures can manifest in various ways depending on the age of the child in infants seizures can be very subtle often presenting with minor twitching or changes in behavior that may go unnoticed in older children seizures are generally more obvious and typically consist of repetitive muscle contractions loss of awareness and unresponsiveness once the seizure stops the patient muscles typically relax and breathing may become labored entering a phase known as the postal State the duration and intensity of the seizure influence the length of postictal unresponsiveness and confusion the longer and more intense the seizure the longer the postictal state may last the post IAL state is considered over when the Pediatric patient regains a normal level of responsiveness seizures that occur every few minutes without regaining responsiveness or last longer than 30 minutes are classified as status epilepticus such recurring or prolonged seizures should be considered life-threatening and requiring immediate intervention in order to prevent severe complications such as hypoxia brain injury or death initial management focuses on securing the airway providing oxygen and ensuring adequate circulation IV access should be established as soon as possible to administer firstline medications like benzodiazapines which aim to Halt the seizure activity quickly continuous monitoring of Vital Signs especially oxygen saturation and heart rate are critical in order to detect any signs of respiratory compromise or hemodynamic instability the general management of seizures focuses on securing and protecting the airway as a top priority Begin by positioning the child's head to open the airway effectively clear the mouth using suction to remove any secretions or obstructions If the child is vomiting and suctioning is inadequate consider placing them in the recovery position to prevent aspiration additionally provide 100% oxygen to ensure adequate oxygenation during and after the seizure this approach helps stabilize the patient and minimizes the risk of respiratory complications remember if the patient is seizing they are not breathing and we need to be prepared to provide artificial ventilation should the need arise if febr seizures are caused by an Abrupt rise in body temperature with most pediatric seizures resulting from fever alone these seizures typically occur on the first day of a febr illness and are characterized by generalized tonic clonic seizure activity they usually last less than 15 minutes and may have a short or negligible post-ictal State while FBR seizures are generally benign they may indicate a more serious underlying problem such as menitis it's important to determine if the patient has a history of past feal seizures as this information can help guide assessment in management management of FBR seizures involves several key steps first assess the ABCs to ensure the patient stability Implement cooling measures using tepid water to help reduce body temperature prompt transport to a medical facility is essential for further evaluation and Care additionally establish IV or IO access as needed and obtain a blood glucose reading to rule out hypoglycemia If the child is found to be hypoglycemic administer glucose to address this condition.",
        "Meningitis and Gastrointestinal Emergencies": "menitis is characterized by inflammation of the meninges the protective membranes covering the brain and spinal cord this condition can be caused by infections from bacteria viruses fungi or even parasites if left untreated menitis can lead to severe complications including permanent brain damage or death certain populations are at a greater risk for developing menitis these include males newborn infants and geriatric patients individuals with the prior history of menitis are also at an increased risk as are those living in crowded conditions additionally children who have not received proper immunizations and individuals with compromised immune systems are more susceptible a history of head trauma or brain surgery further elevates the risk as do those with shunts pins or other F bodies within their brain brain or spinal cord the signs and symptoms of menitis can vary based on the patient's age common symptoms across all age groups include fever headache and altered levels of consciousness in infants younger than 2 to 3 months additional signs may include apnea cyanosis Fever A distinct high-pitch cry or hypo Thia menial irritation or menial signs are particularly important indicators these include nucal rigidity where bending the neck forward or backward causes significant pain as well as a characteristic stiff neck patients may even refuse to move their neck lift their legs or curl into a C position and infants increasing irritability and a bulging font nil without crying can also indicate menitis neria menitis is known for causing a rapid onset of menitis symptoms which can quickly lead to shock and death in affected children small pinpoint cherry red spots or larger purple or black rashes may appear on the face or body indicating a severe and potentially life-threatening condition all patients with possible menitis should be considered highly contagious and infectious standard precautions must be followed to protect Health Care Providers and others it's also important to follow up with the hospital to learn the patient's final diagnosis if there has been exposure to saliva or respiratory secretions from a patient with suspected menitis appropriate prophylactic antibiotics should be administered to mitigate the risk of infection the treatment of menitis involves several critical steps first provide supplemental oxygen to ensure adequate oxygenation if necessary assist with ventilations to support the patient's breathing frequent reassessment of Vital Signs is essential to monitor the patient's condition if if vitals are unstable obtain vascular access and administer IV fluids to maintain profusion and address any potential shock in gastrointestinal emergencies signs and symptoms can often be vague making it difficult for patients to pinpoint the exact location of pain or discomfort a significant amount of bleeding may occur within the abdominal cavity without outward signs of shock complicating the clinical picture liver and splin injuries are common and can result in life-threatening emergencies so providers must monitor for signs and symptoms of shock continuously a common source of GI upset in pediatric patients is the ingestion of certain foods which may lead to abdominal discomfort accompanied by nausea vomiting and or diarrhea appendicitis is a serious condition that if left untreated can lead to peritonitis or shock it typically presents with fever and localized pain upon palpation of the right lower abdominal quadrant when performing a physical diagnostic exam for appendicitis the primary focus is to assess for signs of localized inflammation and Partin Neal irritation especially in the right lower quadrant of the abdomen start by taking a thorough history of the patient symptoms with attention to the progression of pain often pain begins as diffuse per umbilical discomfort that migrates to the right lower quadrant over time this corresponds to the location of the inflamed appendix ask the patient about Associated symptoms such as fever nausea vomiting or anorexia which are commonly seen in appendicitis during the physical exam begin with light palpation across all quadrants of the abdomen noting areas of tenderness palpation of the right lower quadrant often elicits pain particularly at MC Bernie's Point located onethird of the distance from the anterior superior iliac spine to the umbilicus rebound tenderness is a key sign of perianal irritation after pressing down gently on the right lower quadrant and then quickly releasing an increase in pain upon release rather than during palpation suggests perianal inflammation additionally assess for other signs like the rosing sign which is pain in the right lower quadrant upon palpation of the left lower quadrant as well as so's sign which which is pain with passive extension of the right hip and abator sign which is pain with internal rotation of the flexed right hip which may indicate an inflamed appendix in contact with adjacent structures given the potential for serious complications such as peritonitis or septic shock if appendicitis progresses untreated rapid identification and prompt transport to the hospital are required once in the hospital further diagnostic testing such as ultrasounds or CT scans as well as a surgical consultation will be needed for definitive management typically via appendectomy when assessing a pediatric patient with GI concerns it's important to obtain a thorough history from the parent or primary caregiver key questions include how how many wet diapers has the child had today is the child tolerating liquids and are they able to keep them down how many times has a child experienced diarrhea and for how long additionally inquire if tears are present when the child cries as this can provide insight into hydration status and overall well-being.",
        "Poisoning and Dehydration": "poisoning is a common concern among children and can occur through various routes including ingestion inhaling injecting or absorbing a toxic substance each mode of exposure can lead to different clinical presentations and requires prompt recognition and intervention understanding the potential sources and routes of poisoning is essential for Effective assessment and management common sources of poisoning in children include alcohol aspirin acetaminophen household cleaning products house plants iron prescription medications illicit drugs and vitamins the signs and symptoms of poisoning can vary widely based on the specific substance involved as well as the age and weight of the child in cases of poisoning the patient may initially appear normal or they may exhibit signs of confusion sleep sleepiness or unresponsiveness poisoning can result from being fed a harmful substance which may occur in situations of child abuse additionally children may be exposed to drugs and poisons in various ways harmful substances left on Floors pose a significant risk and exposure can occur in rooms or automobiles where harmful in illicit drugs are smoked however children's Natural Curiosity can lead them to ingest poisons they find in the Homer garage after completing the primary survey and addressing any immediate life threats it's important to gather further information about the poisoning incident by asking the following questions what is the substance or substances involved approximately how much of the substance was ingested or involved in the exposure what time did the incident occur has the child vomited additionally inquire about the child's weight as this can affect treatment decisions are there any changes in Behavior or level of Consciousness finally ask whether there was any choking or coughing after the exposure in the treatment of poisoning the first step is to perform external decontamination this includes removing any tablets or fragments from the patient's mouth and washing or brushing any poison off of the skin next we assess and maintain the ABCs to ensure the patient's stability If the child demonstrates signs and symptoms of shock position them toine keep them warm and transport promply to a medical facility for further evaluation and management in some cases activated charcoal may be administered provided it was approved by medical control or local protocol however it is not indicated for patients who have ingested an acid Alkali or petroleum product additionally activated charcoal is not recommended for patients with a decreased level of Consciousness who cannot protect their Airway are those who were unable to swallow the usual dose for a child is 0.5 to1 G of activated charcoal per kilogram of body weight dehydration occurs when fluid losses exceed fluid intake with vomiting and diarrhea being the most common causes if left untreated dehydration can progress to shock and ultimately lead to death infants and children are at a greater risk for dehydration than adults due to their smaller fluid reserves the severity of dehydration can range from mild to moderate to severe here young children can compensate for dehydration by decreasing blood flow to the extremities and redirecting it to vital organs which can mask the severity of their condition the treatment of dehydration begins with assessing the ABCs and obtaining Baseline vital signs to evaluate the patient's condition if signs of dehydration are moderate to severe prompt transport to a medical facility is necessary for further evaluation and management for Pediatric patients suffering from severe dehydration the standard fluid Bolis dose is 20 MLS per kg of isotonic crystalloid solution such as normal saline or lactated ringers this bolus is typically administered over 15 to 30 minutes depending on the severity of the patient's condition in cases of severe hypovolemic shock or lifethreatening dehydration more rapid Administration may be required and additional boluses of 20 MLS per kg can be given until there is clinical Improvement it is important to reassess the patient after each bolus to evaluate the response to treatment and to avoid fluid overload especially in children with conditions such as cardiac dysfunction for neonates or infants the same general dosing guideline of 10 to 20 MLS per kg is used but clinicians May opt to start with smaller increments especially in the very young or in patients with potential underlying cardiac concerns the goal is to restore profusion and correct hypovolemia while closely monitoring Vital Signs and clinical status.",
        "Fever and Hypoglycemia": "fever is a common reason caregivers call 911 often arising from an increase in body temperature in response to an infection temperatures of 100.1 de fah or higher are generally considered abnormal while fever itself is rarely life-threatening it can indicate an underlying condition that requires further evaluation and management common causes of fever in pediatric patients include infections status epilepticus neoplasms or cancer drug ingestion collagen vascular diseases including arthritis and systemic lupus and high environmental temperatures it's important to distinguish between fever and hypothermia which is an increase in body temp due to the body's inability to cool itself which would typically be observed in warm environments obtaining an accurate body temperature is critical in assessing fever in pediatric patients for infants and toddlers a rectal temperature is considered the most accurate method in older children taking their temperature under the tongue or in the armpit is appropriate as they are generally able to follow directions for proper thermometer placement fever can have various causes and it's important to recognize Associated signs and symptoms these may include respiratory distress shock a stiff neck rash skin that feels hot to the touch flush cheeks seizures sensitivity to light and bulging font naels and infants additionally it's essential to assess for other signs and symptoms such as nausea vomiting diarrhea decreased feedings and headache in cases of fever with concerning signs and symptoms it's important to provide transport and manage the patients's ABCs unless the fever is associated with shock or severe dehydration IV therapy is generally not necessary hypoglycemia is characterized by an abnormally low blood glucose level and is considered a life-threatening emergency that requires immediate treatment infants and children have limited stores of glucose which can be rapidly depleted due to illness injury or stress if hypoglycemia goes unrecognized or even if treatment is delayed it can lead to permanent brain damage or death the signs and symptoms of hypoglycemia often include hunger malaise tacac cardia tnea diaphoresis and Tremors the severity of hypoglycemia depends on how low the blood glucose level has dropped therefore the provider should obtain a blood glucose reading in a child suspected of being hypoglycemic this measurement will help confirm the diagnosis and guide appropriate treatment ensuring that the patient glucose levels are restored to a safe range in children with a known history of diabetes it's important to ask specific questions to gather relevant information inquire whether they have taken their insulin today and if so what the dosage was ask if their medication regimen has recently changed as this can impact blood glucose levels additionally find out when they last ate and what they consumed as food intake is critical in managing blood sugar lastly ask if they've been playing outside or otherwise exerting themselves as increased physical activity can affect glucose levels in cases of hypoglycemia administer 100% oxygen or provide assisted ventilation if needed to ensure adequate oxygenation it's important to monitor Vital Signs closely throughout the process to assess the child's stability If the child is responsive and alert enough to swallow administer oral glucose in a accordance with local protocol If the child has an altered mental status or is incapable of swallowing IV glucose should be administered for children aged one year and older the recommended dose is 0.5 to 1 G per kg of d25 given via slow IV or IO push for infants and neonates administer 200 to 500 mill gr per kg via slow IV or IO push d10 may be given as an alternative to d25 and many EMS Services now prefer it if an IV cannot be established IO needles can be inserted if both IV and IO vascular access are unavailable medical control May order the administration of 1 mgram of glucagon via IM injection after administering glucose repeat a blood glucose reading 5 to 10 minutes later if the patient remains symptomatic and the blood glucose reading is still below 80 repeat the glucose Administration as needed to restore normal levels if we cannot get the patient's bgl up above 80 the patient should be transported to the closest facility for further evaluation and treatment hypoglycemia in pediatric patients can present as a new onset condition in those developing diabetes militis or is a complication in children with a known history of diabetes if hypoglycemia is not recognized or treated in a timely manner it can lead to severe dehydration and diabetic keto acidosis both conditions are medical emergencies that require immediate intervention to prevent further deterioration and potential life-threatening outcomes identifying early signs of hypoglycemia such as polydipsia polyurea and polyphasia as well as fatigue are critical to prevent the progression to severe complication in cases of pediatric hypoglycemia it's common to find that a dose of insulin was missed the child consumed a larger amount of food compared to the insulin administered or there was a malfunction with an insulin pump the signs and symptoms of hypoglycemia vary depending on the level of blood glucose when assessing a patient it's important to ask the same questions you would of suspected hypoglycemia such as recent insulin Administration fluid intake and any changes in activity level this helps to clarify the the underlying cause and got appropriate Management in managing a patient with hypoglycemia the first step is to ensure adequate oxygenation by administering 100% oxygen or providing assisted ventilation if necessary close monitoring of Vital Signs is essential to track the patient status establish IV access and administer fluid boluses of 20 MLS per kg of normal saline or lactated ringer solution as needed particularly since children with hypoglycemia and dka are often severely dehydrated early and aggressive fluid resuscitation helps to restore circulating volume and support profusion while other definitive treatments are arranged when managing hypoglycemia in a pediatric patient it's essential to closely monitor the ab BCS throughout treatment immediate transport to an appropriate facility is necessary for further care if IV access cannot be obtained an IO should be inserted to ensure fluid administration additionally if the patient's respiratory status worsens call for paramedic backup in order to provide Advanced respiratory support and other necessary interventions.",
        "Drowning and Trauma": "drowning is the leading cause of unintentional death among children aged 1 to 4 in the United States while many drowning incidents occur when children fall into swimming pools or lakes it is important to recognize that drownings also happen in bathtubs and even buckets of water especially in very young children among adolescence alcohol is frequently a contributing factor in drowning incidents as it impairs judgment and physical ability the primary cause of injury and drowning incidence is a lack of oxygen leading to hypoxia in cases of submersion in icy water hypothermia can also occur which complicates the patient's condition additionally diving into water poses a significant risk for",
        "Signs and Symptoms of Drowning": "the signs and symptoms of drowning will vary depending on the type and duration of submersion common symptoms include coughing choking Airway obstruction and difficulty breathing patients may also present with altered mentation or exhibit seizure activity in more severe cases the patient may be un responsive with either a fast slow or absent pulse Additionally the skin may appear pale or cyanotic due to hypoxia and abdominal distension may be observed due to water ingestion",
        "Initial Management of Drowning Emergencies": "when managing a drowning emergency the first priority is ensuring your own safety during the rescue once the patient is out of the water immediately assess and manage the airway breathing and circulation if Advanced interventions are necessary contact a paramedic crew for additional support administer 100% oxygen using a non-ar breathing mask or a BVM if assisted ventilations are needed to ensure adequate oxygenation and to support respiratory function",
        "Trauma Considerations in Drowning Patients": "in managing a drowning patient always be prepared to apply suction to clear the airway of water or debris if trauma is suspected such as from a fall or diving incident apply a cervical collar and carefully place the patient on a backboard ensure that all Open Spaces under the patient are padded before securing them to the board to minimize movement and prevent further injury if the patient is unresponsive responsive and in cardiopulmonary arrest immediately begins CPR to restore circulation and oxygenation",
        "Leading Causes of Pediatric Trauma": "trauma is a leading cause of death among children in the United States infants and toddlers are most frequently injured due to unintentional Suffocation drowning Falls or abuse for children age five and older motor vehicle crashes including incidents involving bicycles and pedestrians represent the most significant threat to their safety other common causes of traumatic injury and death in pediatric patients include Falls gunshot wounds blunt force injuries and injuries sustained during sports activities",
        "Psychological and Developmental Factors in Pediatric Trauma": "psychologically children are less mature than adults which impacts their ability to assess risks and make safe decisions this underdeveloped judgment combined with a lack of experience often contributes to their involvement in accidents and injuries these psychological differences must be taken into account when assessing pediatric trauma as children may not fully understand the severity of their injuries or be able to communicate their symptoms effectively this also underscores the importance of close supervision in tailored injury prevention strategies for children",
        "Anatomical Differences in Pediatric Trauma": "in pediatric trauma the location of injuries often differs from those seen in adults for the same type of accident due to physical differences children's bones and soft tissues are less developed meaning that the force of an injury affects their bodies differently a child's head is proportionately larger than an adults which places more stress on the neck structures during de acceleration injury such as in a motor vehicle crash because of this it's especially important to carefully assess for head and neck injuries in pediatric patients as they are more vulnerable to trauma in these areas these anatomical differences must be considered when evaluating and managing pediatric trauma"
    },
    {
        "Introduction": "professionals must remain cognizant that pediatric patients should not be regarded as miniature versions of adults the inherent dissimilarities extend beyond mere size encompassing distinctive physiological responses anatomical structures and psychosocial considerations regarding these differences is imperative for delivering effective care tailored to the specific needs of pediatric patients physiologically children undergo continuous developmental changes affecting Vital Signs and responses to interventions anatomically the size and placement of organs differ significantly influencing how diseases manifest and are treated moreover the psychosocial aspects including communication and emotional considerations demand a specialized approach when caring for these patients the vulnerability of children to pathologies distinct from those seen in adults underscores the importance of recognizing and addressing pediatric specific medical issues the unique physiology and anatomy of children contribute to an array of conditions that necessitate tailored interventions providers must be attuned to these nuances to effectively manage the specific challenges presented by pediatric patients ensuring appropriate And Timely care the ability of the provider to discern subtle hints of decompensation in pediatric patients is Paramount for their safe transport and treatment given the potential rapidity for which the Pediatric patient can deteriorate recognizing early signs of decompensation becomes crucial for initiating timely interventions the subtleties in symptoms may require heightened observational skills making the provider's vigilance and adaptability indispensable in ensuring the well-being of pediatric patients during Critical Care",
        "Anatomy and Physiology": "transport anatomy and physiology the basic anatomy of the circulatory system in pediatric patients mirrors that of adults yet differences in its function and response necessitate a tailored approach for critical care transport professionals understanding that the structural foundations are similar provides a foundation of care but the recognition of age specific differences is noticeable vital signs a key indicator of cardiovascular health exhibit variation based on age and underlying conditions it is essential for providers to grasp these age related normal variations to accurately interpret pediatric patients physiological status during transport children employ distinct compensatory mechanisms in response to cardiovascular stressors setting them apart from adults these mechanisms are shaped by the ongoing developmental changes in the Pediatric population providers must be attuned to these unique adaptations such as heart rate and blood pressure responses which may differ significantly from their adult counterparts a comprehensive understanding of these distinctions enables the critical care transport professional to discern between normal variations and signs of potential cardiovascular compromise thus facilitating effective intervention and transport strategies for this patient population the respiratory system in pediatric patients exhibits significant physiological and anatomical distinctions from that of adults necessitating an understanding for critical care transport professionals firstly the central regulation of respirations in infants is characterized by immaturity leading to the potential manifestation of irregular respiratory patterns recognizing whether these patterns are within the spectrum of normal development or are indicative of pathology becomes key for providers in assessing and managing respiratory concerns in pediatric patients additionally anatomical differences further contribute to the unique respiratory challenges in children proportionally larger tongue in relation to the size of the mouth can pose difficulties particularly in Airway management Critical Care paramedics need to be Adept at addressing potential obstructions related to tongue size emphasizing the importance of a Vigilant approach in Airway assessment and intervention the smaller and less rigid lower Airways in children when compared to adults increase susceptibility to obstruction and collapse this characteristic not only amplifies the risk of Airway compromise but also augments the resistance to air flow providers must consider these anatomical nuances understanding that the smaller Airways in pediatric patients pose challenges in maintaining adequate respiratory function the respiratory system in pediatric patients presents distinct characteristics with the mucosa displaying less adherence to the Airways rendering more susceptible to edema development this increased propensity for edema underscores the critical need for vigilance among Critical Care transport professionals as it can contribute to Airway compromise and respiratory distress in pediatric patients additionally at Birth The Limited number of peripheral Airways poses a heightened risk for severe symptoms associated with lower airway diseases emphasizing the vulnerability of neonates to respiratory challenges furthermore the inability of children to effectively ventilate Airway distal to an obstruction places them at an elevated risk of adal acasis either complete or partial lung collapse necessitating prompt recognition and intervention during transport understanding the Pediatric neurologic system requires attention to key developmental mileston such as font nail closure the anterior font nail closing at 18 months and the posterior fontel closing at 2 months serve as vital indicators of neurologic maturation a normal fontel is characterized by a soft flat surface with a feeling of fullness reflecting appropriate cerebral spinal fluid pressure Critical Care transport professionals must be Adept at addressing font nails as a sunken or depressed font nail can signify volume loss commonly associated with dehydration in this age group the closure of the anterior font nail at 18 months marks a critical milestone in pediatric neurodevelopment notably children lack the compartmentalization of the brain seen in adults leaving minimal room for movement within the skull this anatomical distinction renders children more susceptible to brain injuries emphasizing the need for meticulous care and attention during Critical Care transport newborns particularly those delivered with forceps or vacuum assistance May exhibit sealo hematoma characterized by localized bleeding between the skull and the periostium while such hematomas typically resolve within 4 to 6 weeks they may be associated with linear skull fractures necessitating thorough assessment by Critical Care transport professionals additionally kaput Sedum a soft tissue swelling often present at birth usually resolves within 24 hours highlighting the transient and self-resolving nature of certain neurologic conditions in the neonatal period the mus UL skeletal system in children exhibits distinct characteristics that necessitate specific considerations during transport notably children have fewer calcified bones making their skeletal structure more pliable in response to kinetic forces children's bones tend to buckle rather than fracture reflecting more porous Natures providers must be attuned to these biomechanical differences to accurately assess and manage these injuries in this population furthermore a notable concern is the vulnerability of epical medial growth plates accounting for a significant proportion of fractures in children ligaments and children are robust and resilient to tensile forces contributing to the Rarity of dislocations however the Pediatric spine presents distinct vulnerabilities featuring incomplete osificante flexation and torsion forces are commonly observed in pediatric patients necessitating a heightened awareness of potential spine related complications the muscular skeletal characteristics of children present unique considerations for professionals the pliability of a child's thorax allows it to withand Greater kinetic forces without fracturing a factor that demands careful assessment in atic scenarios rib fractures while uncommon in children should raise suspicions of potential internal injuries particularly in small children where such fractures May indicate child abuse and necessitate thorough evaluation Additionally the Pediatric pelvis is more flexible than that of adults and neonates in particular may experience hip laxity putting them at risk of dislocation or subluxation physiologic disparities in the GI system of children elivate the risk of regurgitation and aspiration necessitating a focused approach during transport given that young children tend to eat frequently obtaining a thorough history of their recent oral intake becomes essential for critical care transport professionals this information is crucial not only for understanding the nutrition status of the child but also for anticipating potential challenges during interventions such as positive pressure ventilation or otal intubation both of which may elicit vomiting by being proactive in obtaining a comprehensive oral intake history providers can prepare and mitigate risks associated with regurgitation ensuring a more secure and effective transport of pediatric patients while minimizing the potential for complications related to aspiration the immaturity of liver function in pediatric patients leads to fewer glucose stores a consideration for providers managing the GI system this limited glycogen Reserve underscores the potential for quicker depletion of energy stores in children necessitating Vigilant monitoring of blood glucose levels during transport additionally the weakness of abdominal muscles in children increases the susceptibility to injuries involving internal organs providers must be cognizant of these vulnerabilities adopting a cautious approach to minimize the risk of trauma to abdominal structures the renal system in children exhibits distinct characteristics that demand careful consideration during transport notably children have a higher percentage of body water than adults rendering them more vulnerable to dehydration this heightened susceptibility is further compounded by their inability to concentrate urine as effectively as adults leading to increased fluid loss children may experience a higher rate of electrolyte loss due to elevated clearance rates of blood Ura nitrogen creatinine and electrolytes understanding these renal nuances is critical for providers as they monitor and manage pediatric patients moreover recognizing age specific urine output Norms is essential infants typically produce 2 MLS per K an hour children 1 ml per K an hour and adults 0.5 MLS per kg per hour this information guides assessments of renal function aiding providers in addressing potential imbalances and ensuring appropriate fluid management during transport Thermo regulation poses unique challenges in pediatric patients particularly in infants whose regulatory mechanisms are not fully developed rendering them susceptible to hypothermia the thinner skin an absence of subcutaneous layers of fat in infants contribute to increased heat loss moreover the inability to shiver and the propensity to lose heat through the head further accentuate their vulnerability to temperature fluctuations in children the high ratio of body surface area to mass in contrast to adults allows for Rapid heat dissipation while this characteristic IC proves advantageous in dissipating heat quickly it also exposes children to potential difficulties in extreme temperature conditions Critical Care transport professionals must be keenly attuned to these Thermo regulatory details implementing measures to maintain optimal body temperature during transport especially in infants who are more prone to heat loss and hypothermia children possess a higher metabolic rate than adults a characteristic with notable implications for providers infants in particular display a metabolic rate that is twice that of adult patients emphasizing the dynamic nature of their energy needs this heightened metabolic activity demands meticulous monitoring during transport as the rate of onset of hypercapnia and hypoxemia coupled with bradia is accelerated in this population the rapidity with which these metabolic imbalances can occur underscores the need for observation and prompt intervention by providers understanding the intricacies of pediatric metabolism is important enabling effective assessment and management of metabolic demands to ensure the delivery of appropriate care during transport infants and children face unique challenges regarding glucose requirements primarily stemming from decreased glycogen reserves in an immature liver that is not fully capable of stimulating glycogen stores this vulnerability predisposes pediatric patients to the development of hypoglycemia a risk further Amplified by secondary factors and the additional Str stress imposed by illness or injury the nature of pediatric hypoglycemia underscores the need for providers to tailor treatment regimens based on factors such as the patient's weight age and clinical status acknowledging these intricacies of glucose metabolism in this population allows for the effective management of their energy needs during transport ensuring timely interventions to prevent and address hypoglycemic episodes in this population with diminished glycogen reserves and heightened susceptibility to metabolic",
        "Growth and Development": "imbalances growth and development monitoring physical growth and development is integral during Critical Care transport as deviations from normal developmental Milestones can signal underlying illnesses family crisis or neurologic injuries in pediatric patients knowledge of a child's developmental level is important in order to guide safety considerations and to tailor communication approaches during transport providers must recognize that parents and caregivers serve as the primary sources of information regarding a child's typical reactions in normal circumstances they offer valuable insights into the child's behavior and their preferences effective communication with children lacking language skills involves Innovative techniques such as sign language observation of facial expressions or Simply Having the child respond through eye movements this approach allows for not only the physical well-being of the patient but also addresses their developmental needs and enhances communication strategies in order to foster a secure and supportive environment for both the patient and their caregivers understanding psychosocial growth and development is essential for care providers managing pediatric patients in infants the primary fear revolves around separation from their parents emphasizing the importance of maintaining a supportive and comforting environment during transport toddlers share a similar fear of Separation but also grapple with apprehensions about losing control emphasizing the need for reassurance and familiarity during transport preschoolers extend their fears to include not only loss of control and separation but also anxieties related to bodily injury School AG children like preschoolers Harbor concerns about bodily injury highlighting a consistent theme across these developmental stages recognizing and addressing these age specific fears is needed in order to foster a sense of security during transport facilitating effective communication and mitigating psychosocial distress in pediatric patients addressing the psychosocial aspects of growth and development in adolescence and teenagers is vital during transport the primary fears in this age group revolve around the potential loss of control or alterations to their physical appearance encouraging their active involvement and respecting their privacy become key strategies for fostering a positive experience adolescent tend to be more compliant when allowed to participate in decision-making processes providing them with a sense of autonomy and control it is extremely important to establish trust early and this is achieved through communication at I level using first names and explaining medical procedures using age appropriate language these practices not only enhance the Adolescent understanding but also contribute to a collaborative and",
        "Pediatric Assessment": "supportive environment during transport promoting a sense of agent and Trust in the healthcare process pediatric assessment the Pediatric assessment triangle or Pat serves as a tool for quickly and effectively assessing the overall condition of a pediatric patient comprising the child's appearance work of breathing and circulation the pat provides a rapid yet comprehensive snapshot of the child's physiological state to delve deeper into specific aspects of the assessment the tickles acronym further breaks down key indicators tone assesses muscle tone interactiveness gauges the child's level of alertness and engagement consolability evaluates the ease with which the child can be comforted look or gaze determines eye contact and responsiveness and speech or cry assesses vocalization patterns a pivotal component of the Pat is understanding the nature of the child's Airway sounds and recognizing signs of increased breathing effort important elements in evaluating respiratory function following the Pat the evaluation of cir circulation involves Vigilant observation for power modeling or cyanosis critical indicators that offer insights into the child's circulatory status subsequently a comprehensive primary assessment is essential to delve deeper into the child's physiological well-being this includes evaluating Airway patency respiratory rate and quality pulse rate and quality skin temperature capillary refill time blood pressure and neurologic Status the assessment of neurologic status involves forming a general impression and evaluating the child's level of Consciousness and pupilary reactions for young infants an assessment of the suck reflex and axial tone is key while older children's neurologic status is assessed by their ability to interact appropriately follow commands and respond to questions further more the flak or faces scale is employed to assess pain in all children ensuring a comprehensive evaluation that guides Critical Care transport Professionals in tailoring interventions and care strategies during transport based on the child's individual needs and condition parents and caregivers play a vital role in providing essential information about the child's medical history helping providers in formulating a comprehensive assessment it is imperative to obtain a baseline history before departure and for infants this includes perinatal details delivery history gestational age and gestational weight all that contribute to understanding potential underlying issues in the case of chronically ill or technologically dependent children with abnormal Vital Signs and physical exam findings parental reports become especially valuable in constructing a comprehensive medical picture additionally information about the scene and situation provides context offering insights into any potential environmental factors or events that may have precipitated the need for critical care transport collectively a thorough pediatric assessment triangle including a comprehensive history ensures a holistic approach to the care and transport of pediatric patients nearly all emergent medications are administered based on weight specific doses with certain medications having age restrictions this emphasizes the importance of accurate dosage calculations by Critical Care transport professionals a process that introduces an inherent risk of error the weight specific dosing underscores the need for precise and accurate calculations to ensure the delivery of optimal therapeutic effects while minimizing the risk of adverse reactions particularly for high alert medications like opioids Hein insulin and potassium chloride and additional layer of safety is incorporated through an independent recheck after Administration aiming to enhance medication safety and reduce the potential for dosage related complications during transport in pediatric medication delivery various methods are employed including IV push syringe pump or infusion pump each chosen based on the specific clinical scenario and patient requirements these modes of administration offer flexibility in delivering medications tailored to the child's needs during Critical Care transport when it comes to administering resuscitation medications the vascular access device emerges as the optimal choice this method ensures rapid and Direct Delivery facilitating prompt response to life-threatening situations the selection of the most appropriate delivery method is essential to ensure the efficient and safe administration of medications to Pediatric patients during transport this emphasizes the adaptability and precision required by Professionals in these therapeutic interventions the unique characteristics of the Pediatric Airway particularly in infants necessitate care careful consideration infants being obligatory nose breathers primarily respire through their nasal passages resorting to mouth breathing only when crying consequently nasal congestion in infants can lead to significant respiratory distress addressing this concern typically involves interventions such as irrigation with normal saline spray and suction using a bulb syringe a effectively clearing the nasal Airways additionally positioning the infant with the head elevated at a 30 to 45\u00b0 angle proves beneficial in maintaining nasal Airway patency in some cases the administration of oxygen via a nasal canula may be a viable method to support respiratory function and alleviate distress these considerations highlight the importance of recognizing and promptly managing nasal congestion in infants during transport children pose unique challenges in Airway management due to the proportionately large size of their tongues in relation to their mouths successful intubation in pediatric patients relies on the proper choice of blade size correct positioning and effective sweeping of the tongue recognizing the anterior position of the trachea is important and pediatric patients May further complicate Airway management with large tonsils and increased oral secretions the upper Airway in children is more susceptible to compression emphasizing the importance of strategic positioning placing a child in the sniffing position often achieved with the aid of towel rolls proves beneficial in aligning the airway structure for optimal intubation conditions these considerations underscore the Precision and adaptability required by providers when managing the Pediatric Airway ensuring successful interventions while minimizing the risk of complications associated with anatomical challenges in this patient population identification of upper Airway obstruction in children during transport is vital and can be indicated by observable signs such as teyia nasal flaring abnormal respiratory sounds and the use of accessory muscles characterized by retractions a child's deteriorating level of Consciousness May necessitate intubation especially when they can no longer protect their Airway understanding the order of loss of reflexes assists in assessing the severity of the situation first the swallowing reflex is compromised followed by coughing the gag reflex and eventually the corneal reflex which is also known as the blink reflex or eyelid reflex and is an involuntary blinking of the eyelids elicited by stimulation of the cornea although it could result from any peripheral stimulus early signs of respiratory distress often manifest as teyia and the use of accessory muscles indicating increased respiratory effort proper assessment of breathing requires exposing children to the primary evaluation a step in evaluating their work of breathing for infants and young children this assessment may reveal nasal flaring or pursed lips visible indicators of respiratory distress understanding the phenomenon of grunting is essential as it occurs when a child attempts to Exhale against a partially closed glotus creating a physiologic autop positive end expiratory pressure to stent open the distal Airways given that young infants are oblate nose breathers Critical Care transport professionals should also assess for a significant nasal mucous burden recognizing the potential impact on respiratory function and tailoring interventions accordingly during transport to ensure optimal respiratory support for our patient children grappling with breathing difficulties frequently adopt a tripod position characterized by the child sitting upright leaning forward and supporting themselves with their hands on their knees or other surface this posture AIDS in maximizing respiratory effort and minimizing the work of breathing to effectively assess the severity of respiratory distress providers employ various tools these include evaluating for signs such as Strider snoring restrictions head bobbing accessory muscle use tripoding nasal flaring wheezing and grunting each of these indicators offers valuable insights into the child's respiratory effort and potential Airway compromise guiding interventions during transport to ensure optimal support for Pediatric patients facing respiratory challenges the diaphragm is essential to the respiratory process especially considering that intercostal and accessory muscles are not fully developed until the child reaches about school age a critical concern arises if the diaphragm fails in young pediatric patients potentially leading to paradoxical breathing recognizing this distinctive pattern assists Professionals in promptly addressing respiratory compromise additionally as respiratory distress intensifies the respiratory rate may shift to a slower and more irregular Pace indicating the progression of respiratory compromise children's inherently High metabolic rate and oxygen demand underscore the importance of Swift and targeted interventions during transport to prevent the onset of hypoxia ensuring optimal respiratory support for this vulnerable population hemodynamic monitoring serves as an adjunct to clinical assessment during the evaluation of breathing this comprehensive approach ensures a thorough and Dynamic understanding of the child's respiratory status providers should seamlessly integrate data from hemodynamic monitoring with findings from the clinical assessment enhancing the accuracy of their evaluation the pat emerges as a valuable Dynamic tool for continuous re-evaluation of the child's level of Consciousness with a specific focus on appearance work of breathing and circulation additionally monitoring of respiratory rate pattern oxygen saturation levels and ECG way form is imperative for detecting any changes in heart rate or function oscilation Remains the primary tool for assessing the adequacy of a child's respiratory effort assessing the adequacy of breathing in pediatric patients involves employing measurements that offer valuable insights oxygen saturation as measured by pulsox symmetry serves as a fundamental parameter providing realtime information about the child's oxygenation status additionally entitled carbon dioxide values gauge ventilation Effectiveness these measurements rapidly assess the child's respiratory status and guides interventions during transport furthermore arterial blood gas analysis is a valuable tool for a more comprehensive evaluation offering detailed information about the child's ventilation and oxygenation efforts incorporating these measurements into the breathing assessment armamentarium during transport ensures a comprehensive understanding of the child's respiratory status and enables targeted interventions to optimize breathing adequacy in the dynamic trans support environment the child's General appearance and level of Consciousness are key indicators of profusion status a well profused child is typically alert and observant actively engaging with their surroundings and the provider can often visually discern the heartbeat through the skin observing for clubbing the broadening of fingers and toes in response to chronically low oxygen levels provides additional insights into the child's long-term oxygenation status when evaluating respiratory status it's imperative to include a thorough assessment of Vital Signs encompassing pulse rate and quality as well as blood pressure and capillary refill time these parameters collectively offer a comprehensive snapshot of the child's circulatory status which AIDS providers in rapidly identifying any deviations from the norm and guiding timely interventions during transport to optimize profusion as well as overall cardiovascular well-being in our pediatric patients in the assessment of Vital Signs Precision in oscilating cardiac sounds is Paramount for infants optimal heart sound detection involves placing the stethoscope over the second interc space at the midclavicular line This positioning allows for a focused and accurate evaluation of the infant's cardiac activity in contrast older children the fourth intercostal space becomes the preferred location for stethoscope placement the absence of abnormal sounds such as rubs murmurs gallops or secondary sounds is a critical aspect of the assessment for young infants palpating the heart rate involves identifying the brachial artery in the medial upper arm or the femoral artery reflecting the distinct anatomical features of this age group as children grow older the radial pulse becomes a more reliable indicator of heart rate blood pressure readings demand the use of age and size appropriate equipment to ensure accuracy the mean arterial pressure assumes significance in evaluating end organ profusion providing valuable insights into cardiovascular help map can be measured through an invasive arterial line for precise monitoring or via a non-invasive blood pressure monitor offering providers essential information to tailor interventions and optimize profusion during transport the determination of cardiac output in pediatric Critical Care transport as in adults hinges on the interplay between stroke volume and heart rate in children an increase in heart rate stands as the primary compensatory mechanism employed to enhance inorgan profusion and uphold blood pressure assessment of pulse rate becomes pivotal and for children older than one year thorough evaluation involves assessing the cored radial femoral and dorsalis Pettis arteries for infants younger than one year the brachial andoral arteries are the primary sites for pulse assessment in scenarios where the pulse cannot be palpated Doppler ultrasonography emerges as a useful tool providing a non-invasive means to assess vascular flow additionally point of care ultrasonography serves as another valuable method for evaluating cardiac function and volume status during Critical Care transport offering real-time insights that guide interventions to optimize cardiovascular well-being in pediatric patients the skin serves as a reliable indicator of circulation and can reveal the presence of hypo perfusion early compensatory mechanisms in response to decreased perfusion prioritize vital organs over peripheral tissues leading to blood shunting away from the skin consequently as hypo profusion intensifies the child's skin May exhibit signs such as coolness po modeling or cyanosis reflecting the systemic compromise of profusion capillary refill time which is an additional aspect of skin assessment proves valuable engaging peripheral profusion a prolonged capillary refill time May signify inadequate blood flow to the periphery blood pressure serves as a key indicator of circulatory Health initially children can maintain a seemingly normal blood pressure despite other indicators of shock as compensatory mechanisms work to uphold profusion however maintaining a normal blood pressure may be transient lasting only until compensatory mechanisms are depleted measuring blood pressure in children poses challenges often related to Cuff size making it important to ensure an appropriate fit to maintain accurate readings while while lower extremity measurements may be more accessible it is advisable to document both upper and lower extremity blood pressure values to ensure correlation considering the child's normal range and clinical condition external factors like pain fear and anxiety can influence a child's blood pressure emphasizing the need for context aware interpretation by Critical Care transport Professionals in some disease processes mean arterial pressure May provide a more comprehensive measure of end organ profusion obtainable through either invasive arterial lines or non-invasive blood pressure monitors guiding interventions to optimize cardiovascular well-being during transport in the context of pediatric Critical Care transport understanding fluid volume and ensuring appropriate access are fundamental aspects of managing circulatory compromise quantifying volume loss and calculating fluid placements requires an understanding of circulating blood volumes for children with an estimate of 80 MLS per kg of body weight being deemed appropriate conditions leading to fluid loss whether due to trauma or medical issues necessitate prompt IV access for volume replacement the utilization of IO access has become more prevalent especially in infants or children requiring immediate intervention the anterior tibia is the most common site for Io access typically achieved using a bone injection gun in cases of trauma with signs of refractory hemorrhagic shock initiating blood products after 40 MLS per kg of volume resuscitation is considered reasonable monitoring urine output serves as an objective guide in assessing pediatric circulatory status and evaluating the effectiveness of volume replacement during transport the neurologic assessment during pediatric Critical Care transport involves a comprehensive evaluation of the child's overall well-being and responsiveness providers should start by observing the child's General appearance gauging their level of alertness and engagement with the environment assess whether the child is responsive and awake indicating a healthy neurologic state or unresponsive and lethargic potentially signaling underlying issues providers should pay particular attention to font nail status as a sunken fontel may suggest dehydration providing a visual cue to the child's fluid balance infants typically exhibit normal muscle tone with flexed elbows and knees the presence of completely flaccid extremities is considered an abnormal finding and may signal underlying neurologic issues additionally reflexes such as the moro reflex which is characterized by infant response to a loud noise with a startle or jump and the stepping reflex where the infant moves the legs up and down when held in the air are observed monitoring these reflexes helps gauge the Integrity of the nervous system notably minimal movements especially in response to a noxious stimulus should raise concerns for potential neurologic impairment evaluating mental status involves Keen observation of age approach appropriate behaviors and thought processes the Glascow Coma Scale stands out as a highly effective tool for assessing mental status in children additionally checking the size of the child's pupils and their response to light provides valuable insights into neurologic function very constricted or pinpoint pupils May indicate an opioid overdose while a single dilated pupil is often consistent with brain injury in instances where a child presents with a decreased level of Consciousness the presence of protective reflexes becomes pivotal in determining the need for OT tral intubation in the assessment of renal function valuable information can be gleaned from parents or caregivers regarding the child's fluid intake wet diapers voids stools and vomiting frequency paying attention to changes in diapers becomes a pertinent indicator and caregivers can provide insights into potential issues by reporting alterations in diaper patterns a judicious approach involves weighing diapers to quantify fluid loss aiding in the assessment of hydration status the physical assessment may extend to font naels and infants skin turer and the presence or even absence of Tears while fluid overload is less common in children it may manifest in certain conditions like congenital heart defects or renal insufficiency considerations for exposure involve recognizing the vulnerability of infants to temperature fluctuations unlike adults infants lack the ability to shiver making them particularly SU susceptible to hypothermia therefore resuscitation efforts must prioritize maintaining an optimal body temperature care should be taken to avoid overwheling the patient striking a balance to prevent adverse effects the infant's disproportionately large head accentuates their susceptibility to temperature changes underscoring the need for attention to Thermal management to minimize heat loss during assessment a strategic approach involves replacing blankets only on areas that have been assessed ensuring that the child's overall body temperature is regulated effectively throughout the transport",
        "Transport Considerations": "process transport considerations ensuring the availability of suitable equipment is fundamental in the context of pediatric Critical Care transport historically there has been notable Divergence among agencies and states in defining the prerequisites for Pediatric specific equipment during transport a standard of care for intubated pediatric patients includes ECG monitoring complemented by pulse oxymetry and entitled capnography to accommodate the varying sizes of pediatric patient patients carrying an array of ECG leads pulse oximetry probes and blood pressure cuffs is essential this Diversified equipment inventory is vital for obtaining accurate and reliable Vital sign values facilitating the precise assessment of the child's physiological status and enables appropriate interventions during the transport administering IV fluids Demands a meticulous approach to ensure precision and safety employing an infusion pump calibrated for accurate infusions is imperative during IV fluid administration this ensures a controlled and regulated delivery preventing inadvertent errors in fluid management when administering fluid boluses and resuscitation medications utilizing a syringe and stop technique is recommended this method offers precise control over the rate and volume of fluid or medication delivered allowing for careful adjustments in response to the child's Dynamic physiological needs standardizing and calculating fluid and medication formulas before embarking on pediatric Critical Care transport is a fundamental practice to ensure Precision in therapeutic tic interventions this approach minimizes the risk of dosage errors and streamlines the administration process aligning with the principles of meticulous care Additionally the inclusion of equipment for therm regulation such as a disposable gel heated mattress or an incubator is essential in maintaining a stable temperature for Pediatric patients during transport being well-versed in the capabilities of the transport ventilator is equally important this includes understanding features like pressure modes of ventilation the ability to accommodate pediatric ventilator settings and the availability of pediatric circuits the exchange of pertinent information is fundamental for seamless and effective care critical details required by providers include the patient's age weight diagnosis and the reason for transfer equally important are comprehensive insights into the patient's physical exam findings along with lab and diagnostic test results knowledge of the patient's existing IV access status consent for transport and immediate recommendations further informs the transport plan upon arrival at the sending fac facility a thorough assessment is conducted to identify the necessity for any additional procedures before transfer effective communication tools such as the SAR meaning situation background assessment and recommendations format play a key role in standardizing information exchange ensuring Clarity and precision to enhance safety a predeparture safety checklist should be utilized enabling the team to evaluate potential threats and discussed concerns with both the referring and receiving Physicians which in turn Fosters a collaborative and comprehensive approach to Critical Care transport secure and appropriate restraint is a fundamental aspect for maintaining patient safety although there are no federally mandated standards for Pediatric safety equipment recommendations from the national highway traffic safety administration guide this critical aspect of care for younger children the use of a fivepoint restraint is advised providing a secure and comprehensive method of restraint older children aged over four years may be safely secured using standard stretcher straps in cases where a child requires resuscitation positioning them toine in ensuring a secure attachment to the stretcher is essential however if there is no immediate threat to physiological stability transporting the child in an upright secured position is a suitable approach however the patient should never be allowed to ride in the arms of a parent the presence of a parent or caregiver during transport does play a role in alleviating a child's anxiety and emotional stress while prioritizing the safe transport of the child it is important to carefully consider factors such as the Comfort level of the caregivers and the potential for any disruption in the provision of care during the journey seating arrangements for the parent or caregiver should be thoughtfully planned and clear guidelines need to be communicated and discussed before the transport begins as stated earlier it is imperative to establish that no child child should be held in a caregiver's lap during transport emphasizing the need for secure and designated seating arrangements ensuring the safety of both the child and accompanying adults throughout the transport process Airway management devices the flow initiating bag commonly employed for anesthesia purposes operates by necessitating an external gas source for inflation this apparatus is equipped with essential features including a pressure gauge port a flow Inlet dial and an overflow Port one notable characteristic of Flo inflating bags is their ability to provide positive end expiratory pressure even in the absence of ventilations when fully inflated this functionality enhances its utility in maintaining airway pressure During certain clinical scenarios as a routine tool for anesthesia the flo inflating bag demonstrates versatility in its application contributing to effective respiratory Management in a variety of medical contexts the self-inflating bag presents a ventilation method that Demands a higher level of expertise and Equipment manipulation to ensure effective ventilation due to its intricacies it is not recommended for use outside a hospital environment unless the health care professional has undergone extensive training unlike other ventilation devices the self-inflating bag doesn't rely on a compressed gas Source offering a degree of flexibility in various clinical settings one notable safety feature of self-inflating bags is the inclusion of a pressure release valve which serves to prevent excessive Airway pressures during ventilation this mechanism not only safeguards against potential complications but also addresses the specific concern of minimizing the risk of pneumothorax while ventilating pediatric patients emphasizing the importance of careful and skilled application in healthcare settings the oxygen Hood proves beneficial for Pediatric patients aged less than one year offering a specialized solution tailored to their size and needs however its utility diminishes for older children who cannot comfortably fit into the device due to size constraints one notable advantage of the oxygen hood is its capacity to concentrate oxygen levels to 80 or 90% providing a controlled and enriched oxygen environment Additionally the device facilitates the warming and humidification of air enhancing patient Comfort during respiratory support while not universally applicable across age groups the oxygen Hood remains a valuable tool in Pediatric Care particularly for infants enabling precise oxygen delivery and environmental adjustments to meet the spe specific respiratory requirements of this demographic blade options in Airway management offer distinct advantages for specific age groups without overstating their importance the Miller blade featuring a straight design proves optimal for infants and younger children its straight form facilitates a more straightforward insertion process in this particular age range on the other hand the Macintosh blade characterized by its curve shape emerges as a preferred choice for older children the curvature of the Macintosh blade is advantageous in displacing the tongue making it more effective for creating a clear visual field during intubation procedures in older pediatric patients uncuffed into trul tubes in pediatric Airway management are utilized within certain limitations while they may find applicability in specific scenarios the preference leans towards using appropriately sized cuffed ET tubes for children the use of cuffed tubes allows for better control over the airway and minimizes the risk of leakage enhancing the effectiveness of ventilation to ensure patient safety precautions are advised including securing the airway before departing from the referring site whenever feasible additionally considering alternative Airways and rescue devices such as a super glottic Airway device is recommended restricting Airway attempts to the most skilled and experienced provider further contributes to the overall safety and success of pediatric area management without overstating the significance of the tube type",
        "Respiratory Conditions": "chosen respiratory conditions respiratory distress is evident in the increased work of breathing marked by elevated respiratory rate and potentially increased depth clinical signs include nasal flaring retractions and the use of acccessory muscles conversely respiratory failure is characterized by inadequate oxygen intake or exchange and lacks a universally precise definition but does involve a critical compromise in respiratory function providers follow protocols to sustain a patent Airway and preserve hemodynamic stability in cases of respiratory failure upper Airway obstructions commonly caused by foreign body aspiration or infection impede air flow to the upper respiratory tract lower airway conditions impact structures like the trachea and bronchi affecting the conduits for air movement to and from the lungs peripheral Airway diseases such as asthma and bronchiolitis primarily affect smaller air passages contributing to respiratory distress and potentially progressing to respiratory failure without proper management croo is a prevalent viral upper Airway infection that predominantly affects the linic and may extend to the trachea and bronchi it is most frequently observed in children under 3 years old presenting with symptoms like a low-grade fever and a distinctive barking seal cough effective management begins with creating a calm environment followed by the administration of humidified oxygen depending on the severity of symptoms therapeutic options may include reic epinephrine helox continuous positive airway pressure or by level positive airway pressure and systemic corticosteroids such as methyl prednizone in cases of severe obstruction the consideration of intubation may be warranted though this is an extremely rare occurrence on the other hand EPO titis is a bacterial infection primarily caused by hemophilus influenza and is typically prevalent in children aged 3 to 5 years manifesting with a rapid onset of fever Strider and pronounced signs of toxicity this condition poses a risk of acute and complete Airway obstruction in affected children given the potential severity of the airway compromise invasive procedures should be approached with caution and minimize to reduce the risk of exacerbating the condition timely recognition of symptoms and appropriate management strategies are essential in addressing epiglotis and ensuring the preservation of the compromised Airway the management of foreign body Airway obstruction involves adhering to established guidelines particularly those outlined by the American Heart Association and the American Academy of Pediatrics removal of a foreign body should be approached cautiously with specific techniques tailored to the age group for infants chest thrusts are recommended while abdominal thrusts are appropriate for older children in children under one year back blows are alternative the decision to proceed with direct visualization of the trachea and removal of the foreign body should be reserved for situations involving impending respiratory failure emphasizing the importance of careful evaluation and adherence to establish protocols to prevent potential complications inflammation within the upper Airway can manifest as a consequence of various factors including inhalation Burns or electric Andor anaphylactic reactions this General inflammatory response in the upper Airway has the potential to compromise the normal functioning of respiratory passages inhalation Burns often stemming from exposure to noxious substances can inflict damage and trigger an inflammatory process additionally allergic reactions or anaphylaxis May induce inflammation in the upper Airway contributing to Airway narrowing or obstruction recognizing and addressing the underlying causes of this inflammation is essential in providing effective care that mitigates the impact on respiratory function and ensures optimal patient outcomes bronchiolitis arising from viral infections predominantly attributed to the respiratory sync deal virus or RSV constitutes an inflammatory condition affecting the bronchioles in clinical presentation wheezing is a characteristic feature often accompanied by retractions noisy breathing and compromised feeding management strategies for bronchiolitis primarily revolve around supportive care including the provision of supplemental oxygen and intravenous fluids notably brocho dilators and steroids are generally not administered as routine interventions except in cases where there is a strong family history of asthma or atopy this cautious approach aligns with current guidelines emphasizing tailored treatment plans that considered individual patient factors and avoid unnecessary interventions in the absence of specific indications related to the patient Pati's clinical history asthma characterized by chronic inflammation of the lower Airways leading to Broncos spasm and edema encompasses a spectrum of triggers such as allergens exercise emotions infections or simply exposure to cold air reactive airway disease or rad a term often interchangeably used with asthma is particularly prevalent in children under 3 years with the potential to progress into full-fledged asthma transport requests for asthma related conditions typically indicate that conventional treatments have proven ineffective necessitating Advanced therapeutic interventions Gathering a comprehensive patient history from parents or caregivers is important when managing asthma cases during transport treatment strategies involve the use of oxygen therapy and bronchodilators to alleviate bronos spasm additionally anti-inflammatory medications like corticosteroids are commonly employed in conjunction with other therapeutic modalities to address the underlying inflammatory component of asthma pneumonia can manifest as a consequence of viral bacterial or mixed infections during transport attention to the patient's work of breathing and hydration status is needed in order to provide effective management the clinical approach involves a thorough assessment to monitor respiratory effort and ensure adequate hydration given the Infectious nature of pneumonia antibiotic therapy is a necessary component of of the treatment plan during transport by addressing both the Infectious etiology and the associated respiratory distress transport professionals aim to optimize the conditions for recovery and maintain stability throughout the patient's journey in the context of acute respiratory distress syndrome or ARS which is characterized by intrapulmonary shunting unresponsive to oxygen therapy management revolves around comprehensive supportive measures regardless of the underlying cause the focus is on providing necessary assistance to the compromised respiratory function mechanical ventilation plays a pivotal role in optimizing oxygenation with the inclusion of Peep to enhance alv Recruitment and maintain Airway patency simultaneously cardiovascular support is implemented to address the intricate interplay between respiratory and circulatory functions the management strategy is centered on mitigating the effects of intrapulmonary shunting and alleviating the burden on the respiratory system this holistic approach aims to stabilize the patient during transport recognizing the complex pathophysiology of ARs and tailoring interventions to address the unique challenges associated with this severe respiratory",
        "Mechanical Ventilation": "condition mechanical ventilation non-invasive mechanical ventilation specifically through the use of high flow nasal canulas offers a versatile respiratory support modality during transport high flow nasal canulas involve the administration of humidified oxygen at flow rates ranging from 2 to 60 L per minute this method ensures a broad spectrum of fraction of inspired oxygen levels spanning from 0.21 to1 while the hfnc provides a modest level of positive end expiratory pressure the extent of Peep is constrained and can vary based on the specific ventilator employed implementation of these devices during transport by Critical Care transport professionals is contingent upon factors such as the ventilator type available the oxygen supply on hand and the prescribed flow rate to optimize this technique providers can employ mathematical calculations to predict oxygen availability factoring in variables such as flow rate transport duration and the size of the oxygen tank this approach allows for Effective non-invasive ventilation contributing to respiratory support for patients during Transit CPAP stands as a foundational non-invasive respiratory strategy within the array of available interventions for children positioned as an intermediate measure for patients capable of maintaining in their Airway but necessitating substantial respiratory support CPAP exerts pressure to consistently stint open distal Airways this method is notably advantageous in cases of pneumonia asthma or reactive airway disease bronchitis and other conditions associated with distal Airway Collapse by providing sustained pressure CPAP helps to alleviate Airway obstruction ction ensuring effective ventilation and promoting improved respiratory function it's application especially in pediatric cases highlights its versatility as a valuable tool for managing a spectrum of respiratory pathologies during patient care and transport by Lev positive airway pressure or BiPAP featuring two distinct pressure levels offers an advanced tier of ventilatory support compared to CPAP it operates in tandem with the patient's respiratory efforts with a backup rate feature ensuring a minimum number of breaths per minute this Dynamic approach to pressure management allows for a more nuanced response to the intricacies of respiratory distress in the realm of non-invasive positive pressure ventilation nasal bypass app akin to its General counterpart incorporates a set respiratory rate this tailored application of BiPAP with its adjustable parameters demonstrates versatility in accommodating individual patient needs providing effective respiratory support and representing a valuable option for clinicians in the management of diverse respiratory conditions during patient care and transport skilled providers should be prepared to navigate the complexities associated with challenging Airways necessitating the use of rescue devices and medications to facilitate rapid sequence intubation once intubated providers must exhibit Proficiency in employing various ventilation strategies maintaining a Target title volume of 7 to 10 MLS per kg is recommended to mitigate the risk of hypoventilation and adal latices the initial Peak inspiratory pressure or pip should be carefully calibrated aiming for the lowest value that ensures adequate chest Excursion for most children a pip ranging from 20 to 30 cm of H2O is sufficient although those with underlying lung diseases May necessitate higher values such as 30 to 39 in instances where a pediatric patient requires a pip exceeding 40 cm of H2O providers might consider alternative mechanical ventilators to optimize patient care furthermore physiologic positive end expiratory pressure is crucial in maintaining adequate lung function for infants and children a recommended peep range of 3 to 5 cm of H2O is considered physiological that being said practitioners should be vigilant and if the patient requires peep values surpassing 10 cames of H2O it may prompt the exploration of alternative mechanical ventilator options the intricate calibration of these ventilation parameters is essential to tailor respiratory support to the specific needs of each pediatric patient ensuring optimal oxygenation and ventilation during transport as well as critical care scenarios the application of pressure support proves particularly beneficial for certain patient scenarios this mode is especially advantageous for individuals who exhibit an optimal response to mechanical ventilation when maintaining a spontaneous respiratory pattern or for those undergoing the process of weaning from mechanical ventilation pressure support AIDS in augmenting the patient's own efforts during breathing facilitating a smoother transition during the weaning process however in infants and children with severe lung disease an alternative approach may be deemed more suitable such as the utilization of an oscillator the oscillator functions by delivering smaller tidal volumes at rapid respiratory rates this approach is particularly well suited for patients with compromised Long Function where conventional ventilation methods might be less effective adjusting ventilator settings is a dynamic process influenced by the patient's respiratory needs and the underlying condition in pressure and volume cycled ventilation optimizing oxygenation involves modifying several parameters elevating the fraction of inspired oxygen or F2 inspiratory time and Peep collectively contribute to enhanced oxygenation likewise increasing pip and tidal volume while staying within the designated Target range further supports improved oxygenation the specific Strategies employed depend on the patient's initial respiratory rate reflecting the unique requirements in each case when considering ventilator setting changes the adjustment of the respiratory rate is a strategic maneuver to address specific respiratory parameters incrementing the respiratory rate can be a valuable approach to achieve the intended reduction in retained carbon dioxide however a critical consideration is ensuring an adequate expiratory phase duration to facilitate effective gas exchange it is noteworthy that escalating the respiratory rate Beyond a certain threshold does pose a challenge potentially leading to shortened expiratory times which could adverse impact ventilation in such instances providers might find alternative strategies more effective such as increasing the PIP or adjusting the title volume within the predefined target",
        "Cardiac Conditions": "range cardiac conditions the spectrum of pediatric cardiac conditions requiring transport is Broad encompassing various scenar scarios from hypohemia stemming from traumatic events to congenital anomalies like structural heart defects Critical Care transport professionals frequently encounter children falling into four distinct categories of heart rated issues during their care firstly patients may present with a known cardiac defect and the transport simply becomes a Continuum of managing their condition secondly providers might engage with cases involving unknown or suspected cyanotic defects which would necessitate specialized attention and monitoring thirdly cardiac arrhythmias present another facet demanding Vigilant assessment and intervention and then finally the realm of shock whether cardiogenic septic hemorrhagic neurogenic or anaphylactic it comprises a category where providers play a decisive role in stabilizing and transporting these critically ill pediatric patients children requiring surgery often present with ductal dependent lesions a condition where their survival hinges on the patency of the ductus arteriosis the critical factor in ensuring their well-being is early recognition of the issue prompt initiation of IB prostag glandon therapy and Swift transport to an appropriate medical facility in some instances congenital cardiac anomalies may not manifest until the neonate reaches one to two weeks of age during which the ducus arteriosis remains open facilitating the adequate mixing of oxygenated and deoxygenated blood the initial clinical presentation may include signs of ill appearance poar poor feeding Lethy and cyanosis however these symptoms can also overlap with conditions like sepsis trauma and inborn errors of metabolism potentially complicating the diagnostic process interpreting an ECG rhythm in pediatric patients requires a nuanced approach distinct from that applied to adults one key consideration is minimizing respiratory artifact and to achieve this it is advisable to avoid placing ECG leads at the level of the diaphragm instead strategic placement on the lower abdomen or thighs often proves effective while a 12 lead ECG is not as routine in pediatric cases it does become pertinent for children displaying abnormal findings on the Rhythm strip who are experiencing arrhythmias may be diagnosed with congenital or acquired heart diseases have sustained chest trauma or simply suspected of ingesting cardiotoxic substances the initial phase in pediatric ECG interpretation involves scrutinizing the Rhythm strip to determine if the rate aligns with the child's age setting the foundation for a comprehensive analysis subsequently attention shifts to a meticulous evaluation of Rhythm components particularly the interval and the width of the QRS complex recognizing the age specific normal values is imperative with a general guideline indicating a PR interval of 0.16 or less and a QRS complex of 0.08 or less for children deviations from these benchmarks signal potential abnormalities for instance a PR interval exceeding 0 .20 suggests a first-degree heart block while a QRS complex surpassing 0.08 indicates a wide complex arhythmia this systematic approach ensures a detailed interpretation enabling healthc Care Professionals to identify and address cardiac irregularities specific to the Pediatric patient Pediatric arhythmia Encompass a spectrum with Brady arrhythmias being relatively uncommon in neonates and young children incidental identification of first-degree heart block is often inconsequential while symptomatic bardia raises concern for underlying conditions such as sepsis myocarditis Lyme disease and poisoning third degree AV block although rare has been documented in patients with lime carditis and occasionally in neonates born to mothers with systemic lupus in the presence of symptoms adherence to the American Heart Association guidelines is important for appropriate management as it ensures that Healthcare Providers can effectively address the diverse array of Brady arhythmic presentations in pediatric patients pediatric tachar rhythm is present a diverse clinical picture with narrow complex teac cardias predominantly super ventricular teac cardias being more prevalent in children while School aged Children and adolescents May report palpitations younger children and infants often exhibit symptoms such as fussiness or poor eating notably young children can endure Tachi arithmos for more extended periods compared to adults which leads to delayed presentation and is frequently accompanied by signs of heart failure ventricular Tachi arhythmia though infrequent may be observed in children with the history of cardiac surgery which highlights the need for an understanding of the diverse clinical presentation of tach rhythmia discussions with both the referring and receiving Physicians help identify pediatric patients that may be at a heightened risk of cardiac arrest during transport these discussions serve as a platform to evaluate the patient's medical condition comprehensively potentially prompting a reconsideration of the chosen mode of transportation to ensure Optimal Care in instances where a child has experienced Cardiac Arrest prior to transport the critical care transport team should take a proactive approach by collaboratively discussing anticip iated medical challenges and establishing clear goals of care detecting and responding to shock in pediatric patients involves an understanding of various indicators that collectively contribute to a comprehensive assessment in early stages of shock children often exhibit the ability to maintain profusion through compensatory mechanisms however ever it's important for healthc Care Professionals to remain Vigilant as once these compensatory systems begin to fail the child's condition can deteriorate rapidly the indicators Encompass a multifaceted evaluation including blood pressure level of Consciousness heart rate skin temperature respiratory rate and pattern capillary refill time and urinary output these parameters serve as checkpoints engaging the child's circulatory status and response to potential shock a thorough and systematic assessment of these indicators is imperative for recognizing the early signs of shock enabling timely intervention to prevent progression to more critical stages and optimizing the chances of a positive outcome hypovolemic shock the most prevalent form observed in pediatric cases is characterized by an insufficient intravascular volume often necessitating a keen understanding of its various causes and prompt intervention trauma stands out as the primary contributor to hypovolemic shock in children underline the critical importance of recognizing and addressing injuries swiftly a noteworthy aspect is that fluid loss due to vomiting and diarrhea although seemingly retain can be deceptively underestimated in its impact on intravascular volume regardless of the specific cause triggering hypothalamic shock the key principle in managing this condition involves arresting further volume loss and initiating appropriate measures to replace the depleted volume providers must adopt a comprehensive approach to identify the root cause Implement targeted interv itions and closely monitor the child's response emphasizing the need for Swift and effective measures to restore intravascular volume and mitigate the repercussions of hypmic shock hypmic shock progresses through distinct stages each marking a critical juncture in the Continuum of compromised profusion in stage one the child may appear asymptomatic masking the underlying volume deficit however as shock advances to stage two compensatory mechanisms kick in and the child begins to offset volume losses nevertheless these compensatory efforts reach their maximum capacity in stage two the transition to stage three Heralds a pivotal Turning Point characterized by the child's inability to sustain compensation this stage manifests with hypotension accompanied by profound alterations in mental status and a reduction in urine output a constellation of signs that are indicative of severe decompensation the final stage stage four underscores the gravity of the situation as Death Becomes imminent without prompt intervention to eliminate fluid loss and initiate fluid replacement cardiogenic shock is a spectrum of conditions that compromise the heart's ability to pump blood effectively resulting in inadequate profusion this type of shock can be attributed to various causes spanning congenital cardiac defects drug toxicity metabolic abnormalities hypohemia myocarditis and arrhythmias the child in cardiogenic shock typically manifests the classic signs of shock reflecting the impaired cardiac output these signs include teoc cardia accelerated respiratory rate hypoxia due to diminished oxygen delivery alterations in mental status indicative of cerebral hypo profusion and changes to skin condition recognizing these critical cues is essential for healthcare providers to to identify cardiogenic shock prly and Institute appropriate interventions tailored to the underlying cause with the ultimate goal of restoring cardiac function and mitigating the impact of systemic profusion in cardiogenic shock the child often presents with additional clinical manifestations reflecting pulmonary involvement oscilation May reveal crackles indicative of pulmonary congestion resulting from the heart's compromised ability to pump blood effectively jugular Venus distension an observable sign of increased Central Venus pressure may be evident these clinical findings underscore the intricate interplay between Cardiac and Pulmonary functions complimentary to the clinical assessment a chest x-ray May disclose cardiomegaly provid providing A visual representation of the heart's enlargement in managing cardiogenic shock the treatment strategy is multifaceted the primary focus is on enhancing cardiac function through fluid resuscitation and the use of inotropic agents that augment myocardial contractility simultaneously clinicians address the root causes contributing to the cardiogenic shock Tailoring interven ions to the specific ideology lastly pharmacological support is employed to sustain an optimized cardiac function aligning with the overarching goal of restoring hemodynamic stability in improving the child's overall prognosis distributive shock comes in various forms each demanding specific therapeutic strategies the overarching treatment objectives for distributive shock involve arresting excessive Vaso dilation replenishing volume within the intervascular space and enhancing tissue profusion among these neurogenic shock presents distinct challenges in cases of neurogenic shock where autonomic dysfunction leads to vasod dilation the primary therapeutic interventions revolve around volume replacement using Crystal oids simultaneously vasoactive medications are employed to address the underlying vascular tone disregulation these combined approaches aim to restore vascular tone optimize fluid status and ultimately improve tissue profusion anaphylactic shock in children manifests as a systemic and potentially life-threatening hypers sensitive ity reaction characterized by spectrum of symptoms these may include General body edema hypotension rash ticaria anxiety and warm flush skin Swift and comprehensive management is needed to mitigate the severity of anaphylactic shock the primary focus involves prompt removal of the allergen addressing the underlying trigger for the immune respon response concurrently volume replacement is initiated to counteract hypotension and maintain adequate tissue profusion epinephrine Administration represents a Cornerstone in the treatment Arsenal as it serves to alleviate Bronco constriction enhance cardiac output and counteract vasod dilation all of which are alpha and beta properties the combination of allergen removal volume replacement and epinephrine application form a multifaceted approach aimed at swiftly mitigating the systemic effects of anaphylactic shock in children thereby restoring hemodynamic stability and averting potentially severe complications systemic inflammatory response syndrome or Sears and septic shock are a complex Cascade of physiological events that pose a significant threat this syndrome is characterized by a robust inflammatory response marked vasod dilation and pronounced increase in microvascular permeability as well as an accumulation of lucaites collectively leading to hypotension and end organ dysfunction in pediatric cases Sears mirrors its adult counterpart manifesting as an inflammatory response triggered by diverse factors such as trauma or infection the Hallmarks of Sears and children involve altered Thermo regulation presenting as hypothermia or even hypothermia along with tardia teyia and age specific alterations in white blood cell counts the transition from Sears to septic shock occurs when this inflammatory response coincides with a confirmed confirmed or suspected infection recognizing the signs and symptoms of Sears in pediatric patients is crucial for timely intervention and targeted treatment to mitigate the potential progression to septic shock and its severe",
        "Renal Conditions": "consequences renal conditions pre-renal disorders prevalent among renal conditions in children are predominantly driven by factors such as dehydration and diminished renal profusion dehydration often stemming from causes like vomiting diarrhea dka shock or Burns stands as a primary contributor to these disorders in the context of pre-renal disorders the reduction in renal blood flow and profusion becomes a concern leading to a Cascade a physiological response responses clinically a child affected by pre-renal disorders May exhibit symptoms such as nausea vomiting and diarrhea underscoring the impact of fluid imbalance on renal function intra renal disorders a category of renal conditions affecting the internal structures of the kidneys bring attention to the vulnerability of the proximal cells with their heightened metabolic demands the network of renal arteries which are needed to maintain optimal blood flow can face occlusion due to factors such as IMI or thrombosis this compromised blood flow often a consequence of es schic insults poses a significant risk to renal Health in cases where the renal arteries are obstructed infarction becomes a consequential outcome precipitating a further impairment in the kidney's ability to function understanding the susceptibility of proximal cells to es schic challenges underscores the need for diligent monitoring And Timely intervention to address INR renal disorders and preserve renal well-being hemolytic gmic syndrome or sus stands as a significant contri contributor to acute kidney injury or Aki in infants and children under the age of four its clinical presentation is characterized by the classic Triad of microangiopathic hemolytic anemia thrombos cpia and acute renal injury marking a distinctive profile in the spectrum of pediatric renal disorders Theology of hus is believed to be multifactoral often associated with ious bacterial and viral infectious agents at its core the syndrome is rooted in endothelial cell injury with the renal cortex triggering localized vascular coagulation and the desposition of fibrin the clinical onset is frequently linked to a preceding gastroenteritis type illness manifesting with symptoms such as vomiting abdominal pain and bloody diarrhea however as the GI syndromes wne a critical shift occurs and the child's condition deteriorates rapidly this is marked by signs of systemic distress including irritability power a peal rash and indications of fluid overload the therapeutic approach to hemolytic ureic syndrome revolves around a multifaceted strategy aimed at maintaining fluid and metabolic equilibrium while addressing specific complications associated with the condition the Cornerstone of treatment involves attention to fluid balance to prevent dehydration and sustain renal profusion managing hypertension is another critical facet requiring interventions to regulate blood pressure levels effectively transfusion of packed red blood cells and platelets becomes a consideration if warranted by the severity of hemolytic anemia or thrombos cenia Additionally the aggressive treatment of acute kidney injury is imperative with potential recourse to dialysis or continuous renal replacement therapy within the hospital setting hn manifests as a renal disorder Associated by a Triad of clinical features edema hypertension and hemat Ura the underlying pathophysiology involves the desposition of circulating immune complexes within the kidney basement membrane leading to a reduction in glomar filtration various infectious agents can induce the syndrome with group a beta htic straky being the most prevalent causitive organism the immune complex mediated inflammation impairs renal function resulting in the distinctive clinical presentation of AGN the edema often noticeable in the face and extremities is a consequence of fluid retention secondary to compromised renal filtration concurrently hypertension arises due to the disregulation of blood pressure control mechanisms associated with renal dysfunction hemat Ara the presence of blood in the urine further underscores the renal involvement in ag recognizing the link between infection and the subsequent development of AG is fundamental in both diagnosis and management as targeted treatment strategies may be directed toward addressing the underlying infectious cause apig is a renal condition that ensues following an in infection by strepto cocky whether originating from a skin infection or a Fingal infection this condition predominantly affects school-aged children and Exhibits a higher incidence in males and females the characteristic presentation typically emerges one to two weeks after the initial streptococcal infection with a notable symptom being the presence of gross himat ARA leading to brown colored urine the temporal assoc assciation with the antet infection AIDS in the diagnosis management of severe cases primarily revolves around supportive measures emphasizing fluid restriction and intravenous solutions to mitigate the risk of exacerbating peripheral and pulmonary edema given the self-limiting nature of apig supportive interventions aim to alleviate symptoms and promote recovery acknowledging the importance of time in the resolution of this post-infectious renal complication ATN is a renal condition characterized by damage to the tissue of the kidney tubules and it can be attributed to various causes the foremost cause is renal esmia often triggered by hypohemia which results in compromised blood flow to the kidneys additionally tubular damage leading to ATN May stem from toxic insults such as exposure to heavy metals or the accumulation of myoglobin or hemoglobin within the tubules following severe Crush injuries Burns or hemolytic crisis the renal tubular cells undergo necrosis when deprived of adequate oxygen or subjected to the toxic effects of certain drugs clinically ATN is demarcated to three distinct phases the first phase known as the olur phase is characterized by severe olua lasting approximately 10 days prolonged olua or anara Beyond 3 to 6 weeks poses a significant challenge for renal recovery the subsequent phase the diuretic phase manifests as the passage of large volumes of isod nuic urine containing sodium levels within the range of 80 to 150 mil equivalents per liter the Final Phase termed the recovery phase is marked by the rapid resolution of signs and symptoms attributed to the Regeneration of tubular epithelial cells this delineation of phases AIDS in understanding the trajectory of ATN and guides clinical management strategies emphasizing the importance of recognizing and addressing the underlying calls to optimize renal recovery post-renal or obstructive renal failure encompasses a spectrum of conditions with diverse etiologies contributing to urinary obstruction the multiple causes of post-renal disorders often lead to the development of flank or abdominal pain serving as clinical indicators of obstructive processes within the system prolonged and unrelieved obstruction poses a significant threat as it can induce irreversible paranal damage due to the interplay of infection and heightened hydrostatic pressure the obstruction of urine outflow in the renal system induces a Cascade of physiological changes this obstruction instigates an increase in hydrostatic pressure at the proximal tubal and glus resulting in a concurrent decrease in glomular filtration and overall renal function the intricate renal architecture designed for efficient urine production and elimination becomes compromised in the face of obstructive challenges a comprehensive understanding of the diverse causes of postrenal disorders is essential for a timely diagnosis and intervention aiming to alleviate obstruction mitigate the risk of a irreversible damage and restore normal renal function the clinical recognition of flank and abdominal pain serve as a key diagnostic cue prompting providers to explore and address the underlying obstructive factors that contribute to post-renal complications complications that arise from acute kidney injury often manifests as disruptions in electrolyte balance adding a layer of complexity to the clinical management of affected individuals one such complication involves hypon Ria characterized by low sodium levels which necessitates an astute approach to fluid management hyponatremia if severe can lead to seizures warranting intervention through the administration of a hypertonic saline solution balancing the restoration of sodium levels with fluid restrictions becomes a delicate therapeutic Endeavor highlighting the intricate nature of electrolyte imbalances in the overall context of Aki another notable complication is hypocalcemia arising from hyperphosphatemia while hypocalcemia is not typically treated unless symptomatic manifestations such as tetany seizures or decreased cardiac contractility emerge managing this electrolyte disturbance requires careful consideration the expeditious correction of hypocalcemia May precipitate the deposition of calcium salts in various body tissues emphasizing the need for a measured and gradual approach treatment modalities Encompass oral administration of calcium carbonate or in emergent scenarios the cautious use of intravenous calcium gluconate at a specific dosage threshold hyperkalemia poses a substantial risk as it can induce life-threatening arhythmia by altering membrane excitability ECG changes associated with hyperkalemia are indicative of the severity of the condition and may manifest as peaked t- waves widening QRS complexes and eventual braic cardia given the potential gravity of the situation the approach to elevated serum potassium levels hinges on both laboratory values and the presence of ECG abnormalities careful monitoring becomes imperative and interventions may involve removing potassium chloride from intravenous fluids utilizing pharmacologic treatments to facilitate potassium excretion or shift it intracellularly and considering the option of dialysis in severe cases hypertension and its potential progression to hypertensive incopy represent severe complications in the context of Aki presenting a life-threatening scenario for affected patients the Genesis of hypertension in Aki is typically rooted in sodium and water retention contributing to an imbalance in fluid dynamics when hypertension advances to hypertensive inyopools including nausea vomiting headache visual changes seizures and alterations in mental status recognizing the gravity of this condition the therapeutic goal is to achieve a meaningful reduction in mean arterial pressure often targeted at a range of 15 to 25% the rationale behind this targeted reduction is to alleviate the excessive pressure burden on the vascular system mitigating the risk of further neurologic complications and aiming to restore hemodynamic equilibrium in the context of Aki Associated",
        "Meningitis": "hypertension menitis with menitis the onset of symptoms is typically abrupt and the presentation can vary based on several factors including the child's age the specific infectious organism responsible and the overall health status of the patient fever chills and nucal rigidity are Hallmark indicators of menitis reflecting the inflammation of the protective membranes surrounding the brain and spinal cord the presence of vomiting photophobia headache and back pain further characterizes the clinical presentation in younger children particularly infants the symptoms may be less specific making the diag nois more challenging neonates might exhibit non-specific signs such as irritability poor feeding and bulging fontell while older children may communicate symptoms more clearly expressing discomfort and exhibiting classic signs such as stiff neck and photophobia seizures can also be a manifestation of menitis underscoring the diverse and potentially severe nature of this infectious condition in infants and young children the symptoms of menitis can manifest with additional indicators distinguishing them from older children and adults alongside the typical signs such as fever chills and nucle rigidity infants May exhibit distinct features including poor feeding marked irritability and agitation a characteristic High pitch cry often associated with menitis in this age group may be accompanied by the presence of bulging font naels further emphasizing the severity of the condition the unique challenges in diagnosing menitis in infants and young children necessitate a heightened awareness of these specific symptoms prompting healthc care providers to consider a broad range of clinical presentations during the evaluation process clinical Maneuvers such as brinsky sign and kerik sign play a role in the diagnostic evaluation of menitis the brinsky sign though contraindicated in patients with potential cervical spine injuries involves attempting to bring the patient's chin to their chest while lying in a suine position an abnormal response marked by flexation of the legs and hips can indicate menal irritation the keric sign is positive if there is pain or resistance to knee straightening on both sides and serves as an additional indicator of potential menal",
        "Trauma": "involvement trauma trauma stands as the predominant cause of mortality in pediatric patients aged one year and older with diverse etiologies such as motor vehicle crashes Suffocation submersion Falls Burns and incidents of violence contributing to this unfortunate statistic for critical care transport professionals evaluating the severity of trauma in pediatric patients two distinct resources serve as valuable tools the Glascow Coma Scale adapted for Pediatric use proves instrumental in assessing neurologic status this modified scale evaluates ey verbal and motor responses providing a standardized measure of Consciousness simultaneously the Pediatric trauma score emerges as a comprehensive assessment tool taking into account critical factors such as weight Airway status central nervous system status systolic blood pressure pulse rate as as well as the presence of fractures and wounds this approach ensures a more nuanced evaluation of traumatic injuries in children facilitating a holistic understanding of their condition beyond the scope of a single parameter traumatic brain injury or TBI ranks as a significant contributor to morbidity and mortality in the Pediatric population motor vehicle crashes involving passengers pedestrians or bicyclists constitute the primary sources of injury leading to TBI in children Beyond vehicular accidents other notable causes Encompass sports related injuries Falls and instances of abuse the vulnerability of a child's developing brain underscores the gravity of TBI necessitating careful consideration of various mechanisms that can lead to head trauma motor vehicle crashes often involving children as passengers or pedestrians are particularly prevalent and can result in severe TBI due to the impact forces sustained during collisions sports related injuries Falls and cases of abuse although less common remain significant contributors to Pediatric TBI primary injuries in TBI are those that occur at the moment of impact resulting in immediate physical and mechanical damage to the brain these injuries can manifest in various forms including paranal injury diffuse axonal injuries and cerebral edema paranal injury involves damage to the brain tissue itself it's often characterized by contusions or laceration diffuse axial injuries on the other hand result from the shearing forces exerted on nerve fibers within the brain leading to widespread damage additionally cerebral edema refers to the accumulation of fluid in the brain tissue in turn contributing to increased intracranial pressure secondary injuries in TBI involve a complex Cascade of cellular destruction that occurs in the aftermath of the primary impact this Cascade includes processes such as inflammation oxidative stress and excitotoxicity which can exacerbate the initial injury if left unaddressed secondary brain injury poses a significant threat potentially leading to irreversible brain damage and in severe cases death increased intracranial pressure poses a significant medical challenge often arising from trauma or malfunctions in cerebral spinal fluid shunts this condition manifests through a spectrum of signs and symptoms ranging from common headaches and irritability to more severe indicators such as fever dizziness nausea and even projectile vomiting patients may also exhibit lethargy visual changes an unsteady gate a high-pitched cry a bulging fontel in infants pupilary dilation seizures and in extreme cases coma with classic Cushing Triad addressing increased ICP necessitates a comprehensive approach with treatment modalities potentially involving the insertion a monitoring device the management of elevated ICP involves several Strat strategies firstly mild hyperventilation with a specific P CO2 range helps alleviate pressure additionally administering 3% sodium chloride which is a hypertonic saline or manitol can Aid in reducing intracranial pressure providers must maintain cerebral profusion pressures above 50 to 60 mm of mercury y proper patient positioning is essential with the stretcher tilted to raise the head between 15 to 30 degrees promoting cerebral Venus drainage normothermia or mild hypothermia is employed to decrease the metabolic rate and Airway management is undertaken as clinically indicated pain management becomes an integral aspect of care in some instances inducing a controlled coma using habituates may be considered as part of the comprehensive therapeutic approach concussion the most frequently observed form of TBI is characterized by its prevalence and diverse range of manifestations while a concussion may involve a momentary loss of consciousness it primarily induces a cluster of cognitive somatic emotional and sleep related symptoms the duration of these symptoms varies extending from a brief episode lasting minutes to a more prolonged presence that can span months or even longer in the transportation of pediatric patients with concussions the provider plays a pivotal role by offering essential supportive measures their responsibilities include executing and documenting a neurologic assessment both as a Baseline and a continuous diagnostic tool throughout the transport process cerebral contusion a consequential injury often resulting from traumatic incidents manifests at the point of impact and potentially extends to the side opposite the forceful contact this distinctive characteristic underscores the complex nature of the contusion as it involves not only the immediate side of trauma but also exhibits a broader impact on the brain the occurrence of cerebral contusion signifies the vulnerability of delicate neural tissues to external forces this injury is marked by localized bruising and bleeding within the brain disrupting normal neurologic functioning understanding the spatial distribution of cerebral contusion is vital for healthc care providers as it aids in predicting and managing the diverse neurological symptoms that may arise epidural hematoma a consequence of blun trauma often involves arterial bleeding originating from vascular injuries with the middle menial artery being a common source notably the accumulation of blood in these instances does not directly contact the brain tissue creating a distinct pathologic scenario the characteristic pattern of an epidural hematoma typically follow as a lucid point during which the individual May exhibit apparent normaly only to be succeeded by rapid neurologic deterioration this unique temporal sequence underscores the acute and potentially life-threatening nature of epidural hematomas interestingly in the Pediatric population the clinical presentation can differ as children may not experience a loss of consciousness or the typical Lucid interval as seen in adults recognizing these variations is critical for accurate diagnosis and timely intervention surgical evacuation is frequently deemed necessary in cases of epidural hematomas emphasizing the imperative nature of prompt medical attention to alleviate the accumulating pressure and mitigate potential neurological Soliloquy associated with this specific type of intracranial hemorrhage a subdural hematoma occurring at a significantly higher frequency than its counterpart presents a distinct clinical profile shaped by its eological factors this type of intracranial bleeding emerges from shearing forces that displace the brain tissue across the base of the skull creating a vulnerability to vascular structures within the subdural space unlike EP ID Dural hematomas subdural bleeding involves the pooling of blood just beneath the Duram matter bringing it into direct contact with the brain tissue the primary causitive factor typically revolves around the disruption of bridging veins are Venus sinuses beneath the dura highlighting the intricate vascular Network's susceptibility to traumatic forces notably subdural hematomas can also be associated with cases of child abuse particularly in instances of shaken baby syndrome this underscores the importance of recognizing the nature of cural hematomas and the diversive mechanisms by which they can occur ranging from accidental trauma to more deliberate acts of harm effective risk assessment and management following closed head trauma in children involve a nuanced understanding of the spectrum of injuries and their corresponding clinical presentations notably a considerable number of children experiencing such trauma exhibit minor injuries rendering them asymptomatic with neurologically normal findings during Examination for this low-risk category management at home under responsible adult supervision May survice acknowledging the self-limiting nature of these cases on the the other hand children categorized with moderate risk injuries typically present with observable symptoms like altered Consciousness Progressive headaches vomiting or may have Associated muscular skeletal injuries addressing this group involves basic trauma care encompassing wound management and spinal motion restriction necessitating radiologic evaluation in contrast high-risk injuries manifest with a depress press level of Consciousness potential neurologic deficits or signs indicative of increased intracranial pressure the urgency of this category often mandates immediate surgical interventions to mitigate the severity of the trauma's impact and enhance the prospects of a favorable outcome in the context of traumatic injuries the initial management constitutes a comprehensive approach centered on the stabilization of fundamental physiological components this encompasses the stabilization of the cervical spine ensuring the Integrity of the airway addressing breathing Dynamics and maintaining circulatory function Beyond these primary measures administering appropriate sedation in analgesia assumes significance not only for alleviating pain but also to prevent sudden spikes in ICP recognizing that any source of bleeding within the cranial region be it from the brain face mandible or even scalp can potentially lead to significant blood loss underscores the need for a thorough examination and prompt intervention to arrest Hemorrhage the concern is accentuated in infants who possess a comparatively larger blood volume in their heads making hypohemia a particularly pressing issue ensuring the patient's head remains positioned at 30\u00b0 in midline represents a practical measure to enhance Venus outflow from the head contributing to the overall management of intracranial Dynamics this strategic positioning is aimed at optimizing the Venus drainage a factor integral to regulating intracranial pressure and maintaining cerebral profusion in the context of intracranial Dynamics the gravest threat arises in herniation syndromes where increased intracranial pressure induces the displacement of the brain this life-threatening scenario manifests in different forms with the brain shifting laterally or more critically downward through the frame of Magnum a phenomenon known as tonsillar herniation this jeopardizes vital structures and compromises neurovascular ular Integrity necessitating prompt recognition and intervention to alleviate the heightened intracranial pressure mortality rates associated with spinal cord injuries among children are disproportionately higher compared to adults highlighting the heightened vulnerability of this population notably serious neurologic injuries are more prevalent in older children underscoring the importance of age specific considerations in understanding and managing spinal cord trauma the injury process itself is often multifaceted involving both a primary insult and subsequent secondary insults that can exacerbate the initial damage recognizing and addressing these dual aspects of injury progression are vital in developing effective treatment strategies in the context of spinal Court injuries the top priority lies in the prevention of further harm emphasizing the significance of appropriately implementing spinal motion restriction measures this involves carefully restricting movement to minimize the risk of exacerbating existing injuries and safeguarding the Integrity of the spinal cord children possess relatively weaker spinal ligaments and increased spinal Mobility compared to adults rendering them susceptible to spinal cord damage even in the absence of a parent vertebral injury this phenomenon is encapsulated in the term spinal cord injury without radiographic abnormalities signifying instances where damage to the spinal cord and ligaments occurs without concurrent visible alterations to the vertebrae recognizing these injuries becomes particularly relevant when clinical signs or symptoms of spinal cord injury are present despite normal cervical spine radiographs in these cases the absence of X-ray abnormalities does not preclude the possibility of significant spinal cord and ligamentous injuries it underscores the importance of a thorough clinical assessment and a high index of Suspicion as relying solely on x-ray findings May Overlook potentially severe underlying conditions breathing abnormalities often arising from various traumatic scenarios Encompass a range of challenges that necessitate a thorough approach in medical evaluation facial trauma and soft tissue swelling common outcomes of accidents or injuries can pose a substantial Risk by obstructing the upper Airway in specific instances direct trauma to the upper Airway way as seen in hanging injuries or clothline incidents can further complicate respiratory function notably hanging injuries are not confined to certain age groups manifesting in toddlers due to crib accidents or window cords and an adolescence as a method of suicide are during risky activities such as the choking game the potential for H injuries to impact breathing adds another layer of complexity to this issue a decrease in the level of Consciousness resulting from head trauma may lead to the tongue obstructing the airway posing a significant impediment to normal breathing patterns addressing breathing abnormalities specifically tension in with thorax demands precise and prompt interventions to alleviate the potentially lifethreatening condition for older children and adolescents the critical aspect of treat involves the insertion of a 14 to 16 gauge angio needle for decompression this procedure is strategically performed in the second to third intercostal space midclavicular on the affected side aiming to rapidly release builtup pressure within the thoracic cavity in the case of infants a more delicate approach is undertaken typically utilizing a 21 to 23 gauge butterfly needle inserted into the second to third intercostal space midclavicular on the affected side the needle is then connected to a stop coock and a 20 ml syringe facilitating the controlled removal of air or fluid from the chest until the condition improves addressing breathing abnormalities associated with Horax involves a procedural approach centered on the precise placement of a chest tube this intervention is strategically undertaken in the fifth intercostal space aiming to efficiently drain and withdraw accumulated blood within the thoracic cavity an additional Dimension to the treatment strategy involves the consideration of autotransfusion a process where the withdrawing blood is collected and subsequently returned to the patient circulation the advantage of this method lies in the potential to minimize the risks associated with donor transfusion this approach however necessitates careful attention to prevent contamination of the collected Blood by open wounds as long as these precautions are observed autotransfusion becomes a viable and even beneficial adjunct to hemothorax",
        "Abuse and Neglect": "management abuse and neglect a facet of any healthc care provider's role is to be aware of various signs of abuse and neglect this includes being vigilant for signs of psychological abuse physical abuse sexual abuse and neglect while certain indicators like bruises in atypical locations Burns or specific fractures may suggest non-accidental trauma it's essential to note that the absence of such findings does not necessarily rule out the possibility of abuse close observation of the child's behavior is an integral part of identifying potential abuse or neglect children below the age of six who have experienced neglect May exhibit a markedly passive demeanor towards their environment on the other hand children age six or older might display initial aggression during evaluations this behavioral Insight provides transport Crews with valuable information for recognizing potential cases and tailoring their approach accordingly adherence to agency protocol concerning the reporting of suspected abuse or neglect is an important and established responsibility for any health care provider respecting and following these procedural guidelines is not only a procedural requirement but a commitment to safeguarding the welfare of the patient under their care preservation of evidence emerges as a procedural imperative emphasizing the importance of meticulous documentation and collection of relevant information during the transport process this diligence in preserving evidence not only facilitates subsequent investigations but also upholds the Integrity of the legal process the documentation of findings from the physical examination couple with statements from the victim or suspected perpetrator becomes an essential component of transfer of documentation this comprehensive record serves as a crucial resource for the ongoing investigation and potential legal proceedings beyond the immediate care setting providers may find themselves called to testify in court regarding cases of abuse or neglect this aspect of their role underscores the gravity of their observation and documentation as their firsthand insights may play a role in legal proceedings aimed at ensuring the safety and protection of the vulnerable individuals",
        "Drowning": "involved drowning drowning constituting a significant threat to children aged 1 to 14 stands as a prominent cause of fatal submergent injury the primary insult in such cases is hypoxemia a consequence of oxygen deprivation which may or may not be linked to aspiration this oxygen deficit initiates a Cascade of physiological responses including metabolic acidosis hypothermia and cardiac compromise a critical determinate of the patient's outcome hinges on the efficacy of resuscitation efforts and the duration of submersion successful intervention relies on prompt and well executed measures early securing of the airway coupled with the provision of positive pressure ventilations and the incorporation of positive end expiratory pressure at an early stage forms the Cornerstone of effective resuscitation these interventions aim to address the immediate threat of hypoxemia and facilitate adequate oxygenation Additionally rewarming the patient becomes a priority to counteract hypothermia while concurrent efforts focus on reversing metabolic acidosis to restore physiological balance in a notable subset of drowning incidents estimated to be around 10 to 20% the occurrence of drowning is intricately tied to the renia spasm this this involuntary contraction of the lenial muscles prevents water from entering the lungs offering a temporary Safeguard against immediate inhalation the duration of the lenes spasm emerges as a critical factor in shaping the ensuing physiological impact determining the extent of hypoxemia which is the diminished oxygen levels in the bloodstream interestingly death resulting from this specific type of drowning is characterized by asphixiation rather than aspiration in instances where the lenes basm is prolonged the Restriction of air flow leads to a gradual depletion of oxygen resulting in its fixation this distinct mechanism distinguishes it from drowning cases primarily attributed to the aspiration of water into the lungs understanding the interplay between L renous spasm hyp hypoxemia and the eventual cause of death is essential for health care providers involved in the management of drowning",
        "Flight Considerations": "victims flight considerations certain considerations contribute to a more holistic and patient- centered approach during flights firstly unlike specific considerations that may be required for adult patients there are no distinct flight considerations outlined for Pediatric cases that being said the unique emotional needs of pediatric patients are acknowledged by the critical care transport provider to address the potential anxiety that children may experience during transport providers can maintain a supply of single-use toys these small but considerate measures aim to create a more comforting environment for Pediatric patients potentially alleviating their distress during the transport process recognizing the significance of familial support efforts are made to facilitate the presence of the parent or caregiver during the transport whenever feasible this practice not only provides emotional reassurance to the child but also ensures a Continuum of Care that integrates the familial support system maintaining open and honest communication principle universally applied in patient care is underscored in the Pediatric context similar to adult patients honesty remains a guiding principle when interacting with Pediatrics emphasizing the importance of trust and transparent communication to foster a positive and supportive environment during Critical Care transport flights"
    },
    {
        "Introduction to Neonatal Emergencies": "chapter 23 neonatal emergencies introduction before we get started we need to cover a few definitions a newborn is an infant within the first few hours of birth a neonate is an infant within the first 28 days of birth a term newborn is one delivered in the 37th to 42nd week of gestation in the United States a substantial proportion specifically 80% of the approximately 30,000 infants delivered annually with a birth weight below 3 PBS necessitate immediate resuscitative interventions the critical nature of these neonatal emergencies underscores the significance of prompt and effective stabilization measures short and long-term prognosis for these fragile neonates are intricately tied to the quality of the initial stabilization efforts undertaken adequate resuscitation in The crucial moments following birth not only influences immediate survival but also plays a pivotal role in shaping the trajectory of the infant's Health in the ensuing months and years it is imperative for critical care param Medics to possess a comprehensive understanding of neonatal resuscitation protocols and techniques as their actions during the initial stabilization phase can significantly impact the overall outcomes for these vulnerable newborns the interconnectedness of short and long-term consequences emphasizes the role that emergency medical professionals play in mitigating adverse outcomes and optimizing the prospects for NE atal well-being Critical Care transport professionals are tasked with a responsibility when it comes to neonatal emergencies necessitating a comprehensive skill set and preparedness firstly providers must exhibit a proactive approach by anticipating potential issues that may arise in neonates during transport this entails a a keen understanding of the unique physiological vulnerabilities and potential complications associated with neonatal patients second providers must possess an in-depth knowledge of neonatal resuscitation and stabilization techniques this includes a thorough comprehension of the physiological differences between neonates and other age groups as well as the ability to adapt interventions to suit the specific specific needs of these delicate patients additionally Critical Care transport professionals must ensure the availability and familiarity with the appropriate resuscitation equipment tailored for neonatal care this involves not only having the necessary tools on hand but also being proficient in their usage to execute timely ande effective interventions finally these professionals must carefully y deliberate on the neonate's ultimate transport plan considering factors such as the Acuity of the condition the distance to the receiving facility and the need for specialized neonatal care the decisionmaking process involves finding a balance between the urgency of the situation and the optimal means of Transport that ensures the safety and well-being of the neonate throughout the journey the seamless integration of anticipation knowledge equipment preparedness and meticulous transport planning is imperative for providers in delivering exemplary neonatal Critical Care Transport",
        "Anatomy and Physiology of a Neonate": "Services anatomy and physiology of a neonate Thermo regulation in neonates is a critical consideration for critical care transport professionals due to the inherent challenges these vulnerable patients face in maintaining optimal body temperature neonates distinguished by a high body surface area to body weight ratio and limited subcutaneous fat are particularly prone to heat loss through the skin this susceptibility is compounded by thermal conduction convection radiation and increased evaporative heat loss necessitating Vigilant monitoring and intervention by providers furthermore neonates exhibit constrained heat production capabilities stemming from factors such as low glycogen stores limited Brown fat and a reduced capacity for heat generation through shivering the concept of a Nar narrow range of neutral thermal environment underscores the delicate balance required for neonatal Thermo regulation the neutral thermal environment representing the temperature at which maintaining normal body temperature demands minimal metabolic effort is critical for neonatal well-being however achieving this balance in preterm infants poses additional challenges due to their thin skin rendering them more susceptible to hypothermia to mitigate the risk of hypothermia during transport providers must adopt proactive measures this involves the utilization of pre-warmed blankets and Equipment including a pre-warmed transport incubator to create an environment conducive to maintaining normothermia recognize in the newborn's ability to metabolize Brown fat comes at the expense of increased oxygen consumption the implementation of such warming strategies becomes crucial in ensuring the neonate's thermal stability during transport the respiratory structure and function of neonates pose distinctive challenges for practitioners demanding a nuanced understanding of anat iCal and physiological considerations the first notable aspect is the developmental timeline where the lungs are incapable of sustaining life outside the womb until 23 weeks gestation or a fetal weight of one pound following birth the neonatal lung albeit proportionally small relative to body size possesses minimal respiratory Reserve accentuating the vulnerability of these delicate organs the patient's respiratory pattern further distinguishes itself featuring a rate of 30 to 60 breaths per minute with a title volume ranging from 5 to 7 MLS per kg anatomically neonates present unique challenges with a dis proportionally large head and a tongue that is relatively large compared to the oral cavity which poses a potential risk for Airway obstruction additionally neonates predominantly breathe through their noses rendering them susceptible to obstructive apnea arising from developmental defects edema of nasal mucosa during suctioning or simply the accumulation of secretions positive pressure ventilation in neonates Demands a careful approach to maintain physiologic tital volume breaths and mitigate complications volut trauma hypercapnia and hypocapnea if not carefully managed during ppv have been associated with adverse outcomes such as bleeding in the brain hearing loss chronic lung disease or Bronco pulmonary dysplasia in essence a comprehensive grasp of neonatal respiratory anatomy and function is imperative for critical care paramedics to navigate the intricacies of ventilation and optimize outcomes for these vulnerable patients oxygen transported neonates is a complex physiological process governed by by distinctive characteristics of their hemoglobin composition and elevated metabolic demands fetal hemoglobin or hbf assumes prominence constituting 70 to 80% of the total hemoglobin in a neonate during the fetal period hbf assists in oxygen delivery to fetal tissues in the hypoxic uterine environment however postnatal it exhibits an affinity for holding on to oxygen in normal conditions influencing the Dynamics of oxygen transport in the transitional phase after birth the neonates heightened oxygen requirements ranging from 6 to 8 MLS per kg are met through a finely tuned interplay of cardiovascular and respiratory adaptations this involves a remarkably High cardiac output of 300 MLS per kg per minute a rapid heart rate ranging from 120 to 160 beats per minute and an elevated respiratory rate spanning 30 to 60 breaths per minute these physiological adjustments are essential to cater to the increased metabolic demands associated with the transition to extra uterine life despite these adaptive mechanisms these patients remain vulnerable to Rapid shifts in oxygenation status a phenomenon characterized by the potential for Swift development of hypoxia and bardia this susceptibility underscores the critical need for Vigilant monitoring and Rapid intervention by medical professionals understanding the intricacies of oxygen transported neonates including the unique attributes of fetal hemoglobin and the interplay of cardiovascular respiratory Dynamics is indispensable for providers involved in the care and management of these patients cardiovascular function in neonates is characterized by unique physiological parameters that necessitate careful monitoring and management by professionals the normal heart rate ranges from 100 to 205 beats per minute reflecting the dynamic nature of the cardiovascular system during the early stages of life in situations requiring intervention neonates respond to carefully administered volume loading typically in the form of a fluid bolus range ing from 10 to 20 MLS per kg this measured approach is designed to elicit an increase in cardiac output optimizing circulatory function that being said it is important to exercise caution to avoid fluid overload as these patients exhibit limited tolerance to excessive volume which can lead to complications and compromise cardiovascular stability the utilization of inotropic Agents is a common practice among these dopamine and debam emerge as the most frequently employed inotropic agents these medications act to enhance myocardial contractility and cardiac output addressing instances where neonates may require cardiovascular support the transitional circulation involves adaptations in the fetal cardiovascular system in utero the pulmonary vasculature exhibits a notably High Resistance as the fetal lungs are nonfunctional and blood is directed away from the pulmonary circulation the major conduit facilitating this redirection is the fan ovil an essential an iCal feature that enables most of the blood returning to the right atrium from the placenta to bypass the pulmonary circulation and pass directly into the left atrium this shunting of oxygenated blood across the Fram and ovile serves as a vital purpose in the fetal circulation by entering the left atrium the oxygenated blood mixes with the Limited pulmonary return that does traverse the fetal lungs from there the Blended blood is propelled through the left ventricle into the aorta and subsequently distributed to critical organs such as the coronary arteries and the developing brain this pattern of blood flow ensures the essential oxygenation is provided to vital organs despite the inherent result resistence of the nonfunctioning fetal lungs in fetal circulation the interplay of blood flow is Paramount for sustaining the developing fetus within the intrauterine environment deoxygenated blood returning from the lungs converges with oxygenated blood in the left atrium forming a mixed composition that is essential for optimal systemic distribution simultaneously the ductus arteriosis diverts most of the right ventricular output directly into the aorta this shunting mechanism allows for the fusion of blood from both ventricles thus ensuring a balanced and oxygen-rich circulatory mixture as this Amalgamated blood traverses the descending aort it embarks on a vital journey to profuse various organs and tissues the lower body in particular benefits from this oxygenated blood supply meeting the metabolic demands for the growth in development of essential structures the orchestrated choreography of the ventricles coupled with the specialized shunting through the ductus arteriosis underlines the the Adaptive Brilliance of the fetal circulatory system this circulatory Arrangement serves as a Lifeline sustaining the fetus and laying the foundation for the transition to Independent postnatal circulation the umbilical arteries emanating from the internal iliac arteries serve as conduits for transporting deoxygenated blood from the fetus to the placenta for oxygenation this process takes place in utero allowing for the exchange of carbon dioxide and waste products for oxygen within the placental environment however the Dynamics of blood flow undergo a profound shift during the transition to extra uterine life upon the clamping of the umbilical cord at Birth a sudden surge in systemic vascular resistance occurs this physiological event marks the commencement of independent circulatory functions in the newborn with the functions taking on the vital role of oxygenating the blood that was previously oxygenated in the placenta as the neonate initiates extra uterine breathing and the lungs undergo expansion several key changes unfold in the cardiovascular system the transition to pulmonary respiration triggers an increase in tissue oxygenation as the lungs actively participate in the exchange of oxygen and carbon dioxide simultaneously the expansion of the lungs leads to a notable decrease in pulmonary vascular resistance facilitating the redirection of blood flow this reduction in resistance prompts an increase in pulmonary blood flow establishing a dynamic equilibrium that optimizes oxygenation and supports the metabolic needs of the newborn this interplay between the clamping of the umbilical cord initiation of pulmonary function and subsequent adjustments in vascular resistance underscores the intricacy of the transitional cardiovascular changes that occur during the immediate postnatal period the closure of the framan OVU marks the transition from fetal to neonatal circulation as a newborn initiates pulmonary respiration the expansion of the lungs leads to increased Venus return to the left atrium this surge in Venus return results in an elevation of left atrial blood pressure surpassing that of the right atrium this pressure differential serves as a physiological mechanism to effectively close the fan OVU the closure of the framan OVU is a complex process and it does not occur immediately after birth instead it takes time for the septum premium and septum seum the anatomical components involved in the frame and ovule to gradually seal the opening this closure process May extend up to 6 weeks postnatally the extended time frame for closure allows for an Adaptive transition ensuring a gradual and controlled closure that aligns with the development of the neonatal cardiovascular system renal function undergoes critical developmental milestones in the neonatal period nephrogenesis the process of kidney development reaches completion at 36 weeks gestation although nephrogenesis concludes tubal growth persists contributing to the ongoing refinement of renal Anatomy the glomular filtration rate or GFR at term is notably low gradually attaining adult Levels by the age of two this developmental trajectory highlights the revolving renal capacity during the early years of life a distinctive feature of neonatal renal function is reflected in the newborn's levels at Birth these levels mirror those of the mother of to the shared circulatory environment however over the initial week of Life the neonates creatine levels undergo a decline aligning with the establishment of independent renal function and inherent vulnerability in neonatal renal physiology is observed in The Limited capacity to tolerate fluid restrictions infants exhibit poor tolerance of fluid limitations rendering them susceptible to Rapid dehydration this heightened susceptibility underscores the importance of vigilant fluid Management in neonatal care settings to ensure adequate hydration and prevent complications associated with dehydration fluid and electrolyte balance in neonates undergoes distinctive adjustments reflective of their physiological development stage the extracellular fluid compartment in neonates is notably expanded representing a critical adaptation to the unique demands of the early postnatal period this expansion is particularly pronounced in premature infants where the total body water constitutes 85% of their body weight a percentage that gradually decreases to 75% in term infants and further diminishes to 60% in adults in the immediate postnatal phase it is normal for neonates to experience a contract of the extracellular fluid compartment accompanied by a corresponding weight loss in the first few days following birth this physiological process is a result of factors such as the initiation of independent respiratory function renal adjustments and the establishment of interal feeding the contraction serves as an Adaptive response as the neate transitions from the intrauterine to extrauterine environment facil facilitating the fine-tuning of fluid balance following the initial contraction of the extracellular fluid compartment and the associated weight loss in the neonate a subsequent adjustment in fluid and electrolyte management becomes imperative to meet the evolving needs of the growing infant it is essential to restrict fluid intake until the post-natal weight loss has occurred recogn izing this as a normal physiological process once the weight loss has transpired there arises a necessity to align water and sodium requirements with the increasing demands of neonatal growth in neonatal transport scenarios a meticulous approach to fluid administration is important beyond the initial 24 hours when adequate urine output is established as an indicator of renal function a specific fluid regimen is is implemented this typically involves administering 10% dextrose and a 0.25% normal sailing solution as a maintenance fluid this carefully calibrated combination serves to address the neonates energy needs while providing essential electrolytes additionally a supplement of 10 mil equivalent potassium chloride in 500 MLS may be introduced unless biochemical assessment reveal abnormal electrolyte levels thereby allowing for tailored adjustments to maintain electrolyte balance the central nervous system in neonates presents challenges and uncertainties particularly concerning cerebral Auto regulation and mean arterial pressures the lower limit for cerebral Auto regulation in neonates remains unknown but it's the theorized to be in proximity to a cerebral profusion pressure of 30 mm of mercury establishing appropriate mean arterial pressures for extremely premature neonates poses a challenge with a general consensus acknowledging that an acceptable mean arterial pressure aligns with the gestational age of the newborn given the intricacies of the developing CNS maintaining adequate profusion pressure is critical no susception and the stress response are intricately linked to neonatal care necessitating a nuanced approach while the lower limit of cerebral Auto regulation and optimal mean arterial pressures are undetermined it is important to prioritize minimizing stress during procedures to achieve this the use of appropriate sedation becomes imperative by employing targeted sedation strategy IES Health Care Providers can mitigate stress responses thereby reducing the risk of complications such as intraventricular Hemorrhage this approach underscores the importance of tailored interventions in neonatal care recognizing the delicate balance required to address CNS considerations manage stress and optimize overall outcomes for these vulnerable patients the developmental aspects of pain perception in neonates underscore the importance of recognizing their well-developed responses to painful stimuli despite being in the early stages of Life neonates exhibit robust reactions to pain necessitating a conscientious approach to their care it's imperative that Healthcare Providers acknowledge and address pain in neonates using appropriate analgesic measures the recognition and management of pain in this population are not only ethical considerations but also assist in optimizing the overall well-being of neonates by implementing tailored analgesic interventions Healthcare professionals contribute to minimizing potential adverse effects associated with untreated pain fostering an environment conducive to the optimal development and recovery of these vulnerable patients skeletal development in neonates is characterized by an incomplete  osificante significance when considering medical interventions such as CPR and neonates healthare providers must exercise additional caution and awareness of the neonatal skeletal characteristics during resuscitative",
        "Neonatal Assessment and Stabilization": "efforts neonatal assessment and stabilization in the the domain of neonatal assessment and stabilization a critical responsibility for the critical care transport professional lies in a comprehensive review of pertinent medical history this includes an evaluation of prenatal issues neonatal symptoms Vital Signs physical exam findings radiographs and laboratory values the thorough examination of these aspects is needed to identify and understand the specific medical needs and conditions of the neonate moreover effective communication among all healthc care providers emerges as a huge Factor throughout the transport process given the delicate nature of neonatal cases seamless and clear communication ensures a cohesive and coordinated approach to care facilitating optimal decision-making and interventions during the critical transport phase understanding the risk factors associated with neonates is required in order to provide effective Care One significant consideration is that the risk complications of neonates escalates with decreasing birth weight and gestational age pre-term infants owing to their underdeveloped physiological systems are particularly vulnerable to various complications Additionally the risk profile extends to term infants when specific maternal factors come into play maternal infection diabetes hypertension as well as the presence of moonium during birth are notable risk factors that elevate the likelihood of complications in term infants recognizing these risk factors is pivotal for healthc care providers engaged in neonatal care the timing of cord clamping has significant implications for neonatal well-being the American Academy of Pediatrics and the American College of gynecologists advocate for delayed cord clamping typically within the range of 30 to 60 seconds for the most vigorous term and pre-term infants when feasible this practice facilitates the transfer of blood from the placenta to the newborn providing essential nutrients and aiding in the transition to Independent respiration however immediate core clamping is warranted if there are concerns about the Integrity of placental circulation for effective communication and continuity of care the critical care transport professional should relay information about whether delayed cord clamping was implemented enabling the Receiving Hospital to factor this detail into the ongoing care and stabilization of the patient the apgar score serves as a standardized numeric assessment tool to gauge a newborn's condition immediately after birth the scoring system involves recording one and five minute appar scores which provide a rapid snapshot of the infant's overall well-being the assessment includes evalua ating five essential signs heart rate respiratory effort muscle tone reflex irritability and color each assigned a score of 0o one or two based on the observed level of performance the maximum total apgar score achievable is 10 with higher scores indicative of better neonatal condition in cases where the infant's condition does not exhibit Improvement ongoing apgar assessments may be conducted to Monitor and respond to any Dynamic changes enabling prompt interventions and appropriate measures to optimize the newborn stability and well-being physical maturity plays a significant role as premature infants May exhibit developmental variations impacting their score maternal medication intake or narcotic use during labor can also influence the newborn's responsiveness and contribute to alterations in the apgar Additionally the presence of neuromuscular or cardiorespiratory conditions in the newborn may impact the individual components assessed in the score it should be noted that while the apgar score provides valuable insights into the immediate condition of the newborn it serves as a limited indicator of the sever of hypoxic injury the score captures specific physiological parameters but is not comprehensively represent the intricacies of neonatal Health particularly in the context of hypoxic events during birth in cases where the apgar score remains in the range of 0 to3 at the 20 minute Mark there is a heightened risk of neurologic problems for the newborn this extended duration of a low apgar score signals a potential compromise in neurologic function necessitating careful monitoring and intervention to address any Associated complications stabilization is imperative when faced with critical conditions such as acute Airway obstruction ineffective respiration or inadequate cardiovascular function the initial steps in neonatal stabilization predominantly involve comprehensive Airway management and ventilation strategies ensuring the neonate is positioned appropriately in the sniffing position is a fundamental aspect of Airway management optimizing the alignment of the airway for Effective breathing additionally suctioning the neonate's mouth and nose is a critical intervention particularly if there are indications of obstruction or excessive secretions these measures in area management and ventilation form the foundational steps in neonate stabilization aiming to promptly address and rectify any impediments to the essential physiological functions of respiration and cardiovascular support the utilization of CPAP becomes necessary when peripheral cyanosis persists despite the neonate exhibiting sufficient respiratory effort and maintain a a pulse rate exceeding 100 beats per minute CPAP serves as a non-invasive respiratory support mechanism providing a continuous positive pressure that aids in maintaining lung volume and preventing the collapse of the small Airway this intervention proves beneficial in enhancing oxygenation and mitigating cyanosis particularly when respiratory effort is deemed adequate conversely positive pressure ventilation is an essential measure required when the neonate demonstrates insufficient ineffective or absent respiratory effort or when the pulse rate Falls below 100 beats per minute ppv involves the delivery of control breaths ensuring the provision of adequate oxygenation and facilitating ventilation to address compromised respiratory function ventilations should be admin mined at a specified rate of 40 to 60 breaths per minute the title volume delivered is calibrated to ensure the adequate expansion of the neonate's chest this approach helps to maintain optimal respiratory function facilitating adequate gas exchange and sustaining the infant's oxygenation in the case of nonvigorous newborns born through meconium stained anotic fluid a distinct protocol is initiated necessitating careful impr prompt intervention the initial steps in this protocol are essential and should be executed immediately moreover Personnel should be trained in endot tral intubation and be present at the delivery this proactive measure addresses potential complications associated with moonium aspiration ensuring a Swift and expert response to optimize the airway and respiratory outcomes for the neonate chest compressions become an acute measure when the neonates pulse Falls below 60 beats per minute and despite assisted ventilation there is no improvement in this pulse rate this intervention is pivotal for maintaining circulatory support and ensuring adequate profusion to vital organs for neonates born before 34 weeks a heightened risk of intracranial hemorrhage exists to minimize this risk healthc care providers must exercise caution to avoid rapid fluctuations in key physiological parameters this includes careful management of blood pressure temperature fluid volume and pH levels in the context of neonatal stabilization and treatment pre-term infants requiring oxygen therapy and mechanical ventilation are particularly vulnerable to the potential for long-term lung damage the delicate and underdeveloped nature of their respiratory systems renders them susceptible to adverse effects from these interventions to mitigate the risk of lasting pulmonary impairment providers must adopt a strategy that minimizes oxygen exposure and avoids excessive pressures during assisted",
        "Neonatal Resuscitation": "ventilations neonatal resuscitation in the systematic approach to neonatal assessment Healthcare Providers adhere to a structured methodology to comprehensively evaluate the newborn's Health the process initiates with a rapid visual assessment encompassing the child's overall appearance work of breathing and identification of abnormal breath sounds simultaneously circular is evaluated to determine the presence of any life-threatening conditions following this initial evaluation a more in-depth rapid assessment is conducted to gauge cardiopulmonary and neurologic function this aims to swiftly identify any issues that demand immediate attention subsequently the assessment continues with the acquisition of a focused medical history and a mtic ulous head-to-toe physical examination these components contribute to a more nuanced understanding of the neonate's health status enabling healthc care providers to identify potential underlying factors or contributing conditions finally the clinical condition of the neonate is systematically categorized based on both type and severity this categorization serves as a foundational step in guiding subsequent interventions and Tailoring ing medical management to the specific needs of the neonate this systematic approach ensures a comprehensive and structured evaluation facilitating effective decision-making and optimized care for neonates in various clinical scenarios in the primary assessment of neonatal resuscitation encapsulated by the components of Airway breathing and circulation a systematic approach is employed to address immediate priorities after drying a wet newborn the sequence begins with the assessment of the airway involving the positioning and clearance of any potential obstructions ensuring a patent Airway is key for unimpeded Respiratory function subsequently the focus shifts to breathing where stimulation is applied to prompt spontaneous respirations if breathing remains insufficient immediate support is provided to secure adequate ventilation and oxygenation following the evaluation of the airway and breathing components attention then turns to the patient circulatory status this involves a comprehensive assessment of pulse rate and color with interventions initiated based on the findings timely and appropriate measures are implemented to address address any identified issues related to circulation ensuring optimal profusion and oxygen delivery to vital organs this structured ABC approach forms the foundation of neonatal resuscitation guiding healthcare providers in the critical moments after birth to address key aspects of the newborn's physiological well-being systematically the primary assessment of a neon commences with a focused evaluation of key parameters namely breathing color and pulse rate in this phase assessing the neonates Airway is imperative to ascertain its patency for infants presenting with cyanosis a thorough approach is employed to ensure Airway openness this involves positioning the infant's head in the sniffing position utilizing bulb suction to clear the the mouth and nose of any secretions as well as gently stimulating the infant to promote respiratory efforts subsequently the assessment extends to observing the movement of the chest and abdomen listening for breath sounds and palpating the air flow at the nose and mouth these observations and tactile assessments contribute to a comprehensive understanding of the neonate's respiratory status the focus on objective indicators such as chest and abdominal movements as well as audible breath sounds ensures a thorough evaluation of the breathing component during the primary assessment another critical parameter is the respiratory rate and a rate exceeding 60 breaths per minute is deemed abnormal across all age groups this metric serves as a key indicator of respiratory distress and warrants prompt attention in the assessment process Additionally the provider must recognize that any alterations in neurologic function can stem from causes Beyond cerebral hypoxia various medical conditions May contribute to neurologic dysfunction emphasizing the need for a comprehensive evaluation to discern the underlying etiology accurately in emergency situations where weight measurement may be impractical Critical Care transport professionals are equipped with a valuable tool the length-based colorcoded resuscitation tape this tape serves as a practical Aid in determining appropriate drug dose and assists providers in selecting the correct size for Pediatric supplies the length-based and colorcoded system provides a rapid and reliable method for estimating a child's weight based on their height streamlining the decision-making process and enhancing the efficiency of pediatric resuscitation efforts in emergency scenarios in the management of Airway and breathing the administration of free flow oxygen is a nuanced practice that requires careful consideration for cyanotic newborn exhibiting inadequate respiratory effort providing free flow oxygen is often little of no value and May in fact impede a propriate treatment leading to delays that being said in the case of an older neonate this intervention may prove useful addressing specific respiratory needs it should be noted that when administering oxygen warming and humidification are crucial aspects to ensure optimal comfort and prevent potential mucosal irritation in situations where positive pressure ventilation is not indicated oxygen can be delivered effectively through a mask held in close proximity to the infant's face alternatively if a self-inflating bag is connected to an oxygen source positioning the oxygen Reservoir near the infant's face can achieve the desired effect continuous positive airway pressure has emerged as the primary approach for ensuring adequate ventilation in a newborn this method involves maintaining positive pressure throughout the respiratory cycle enhancing lung expansion and facilitating improved gas exchange when confronted with a cyanotic or pale newborn the administration of supplemental oxygen is warranted utilizing positive end expiratory pressure or peep set at 4 to 6 cm of H2O this can be achieved through the te piece or the flo inflating bag optimizing oxygenation while providing the necessary respiratory support it is noteworthy that ideally the initiation of resuscitation should commence with room air emphasizing consideration of individualized oxygen requirements based on the newborn's clinical presentation following the immediate newborn period maintaining optimal oxygen saturation levels becomes Paramount for premature infants oxygen saturation should ideally be sustained between 88 and 92% ensuring a balance between oxygenation and preventing potential hyperoxia in contrast term infants should have their oxygen saturation levels maintained within the range of 95 to 98% this management of oxygen levels is critical for avoiding complications related to both hypoxia and hyperoxia the utilization of oral Airways is a practice rarely employed in neonatal care however when situations arise where there is a critical Airway obstruction oral Airways can be instrumental and even life-saving this intervention is particularly relevant in cases of specific anatomical anomalies that impede normal air flow conditions such as bilateral conal atricia where both nasal pth passages are obstructed and PR Robin syndrome characterized by a small mandible and potential Airway obstruction due to the Tong's positioning May necessitate the use of oral Airways to establish and maintain a patent Airway positive pressure ventilation whether ad ministered through a te piece or a bag mask ventilation system is specifically indicated when signs of respiratory distress are evident or when persistent central cyanosis persists despite the administration of 100% oxygen the adjustment of equipment and techniques to meet the precise needs of the infant is key requiring an individualized approach to ensure the efficacy of positive pressure ventilation the face mask employed must establish an airtight seal over over the infant's nose and mouth extending down to the chin without covering the eyes this PR is needed for optimizing the delivery of positive pressure promoting lung inflation and facilitating adequate gas exchange the utilization of positive pressure ventilation in neonates aligns with the principle of tailoring interventions to the specific clinical presentation of each infant in emphasizing the importance of careful adjustments and precise techniques to address respiratory distress effectively in the context of Airway and breathing management for neonates ensuring a patent Airway that is free of secretions is fundamental to optimizing respiratory function this necessitates positioning the infant with the neck slightly extended in the sniffing position which facilitates optimal air flow the initial breaths of a neonate after birth demand higher pressures due to the lungs not being fully expanded and the potential presence of fluid within them in some instances disabling the pop off valve may be necessary to achieve the required pressures for Effective ventilation providers must strike a balance in subsequent breaths delivering them with sufficient pressure to induce visible but not excessive chest rise this delicate approach aims to enhance lung inflation while avoiding potential complications associated with overinflation the emphasis on precise pressure control aligns with the goal of optimizing respiratory mechanics during the moments following birth these considerations underscore the meticulous and tailored approach approach required in neonatal Airway and breathing management to ensure effective ventilation while minimizing the risk of complications three distinct devices are employed to deliver positive pressure ventilation the self-inflating bag with an oxygen Reservoir the flo inflating bag requiring a gas source and the tpce rec citator each device is selected based on the specific clinical context and available resources the self-inflating bag allows for manual ventilation particularly suitable for immediate intervention the flow initiating bag relies on an external gas source for inflation offering precise control over tital volume the tpce resuscitator provides a consistent pressure and Flow contributing to effective and controlled ventilation despite the availability of these devices the efficacy of bag mask ventilation can be compromised by Common challenges the most frequent reasons for ineffective bag mask ventilation include an insufficient Mass seal and incorrect head positioning addressing these factors optimizes ventilation it ensures the delivery of adequate breaths to maintain an appropriate respiratory rate during positive pressure ventilation neonates should receive between 40 to 60 breaths per minute emphasizing the importance of consistent and controlled ventilation in the neonatal resuscitation process a notable shift in practice has been observed D concerning the initiation of neonatal resuscitation and the administration of supplemental oxygen the conventional approach of commencing resuscitation with 100% oxygen has undergone a re-evaluation and is no longer recommended instead a more nuanced strategy should be employed for newborn infants born at 35 weeks gestation or later resuscitation through positive pressure ventilation now commences with a lower concentration of oxygen specifically 21% this adjustment is rooted in a more cautious approach aiming to provide adequate oxygenation without exposing the neonate to potential risks associated with high concentrations of oxygen for newborns delivered prior to 35 weeks gestation the initial oxygen concentration during positive pressure ventilation may vary ranging from 21 to 30% the administration of supplemental oxygen is a distinct process that involves considerations such as the choice between room air or Blended oxygen ventilation initiation can occur with either of these options and the concentration of oxygen is titrated to achieve the target oxygenation saturation this approach allows for a tailored response to the neonates oxygen needs ensuring optimal oxygenation while avoiding potential complications associated with excessive oxygen exposure in situations where the heart rate remains persistently below 60 beats per minute despite corrective ventilation measures the Imp implementation of alternative Airways becomes essential among these Alternatives the use of an ET tube or lenio mask Airway could be indicated these Advanced Airway interventions are deployed to secure a more definitive and controlled Airway facilitating effective ventilation and addressing the underlying issues contributing to the persistently low heart rate a scenario may arise when there is no improvement in the neonate's heart rate despite positive pressure ventilation even if the chest is visibly moving with ventilation efforts in such cases an escalation in the intervention is warranted and the initiation of 100% oxygen along with the commencement of chest compressions may become necessary this multifaceted approach aims to enhance oxygenation while addressing potential cardiac issues contributing to the persistent brto cardia continuous monitoring of the effectiveness of ventilation remains Paramount throughout these interventions the neonate's response to ventilation and the evolving clinical picture must be closely observed to guide further decisionmaking importantly maintaining an optimal thermal environment by keeping the infant warm is integral to overall resuscitative efforts as neonates are particularly susceptible to temperature fluctuations a topic we will discuss further later in the lecture while the majority of neonatal resuscitations can be effectively accomplished through bag mask ventilation there are specific circumstances that warrant the intervention of of OT tral intubation this Advanced area management technique becomes indicated in scenarios where more intricate respiratory support is deemed necessary one such circumstance is the presence of a congenital diaphragmatic hernia which is a condition that can severely compromise respiratory function due to the displacement of abdominal organs into the chest cavity thus impacting lung development additionally intubation is considered when a neonate fails to respond adequately to initial interventions such as bag mask ventilation and 100% oxygen Administration this failure to achieve the desired response may indicate a need for more precise control over ventilation and oxygenation prompting the implementation of otal intubation furthermore prolonged positive pressure ventilation may also necessitate itate intubation this requirement arises when sustained respiratory support is imperative and the intricacies of continued ventilation cannot be adequately managed through non-invasive means in circumstances where prolonged bag mask ventilation is required abdominal extension may eventually impede effective ventilation thus gastric decompression serves as a critical intervention the orogastric tube is utilized for gas decompression aiming to alleviate gastric distension that may compromise respiratory function this intervention becomes especially pertinent in situations where abdominal distension is a notable impediment to achieving optimal ventilation during resuscitation efforts additionally gastric decompression is indicated in cases of a known or suspected diaphragmatic hernia given the potential for abdominal organs to herniate into the chest cavity creating a significant obstacle to normal respiratory function alleviating gastric distension through the introduction of an orogastric tube is imperative this intervention supports the overall goal of optimizing respiratory mechanics by addressing the abdominal factors that that may impede effective ventilation in the domain of Airway and breathing management the aspect of circulation is of high importance particularly in situations where the neonate's heart rate remains persistently below 60 beats per minute despite exhaustive attempts of intervention in such cases the initiation of chest compressions is warranted marking an important phase of neonatal resuscitation the technique employed for chest compressions can involve either the thumb technique or the two-finger technique with the depth of compression set at onethird of the anterior posterior diameter of the chest in maintaining a delicate balance between efficacy and safety it is imperative that the fingers remain in continuous contact with the patient's chest through out the compression process this approach is designed to minimize the risk of trauma while ensuring effective transmission of compressive forces to the underlying structures simultaneously the timing of compressions is synchronized with artificial ventilation which should be sustained during chest compressions to maintain a continuous exchange of gases technical or mechanical equipment problems represent a critical aspect to assess ensuring that all resuscitation equipment is functioning optimally any issues with devices such as bag mask ventilation systems Airway adjuncts or monitoring equipment should be promptly identified and addressed to eliminate impediments to effective resuscitation unrecognized pulmonary complications demand careful scrutiny as undetected issues within the pulmonary system could be hindering the neonate's response to resuscitation efforts this includes conditions such as Airway obstructions pneuma thorax or other respiratory pathologies that may necessitate specific interventions severe metabolic problems should be considered as abnormalities in biochemical processes can profoundly impact the neonate's ability to respond to resuscitative measures this Inc compasses disturbances in electrolyte balance glucose metabolism or acidbase equilibrium with each requiring targeted management the assessment of congenital abnormalities looks for structural or functional anomalies that may compromise the neonate's overall physiological stability a thorough understanding of potential congenital issues enables a more tailored approach to resuscitation lastly severe anemia must be considered as insufficient oxygen carrying capacity can significantly contribute to the lack of response during resuscitation addressing potential anemic conditions involves targeted interventions to restore adequate oxygen delivery to vital tissues the administration of normal saline Bolis or O negative blood blood infusion becomes a consideration in instances of hypovolemia significant blood loss or suspected metabolic acidosis these interventions aim to restore intravascular volume correct deficits in blood components and address underlying acidbase disturbances it is noteworthy that lactated ringer solution once considered is no longer recommended in the context of neonatal recessive ation regarding metabolic acidosis sodium bicarbonate while historically employed is no longer recommended as part of the initial resuscitation efforts however it may be cautiously administered when the degree of metabolic acidosis is precisely known and requires targeted correction the cautious use of sodium bicarb acknowledges the potential risks associated with this Administration and underscores the importance of a nuanced approach to pharmacologic interventions in neonatal resusitation nxone and vasor pressers once considered for initial resuscitation are no longer recommended in the initial phase but may find utility in post-resuscitation care nxone an opioid receptor an antagonist and vasopressors which enhance vascular tone are now judiciously employed based on the neonate's response to initial resuscitative measures epinephrine stands out as a vital pharmacologic intervention particularly when the neonate exhibits a pulse rate of less than 60 beats per minute after 30 seconds of effective ventilation following intubation and 60 seconds of chest compressions the primary goal is to address persistent braic cardia despite adequate resuscitative efforts while IV Administration is the preferred route for epinephrine the Practical challenges of establishing IV access in a timely manner May necessitate alternative approaches in the absence of an established IV an OT tral tube can be employed as an alternative for epinephrine Administration ensuring that the medication reaches the systemic circulation to exert its effects conditions such as abop placente or septic shock may lead to a significant loss of intravascular volume necessitating fluid resuscitation to restore hemodynamic stability the choice of volume replacement becomes pivotal in addressing the underlying calls and optimizing the neonate's cardiovascular function to facilitate fluid resuscitation in a newborn a low umbilical Venus catheter can be strategically employed this catheter is inserted into the large vein within the umbilical cord offering direct access to the neonates circulatory system the placement involves advancing the catheter just far enough to enable blood return ensuring that it does not enter the liver this technique allows for the administration of fluids blood products or medications directly into the central circulation effectively replenishing intravascular volume and addressing the specific etiology contributing to the neonate's compromised hemodynamics most neonatal transport incubators come equipped equpped with ventilators designed for synchronized intermittent mandatory ventilation allowing for controlled and synchronized breath delivery the ventilator settings are Dynamic and can be adjusted based on the patient's condition ensuring optimal respiratory support during transport however it's essential to be cognizant of potential challenges that may arise during ventilation with transport incubators the ventilator tubing inherent to some ventilator circuits has the potential to influence the measure tital volume Vigilant monitoring of chest rise and Peak inspiratory pressure becomes important in these instances to ensure that the delivered ventilation aligns with the intended parameters in cases of neonates with with very severe lung disease Reliance solely on a conventional ventilator during transport may prove insufficient in providing the necessary respiratory support for term infants experiencing respiratory failure additional interventions may be warranted initiating inhaled nitric oxide can optimize pulmonary vasod dilation enhancing oxygenation in more severe scenarios where cardiopulmonary function is severely compromised ECMO may be initiated in the field to provide Advanced cardiopulmonary support before and during",
        "Respiratory Conditions": "transport respiratory conditions apnea characterized by appalls and respirations lasting more than 20 seconds seconds is a critical consideration in neonatal care it often manifests with clinical signs such as cyanosis poar hypertonia or bardia which necessitates prompt intervention two distinct forms of apnea exist primary and secondary primary apnea is an inherent response to asphyxia that presents at Birth responsive to stimulation and the provision of oxygen primary apnea can often be mitigated effectively in contrast secondary apnea ensues after a brief period of gasping breaths and exclusively responds to assisted ventilation and supplemental oxygen the distinction between primary and secondary apnea delineates the stages of an infant's response to aixia and guides appropriate interventions primary apnea represents the initial phase of response to oxygen deprivation where the neonate exhibits a diminished respiratory effort this stage is characterized by the infant's capacity to respond favorably to stimulation and the provision of supplemental oxygen in contrast secondary apnea ensues after a brief period typically following a series of gasping breaths observed in primary apnea during secondary apnea the infant's respiratory drive further diminishes and spontaneous efforts to breathe become inadequate at this stage the infant no longer responds effectively to stimulation alone and necessitates active intervention in the form of assisted ventilation coupled with supplemental oxygen Administration the occurrence of apnea in neonates can be attributed to a spectrum of underlying factors each necessitating an evaluation to ascertain the precise etiology fixed anatomic obstruction constituting one category of causitive factors involves structural impediments in the airway ways that hinder the smooth flow of air positional obstruction another contributor implies disruptions in air passages due to the infant's specific body position secretions such as mucus or other bodily fluids can impede air flow and result in apnea episodes reflux from aspiration introduces a risk wherein regurgitated substances may enter the pathways triggering apnea metabolic causes encompassing disturbances in biochemical processes and cardiovascular causes which involve issues with the heart and blood vessels are potential triggers infections ranging from respiratory pathogens to systemic infections can also precipitate apnea lastly neurologic causes affecting the central nervous system play a role in at at Genesis moonium the initial stool of an infant is a unique substance that holds significance in the early stages of Life typically meconium is expelled by the newborn afterbirth signaling the initiation of GI function however in certain situations where the fetus undergos stress or experiences dis distress in utero meconium can be expelled before birth this prenatally released meconium can pose a risk leading to a condition known as meconium aspiration this occurs when the infant inhales a meconium either within the uterus or simply during the process of delivery inhalation of meconium can have adverse consequences causing respiratory complications and necessitating careful medical attention the presence of moonium in the Airways can lead to meconium aspiration syndrome a condition characterized by respiratory distress and potential complications meconium aspiration syndrome can lead to hypoxia which in turn will subsequently contribute to complications such as adelais persistent pulmonary hypertension pneumonitis and pneuma thorax the consequences of moonium aspiration syndrome underscore the critical importance of identifying and managing respiratory distress promtly in neonates neonates are particularly vulnerable to pneumonia due to their impaired immune response making them more susceptible to respiratory infections the presentation of neonatal pneumonia often includes signs such as teyia increased work of breathing and hypothermia the heightened respiratory rate and increased effort in breathing are indicative of the body's response to the inflammatory process within the lungs given the limited immune defenses in neonates prompt recognition in management of pneumonia mitigate the potential complic ations associated with respiratory distress ensuring optimal outcomes for the patient respiratory distress syndrome or RDS in neonates results from insufficient levels of surfactant a substance that minimizes the surface tension in the lungs which in turn is essential for proper lung expansion neonates with RDS typically exhibit clinical signs such as grunting retractions nasal flaring teyia and often cyanosis reflecting the respiratory compromise associated with this condition premature infants especially those born at less than 32 weeks gestation are at a heightened risk of developing RDS with male infants and those born to mothers with diabetes also having an increased susceptibility RDS may also occur due to interactions with abnormal Alvar proteins such as meconium or blood or in cases of pneumonia albumin the administration of exogeneous surfactant by experienced healthc care providers is a recognized intervention for both surfactant deficiency and dysfunction in neonates with RDS careful monitoring of lung compliance is essential for the critical care transport professional to assess the effectiveness of respiratory support and make appropriate adjustments additionally distinguishing between RDS and pneumonia in newborns can be challenging emphasizing the importance of conducting a sepsis workup before transport a new mathor ax in a neonate can present as a simple num thorax characterized by gas in the plural space leading to lung collapse on the other hand attention num thorax is a more critical condition involving air in the plural space under pressure posing a life-threatening risk ATT tension num thorax will not only affect the damaged lung but also will push on the medius stum affecting the healthy lung patients will generally present with trial deviation and late jvd though in neonates this may be hard to determine the symptoms of pneumothorax a condition characterized by the presence of air in the plural space manifest as a spectrum of respiratory and cardiovascular changes cyanosis indicative of compromised oxygenation is a notable sign neonates with numo thorax often exhibit increased oxygen requirements reflecting the respiratory challenge posed by the presence of air in the plural cavity Topia an accelerated respiratory rate is a common respiratory manifestation accompanied by an increased work of breathing as the affected lung area is compromised agitation May ensue as the infant struggles to maintain adequate resp function the cardiovascular impact is reflected in the potential occurrence of Broc cardia or teoc cardia emphasizing the interplay between respiratory and cardiac functions hypoxia resulting from impaired gas exchange further contributes to the clinical picture additionally num thorax may lead to hypotension underscoring the systemic consequences of this condition recognizing these symptoms is pivotal for early diagnosis intervention as pneumothorax can have significant implications for the neonates respiratory and circulatory stability the management of respiratory distress in a neonate encompasses several strategies including transillumination thoracentesis and intubation transillumination is a diagnostic approach that employs light to identify the presence of air in the plural space aiding in confirming diagnosis of pneumothorax thoracentesis a therapeutic procedure involves the insertion of a 22 gauge butterfly needle attached to an extension tubing and a 20 ml syringe above the third rib to aspirate air from the plural cavity this alleviates the pneumothorax the potential risk associated with intubation in the context of Numa thorax lies in the introduction of positive pressure which may further inflate the plural space therefore the decision to perform intubation in neonates with respiratory distress must be carefully considered weighing the benefits of securing the airway against the potential risk of worsening the pnea thorax thoros nesis involves meticulous steps to ensure safe and effective intervention the process begins with the cleaning of the area surrounding the intercostal space minimizing the risk of infection subsequently the necessary equipment is prepared consisting of a 22 gauge butterfly needle extension tubing a three-way stopcock and a 20 ml syringe a second healthc care provider assists in the procedure by pulling back on the syringe during needle insertion the needle is carefully inserted above the third rib with Precision maintained to avoid injury to underlying structures as the needle is Advanced it should recover air from the plural space the collected air is then removed as much as possible using the syringe aiming to alleviate the pressure within the plural cavity in cases of a symptomatic ongoing air leak an angio catheter attached to extension tubing may be left in place and the end of the tubing positioned under sterile water to create a water seal this additional step helps manage persistent air leaks and supports the reestablishment of plural Integrity the intricacies of these procedural steps highlight the Precision and expertise required in performing thoros enesis as part of a comprehensive management of respiratory distress in neonates respiratory acidosis in neonates is a physiological condition character ized by an elevation of carbon dioxide levels in the blood leading to a decrease in PH it may arise in from various forms including maternal drug use which can induce respiratory depression in the neonate additionally primary pulmonary or neurologic issues can contribute to suboptimal gas exchange further exacerbating respiratory acidosis this acid base imbalance often manifests with visual signs of hypoventilation or increased work of breathing indicative of the patient struggle to adequately eliminate carbon dioxide through respiration the management of respiratory acidosis typically involves assisted ventilation to enhance the removal of carbon dioxide and restore acidbase homeostasis interventions may include positive pressure ventilation or mechanical ventilation depending on the severity of the underlying cause addressing the maternal factors contributing to neonatal respiratory depression is key in preventing and managing respiratory acidosis the complex interplay between maternal pulmonary and neurologic factors underscores the importance of a comprehensive approach to the assessment and treatment of respiratory distress and neonates particularly when respiratory acidosis has been",
        "Cardiovascular Conditions": "identified cardiovascular conditions cyanosis results from an elevation in arterial deoxygenation leading to increased levels of deoxygenated hemoglobin acrocyanosis a benign condition manifests as cyanosis specifically in the extremities while the central skin color remains within the Baseline range this phenomenon is generally considered harmless and often occurs in neonates without underlying pathology however cyanosis can be indicative of more serious cardiovascular conditions when associated with poor profusion or congestive heart failure in these cases cyanosis May signify compromised oxygen delivery to tissues necessitating a thorough evaluation of the cardiovascular system furthermore sinosis may present in the context of shock where systemic profusion is severely compromised or as a consequence of pulmonary or cardiac disorders affecting oxygenation and circulation cyanosis and neonates can be attributed to a diverse range of cardiovascular conditions each with its specific underlying pathophysiology cyanotic congenital heart diseases such as tetrology of f or transposition of the great arteries are primary contributors to neonatal cyanosis these structural abnormalities impede normal blood flow leading to inadequate oxygenation of systemic circulation arrhythmias characterized by irregular heart rhythms can also result in cyanosis as the heart's inability to maintain an efficient pumping pattern compromises oxygen delivery cardiomyopathy a condition affecting the heart's ability to contract effectively May contribute to sinosis by impairing cardiac function the Persistence of the ducus arteriosis beyond the neonatal period can lead to abnormal blood shunting causing inadequate oxygenation myocarditis and inflammation of the heart muscle May further disrupt cardiac function and oxygen delivery resulting in cyanosis persistent pulmonary hypertension marked by elevated pulmonary vascular resistance poses a risk for cyanosis as it hinders oxygenation in the lungs sepsis or pneumonia can compromise the respiratory system contributing to cyanosis while respiratory distress syndrome a condition characterized by surfactant deficiency May impede lung expansion and oxygen Exchange aspiration pneumonitis arising from the inhalation of gastric contents and severe anemia characterized by a decreased capacity to carry oxygen are additional neonatal cyanosis contributors arterovenous Malou formations involving abnormal connections between arteries and veins can disrupt normal blood flow contributing to inadequate oxygen and cyanosis cyanotic congenital heart disease encompasses a group of heart and major blood vessel developmental abnormalities that result in inadequate oxygenation of systemic circulation one notable example is hypoplastic left heart a condition characterized by underdevelopment of the left side of the heart upon encountering a neonate with suspected cyanotic congenital heart disease providers initiate a thorough assessment of the airway breathing and circulation immediate administration of oxygen is crucial to optimize oxygenation and prevent acidosis further supporting cardiovascular function maintaining oxygen saturation levels above 70% is a priority with consideration given to intubation if rest respiratory distress is severe it is important to establish IV access in order to administer medications and fluids laboratory tests including lactate hemoglobin and blood gases provide valuable insights into the neonate's physiologic status of course blood pressure should be measured in all four limbs to assess potential cardiac anomalies a hypoxia test where inspired oxygen levels are temporarily reduced to evaluate the response AIDS in diagnosing cyanotic congenital heart disease prostaglandin Administration under the supervision of a physician may be considered to maintain ductal patency and improve oxygenation lastly Vital Signs including blood pressure are closely monitored and hypotension is managed with a normal saline Bolis sinus tardia refers to a condition characterized by a heart rate faster than the normal range for a child's age in neonates infants and children the normal heart rate varies with age and sinus tacac cardia typically manifests as an accelerated Rhythm originating from the essay node path logically sinus attack may arise due to various underlying causes tissue hypoxia resulting from conditions such as respiratory distress or simply compromised oxygenation can trigger an increase in heart rate hypovolemia is another common pathologic cause often associated with conditions like dehydration or Hemorrhage fever metabolic stress pain pain and anxiety can also contribute to sinus tacac cardia additionally certain medications in drug related effects May induce a faster heart rate anemia characterized by a decreased concentration of red blood cells and reduced oxygen carrying capacity can lead to a compensatory teoc cardia as the body attempts to maintain adequate tissue profusion supraventricular teoc cardia or SVT is characterized by an abnormally fast heart rhythm that originates above the ventricles typically in the Atria or the atrio ventricular node unlike other forms of teoc cardia SVT bypasses the normal electrical Pathways resulting in a rapid coordinated contraction of the heart's upper chambers in infants SVT is often well tolerated although it can manifest with various symptoms these may include congestive cardiac failure a condition where the heart is unable to pump blood effectively leading to symptoms such as poor feeding rapid breathing irritability and a pale or blue discoloration additionally infants with SVT May exhibit vomiting as a result of the compromised cardiac function diagnosing SVT typically involves ECG or other cardiac monitoring methods to identify the characteristic rapid and regular heart rhythm the management in infants may involve interventions aimed at restoring a normal heart rhythm vagal Maneuvers such as applying gentle pressure to the infant's face or immersing the face in ice cold water water may be attempted to stimulate the vagus nerve and interrupt the abnormal electrical pathway in cases where vagal Maneuvers are ineffective medical professionals may consider administering ad Denison a medication that briefly stops the heart's electrical activity allowing the normal Rhythm to reestablish in severe or persistent cases other anti- rythmic medications or cardiov verion may be employed to restore normal cardiac function picardia refers to a heart rate that is slower than the normal range for a given age or clinical condition in neonates bardia is often associated with tissue hypoxia where insufficient oxygen delivery to the body's tissues can lead to a decreased heart rate this condition May manif EST as a response to various factors including respiratory distress heart abnormalities or other conditions that compromise oxygenation one notable cause of neonatal Broc cardia is maternal lupus maternal lupus an autoimmune disorder can affect the developing fetus and lead to cardiac manifestations including bradicardia the maternal antibodies associated with lupus can cross the placenta and interfere with the normal functioning of the fetal heart's electrical system resulting in a slower heart rate the evaluation of neonatal bardia involves a thorough examination of potential underlying causes such as respiratory distress congenital heart defects or infections diagnostic tools including ECG and continuous cardiac monitoring are employed to assess the heart's electrical activity and identify the specific nature of the Brady arhythmia Management strategies depend on the underlying cause addressing and correcting factors contributing to tissue hypoxia are essential in cases related to maternal lupus the involvement of a multidisiplinary team including neonatologists and pediatric cardiologists may be required for comprehensive assess assessment and appropriate intervention cardiac arrest in children is an infrequent but critical medical emergency unlike in adults where Cardiac Arrest May often be the primary in children it is typically result of a progression from respiratory distress to respiratory failure or even shock this highlights the interconnectedness of resp resp atory and circulatory systems in pediatric patients and respiratory distress and failure can lead to inadequate oxygenation and subsequently impaired cardiac function various factors can contribute to cardiac arrest in children including congenital heart conditions severe infections trauma or electrolyte imbalances the decrease in sudden infant death syndrome or SIDS with the Imp mation of the safe to sleep campaign emphasizes the significance of preemptive measures SIDS is characterized by the sudden and unexplained death of an otherwise healthy infant during sleep the safe to sleep campaign encourages parents and caregivers to create a safe sleep environment for infants including placing babies on their backs to sleep on a firm mattress and in a Cris rib or bassinet free of soft bedding in the context of pediatric cardiac arrest prompt recognition of deteriorating respiratory function or shock is needed for early intervention basic life support measures including chest compressions and assisted ventilation should be initiated immediately Advanced life support interventions such as administration of medications and defibrillation may be required depending on the underlying cause persistent pulmonary hypertension of the newborn is a condition characterized by the persistance of elevated pressures in the pulmonary vasculature after birth this elevation of pulmonary vascul resistance hinders the transition from fetal to neonatal circulation leading to to inadequate oxygenation of the blood persistent pulmonary hypertension of the newborn manifests in term and postterm neonates within the first hours of Life the exact cause is not precisely known but is thought to be a result of a combination of factors suspected causes include conditions that can lead to respiratory distress and compromise oxygenation such as meconium aspiration RDS asphyxia pneumonia hypothermia hypoglycemia and sepsis furthermore maternal factors May contribute to the development of this disease the use of non-steroidal anti-inflammatory drugs by the mother during pregnancy infants born to mothers with diabetes and instances of chronic fetal distress or hypoxia are also associated with this condition the pathology involves the Persistence of high pulmonary vascular resistance which results in a right to left shunt across the fetal channels which are the ductus arteriosis and fan U thus diverting oxygen poor blood away from the lungs this leads to systemic hypoxemia exacerbating the existing respiratory distress management involves providing respiratory support to optimize oxygenation as well as addressing the underlying causes such as meconium aspiration or infections in severe cases ECMO may be considered to provide cardiopulmonary support while allowing the infant's lungs to recover shock is a medical condition characterized by insufficient profusion to meet the metabolic demands of tissues resulting in impaired organ function in shock all organ systems can be adversely affected leading to a Cascade of physiological responses aimed at restoring homeostasis various causes can precipitate shock each impacting profusion in distinct ways hypemic shock is often consequence of significant blood loss either externally through trauma or internally due to conditions like gastrointestinal bleeding inadequate fluid intake or dehydration can also contribute to hypovolemia exacerbating the decrease in circulating blood volume renal failure another potential causal shock disrupts the kidney's ability to regulate fluid and electrolyte balance leading to to imbalances that compromise profusion in the context of shock renal failure can contribute to a vicious cycle of impaired blood flow and further organ dysfunction additionally shock can result from conditions such as severe diarrhea where excessive fluid loss leads to a decrease in intravascular volume the loss of fluids rich in electrolytes disrupts the delicate balance required for proper cellular function aggravating the systemic effects of shock cardiogenic shock is a severe and potentially life-threatening cardiovascular condition characterized by inadequate cardiac output to meet the body's metabolic demands the underlying causes can be diverse and often involve significant disruptions to the normal noral functioning of the heart congenital heart disease a common etiology of cardiogenic shock encompasses structural abnormalities present at birth that impair the heart's ability to effectively pump blood these defects may affect the heart chambers valves or major blood vessels leading to compromised cardiac function arhythmia irregular heart rhythms that disrupt the coordinated contraction of the heart muscle can also precipitate cardiogenic shock when the heart beats too fast or too slow the efficiency of blood pumping is compromised resulting in a decreased cardiac output myocardial esmia a condition where the heart muscle receives inadequate blood supply and oxygen is another significant cause this es schea can result from conditions such as coronary artery disease or acute myocardial infarction which impairs the heart's contractile function cardiac tanod which is the accumulation of fluid in the pericardial Sac can compress the heart and impede its ability to pump effectively while pneuma thorax and high intrathoracic pressure from positive pressure ventilation can also contribute to cardiogenic shock by affecting the mechanical dynamics of the heart effective management of cardiogenic shock involves addressing the underlying cause as well as providing supportive measures that enhances cardiac functions interventions may include medications to improve contractility alleviate es schema or regulate heart rate in severe cases Advanced interventions such as mechanical circulatory support or surgical procedures may be considered to to optimize cardiac performance and restore hemodynamic stability the management approach is tailored to the specific iology of cardiogenic shock emphasizing a comprehensive understanding of the cardiovascular pathology at play distributive shock is a form of shock characterized by widespread vasod dilation and impaired distribution of blood flow within the circulatory system which leads to an adequate tissue profusion this type of shock involves a disproportionate decrease in peripheral vascular resistance resulting in a relative hypovolemia despite the presence of normal or increased total blood volume several underlying causes contribute to distributive shock encompassing conditions that induce systemic vasod dilation and cardiac depression sepsis a severe and disregulated immune response to infection is a primary contributor to distributive shock in septic shock the body's inflammatory mediators lead to vasod dilation causing blood vessels to lose their normal tone and responsiveness this vasod dilation combined with increased permeability of blood vessel walls results in a profound decrease in systemic vascular resistance and compromises effective blood circulation cardiac depression another factor in distributive shock involves a reduction in cardiac contractility in output conditions such as myocardial depression in sepsis or the effects of certain medications can impair the heart's ability to pump blood effectively this reduction in cardiac function exacerbates the circulatory imbalance seen in distributive shock as the heart is unable to compensate for the widespread vasod dilation vasod dilation independent of sepsis can also lead to distributive shock this occurs when blood vessels lose their normal tone and responsiveness causing a decrease in peripheral vascular resistance neurogenic shock anaphylaxis and certain drug reactions are examples of conditions that can induce vasod dilation contributing to distributive shock management of this disease involves addressing the underlying cause such as treating the infection in sepsis or reversing the effects of anaphylaxis supportive measures include fluid resuscitation to improve intravascular volume and the administration of vasoactive medications to constrict blood vessels and enhance blood pressure the complex interplay of factors in distributive shock requires a comprehensive approach to restore normal vascular tone optimize cardiac function and ultimately improve tissue profusion symptoms of shock and neonates Encompass a range of clinical signs reflecting inadequate tissue profusion and compromised cardiovascular function hypotension characterized by abnormally low blood pressure is a key indicator of neonatal shock indicating an insufficient profusion of vital organs teoc cardia an elevated heart rate is a compensatory response aimed at maintaining cardiac output in the face of decreased profusion Poe profusion which is a fundamental feature of shock manifests as impaired blood flow to organs and tissues contributing to a Cascade of systemic effects Topia or rapid breathing occurs as the neonate attempts to enhance oxygen intake and then compensate for the compromised circulatory state oliguria which is reduced urine output or anara which which would be the absence of urine production may result from decreased renal profusion indicating impaired kidney function hypothermia is a common manifestation of neonatal shock and reflects the body's inability to maintain normal Thermo regulation in the face of circulatory compromise acidemia which is an abnormal decrease in blood pH occurs due to the accumulation of metabolic byproducts resulting from inadequate tissue profusion additional signs of neonatal shock include weak pulses which are indicative of reduced cardiac output and hepatomegaly which is an enlarged liver as well as cardiomegaly and enlarged heart which reflects the strain on these organs in response to systemic stress peripheral edema the accumulation of fluid in the tissues may occur as a consequence of altered vascular Dynamics and increased capillary permeability associated with shock the treatment of shock and neonates involves a systematic and multifaceted approach focusing on medical interventions to address the underlying causes and restore optimal cardiovascular function the ab C's serve as the foundational components of immediate resuscitation a central aspect of shock management involves checking blood glucose levels to assess metabolic status and address any hypoglycemic conditions promply neonates are particularly susceptible to fluctuations in blood glucose and maintaining normoglycemia is vital for metabolic stability vascular access is established to facilitate the administration of therapeutic interventions obtaining prompt and secure vascular access allows for the infusion of fluids medications and other necessary treatments the choice of vascular access whether through peripheral intravenous lines or other routes depends on the clinical context and urgency fluid resuscitation plays a role in addressing shock by optimizing intravascular volume and improving tissue profusion the type in volume of fluids administered are tailored to the specific needs of the neonate considering factors such as age weight and the underlying iology of shock fluid management aims to restore and maintain adequate cardiac output blood pressure and organ profusion simultaneously the treatment strategy prioritizes identifying and addressing the underlying cause of shock whether attributable to infections cardiac abnormalities or other contributing factors addressing the root cause is essential for Effective and sustained management this may involve administering antibiotics for sepsis initiating inotropic support for cardiac dysfunction or employing other targeted therapies based on the neonate's clinical presentation and diagnostic findings catheterizing the umbilical vein in neonates is a procedural step employed to establish Swift and effective vascular access this procedure adheres to a meticulous protocol first the cord is cleaned with alcohol or for an antiseptic solution to minimize the risk of introducing contaminants into the vascular system a sterile tie is in securely placed at the base of the cord ensuring a controlled environment for the subsequent Steps A Sterile umbilical catheter pre-filled with normal saline using a 3 ml syringe is prepared for insertion the cord is cut below the previously placed clamp allowing access to the umbilical vein the catheter is carefully inserted into the umbilical vein until blood can be aspirated confirming successful access to the vascular system once vascular access is established the catheter is flushed with normal saline to maintain patency and ensure proper functionality subsequently the catheter is securely taped in place preventing dislodgment and maintaining stability this process provides immediate access to the neonate circulatory system facilitating the administration of fluids medications and other therapeutic interventions as needed for resuscitation or simply ongoing Medical Care anemia in neonates characteriz Rise by hypocrit value below 38% in pre-term infants and less than 42% in term neonates can manifest with various clinical presentations while some cases may be asymptomatic others exhibit symptoms indicative of compromised oxygen carrying capacity common signs include teoc cardia palar patii papura jaundice respiratory distress High Drops heart failure visible bleeding cyanosis shock or simply acidosis the ideology of neonatal anemia is multifactoral stemming from increased destruction decreased production or simply a loss of red blood cells management of neonatal anemia is Paramount aligning with the ABC's protocol establishing intravenous access is important for the administration of necessary interventions such as blood transfusions or other therapeutic measures a comprehensive approach involves a meticulous followup to monitor hematic levels and assess the effectiveness of any intervention thus ensuring Optimal Care for neonates affected by anemia hyperbilirubinemia is an excessive accumulation of B Rubin in the blood and is a common condition observed in newborns often manifesting as jaundice in some some cases elevated B Rubin levels May reach a threshold that poses a risk of B Rubin induced neurotoxicity necessitating careful monitoring and intervention there are two primary types of jaundice associated with this disease both physiologic and pathologic physiologic jaundice is characterized by total serum B Rubin levels not exceeding 12 m gr per deciliter with a peak typically occurring around 3 to 5 days after birth this form is considered a normal part of newborn physiology on the other hand pathologic jaundice involves the total serum B Rubin levels that are greater than 12 to 15 milligrams per deciliter or a rate of Rise exceeding 0.2 millgram per deciliter per hour or simply greater than 5 mg per deciliter in 24 hours pathologic jaundice may result from impaired bile formation or interrupted bile flow in the intrahepatic OR extrahepatic biliary system when confronted with neonatal hyperbar rubinia the initial steps in evaluation involve distinguishing between unconjugated and conjugated hyperbar rmia through a combination of laboratory tests and imaging studies unconjugated hyperbar rubinia caused by an excess of indirect h b Rubin often stems from increased breakdown of red blood cells or inadequate processing by the liver on the other hand conjugated hyperbar Rubin IA marked by elevated direct B Rubin levels indicates potential issues with B Rubin excretion and can result from conditions such as bilary atricia or hepatobilary disorders once the type is identified appropriate treatment strategies can be implemented phototherapy which is a common intervention involves exposing the infant to specific wavelength of light facilitating the conversion of unconjugated B Rubin into a water soluble form that can then be excreted in cases where severe hyperbar rubinia persists or opposes a risk of B Rubin induced neurotoxicity additional therapeutic options may be considered intravenous imunoglobulin therapy is one such option which utilizes anal bodies to Aid in the clearance of billar Rubin traditionally in critical situations exchange transfusion may be performed which involves the removal of a small volume of the infant's blood and its replacement with donor blood to reduce B Rubin levels",
        "Gastrointestinal Conditions": "rapidly gastrointestinal conditions neonatal gastrointestinal conditions Encompass a spectrum of congenital anomalies affecting various segments of the GI tract these anomalies can manifest as a treesia which represent the complete absence of luminal continuity stenosis characterized by the narrowing of the tract duplication involving the presence of additional Loops of bow and functional obstructions the presentation of such anomalies in neonates is diverse often marked by distinctive symptoms common presenting symptoms include increased salivation particularly during feeding episodes of choking cyanosis and vomiting especially if the emesis is bile stained abdominal distinction may be apparent and affected infants May exhibit signs of GI bleeding such as blood in the stool are failure to pass stool allog together additionally neonates with GI anomalies might display signs of systemic distress including lethargy and irritability given the critical nature of these anomalies prompt recognition and intervention are vital diagnosis typically involves Imaging studies such as x-rays or contrast studies to delineate the anatomical abnormalities once identified appropriate surgical intervention may be required to correct the defect and restore normal GI function some neonatal GI conditions Encompass abdominal wall defects notably gastrosis and omy each requiring surgical intervention for resolution gastrosis is car cized by a full thickness defect in the abdominal wall allowing the protrusion of a Demus intestine and stomach typically this condition occurs as an isolated defect conversely omy involves the herniation of abdominal contents into the umbilical cord it is often associated with various congenital defects both gastrosis and epy demand prompt surgical correction to restore normal anatomy and function ensuring adequate circulation to the protruding organs is Paramount and attention must be directed toward the neonates Airway breathing and circulation rapid transport to a specialized medical facility equipped for neonatal surgery is essential for optimizing outcomes given the delicate nature of these congenital anomalies the provider should be well-versed in neonatal resuscitation protocols and collaborate closely with the medical team the presentation of vomiting particularly if bile stained signals a potential issue within the GI tract that requires urgent evaluation in neonates vomiting is a symptom that Demands a systematic approach to diagnosis intervention congenital GI obstruction becomes a primary consideration when there is evidence of excess Amic fluid during predal assessments this heightened Amic fluid can result from impaired swallowing of Amic fluid by the fetus which can be indicative of a gastrointestinal anomaly the suspicion of congenital GI obstruction in the neonate necess it Ates a thorough clinical exam Diagnostic Imaging studies and potentially surgical exploration to identify and address the underlying cause esophageal atreia is a congenital anomaly that is suspected at neonates presenting with distinct clinical signs the condition becomes apparent when the infant exhibits increased salivation and experiences choking during feeding importantly the vomitus associated with esophagal treesia is characteristically not B stained the severity of the condition often leads to respiratory distress resulting from the aspiration of oral secretions the diagnostic process for this disease offers several key steps the inability to pass a nasogastric tube into the stomach is a noticeable clinical finding that raises suspicion of a gricia to confirm the diagnosis a chest x-ray is imperative the X-ray serves to visualize the anatomical abnormalities specifically assessing the continuity of the esophagus and noting the presence or absence of air in the stomach Additionally the evaluation extends to identifying any Associated vertebral or rib anomalies which may suggest the presence of vter synd syndrome an acronym encompassing various congenital anomalies during Critical Care transport managing a neonate with suspected esophageal atricia requires specific interventions elevating the infant's head helps mitigate the risk of aspiration and placing a suction catheter in the upper pouch AIDS in maintaining a clear Airway by intermittently removing secretions proximal intestinal obstruction in neonates refers to an obstruction occurring at or above the level of the junam this obstruction can manifest as either complete or partial impeding the normal flow of ingested material through the GI tract one noticeable Association is the increased incidence of proximal intestinal obstruction in infants with trisome 21 commonly known as Down syndrome trism 21 is a chromosomal anomaly characterized by the presence of an extra copy of the chromosome 21 and is recognized as a predisposing factor for various congenital anomalies the presentation of proximal intestinal obstruction may vary with clinical manifestations dependent on the degree and location of the obstruction common symptoms include abdominal tension vomiting and feeding difficulties timely recognition and intervention alleviate the obstruction and mitigate potential complications such as bowel perforation or esea management often involves a combination of medical and surgical approaches medical interventions may include decompression through nasogastric tube placement while surgical options may be necessary to correct the an anatomical abnormalities causing the obstruction proximal intestinal obstruction in neonates presents with distinct clinical features including bilious vomiting minimal abdominal dilation and bloody mucoid stools these symptoms collectively initiate a blockage in the upper segments of the small intestine such as the dadum or the gunum bigus vomiting is a key characteristic signifying the presence of bile in the vomited material suggesting an obstruction that prevents the normal flow of bile into the intestine minimal abdominal dilation may be observed reflecting the proximal nature of the obstruction where the bowel proximal to the blockage retains its contents limiting the extent of abdominal distension additionally the passage of bloody mucoid stools known as curant jelly stools is indicative of compromised blood flow and potential mucosal injury in the affected bowel segment these specific clinical manifestations Aid in distinguishing proximal intestinal obstruction from other GI conditions the urgency of diagnosis and intervention is underscored by the potential for severe complications including bow esia necrosis and perforation timely recognition of these symptoms is needed for prompt medical evaluation which may involve Imaging studies such as contrast studies or ultrasound in order to delineate the location and nature of the obstruction mid gut Ulus is a critical neonatal GI condition characterized by the abnormal twisting of the entire mid gut around the superior mesenteric artery pedicle this torsion disrupts the normal blood supply to the affected bowel segment leading to esea potential necrosis and a subsequent Cascade of severe complications the superior mesenteric artery pedicle serves as a vascular structure that supplies blood to the midgut and when torsion occurs it compromises the vascular flow jeopardizing the viability of the involved intestinal Loops the clinical consequences of midgut volvulus are profound necessitating prompt recognition and intervention patients with this condition may present with symptoms such as abdominal distension bilous vomiting and signs of bowel obstruction Additionally the compromised blood flow to the Twisted midgut can lead to esea and if left untreated may result in gain Green in perforation further exacerbating the severity of the situation given the potentially fatal nature of midgut volvulus urgent surgical intervention is imperative the surgical procedure typically involves derotation of the twisted bowel segments and assessment of bowel viability in some cases additional surgical interventions may be required to address any resultant ischemic damage or necrosis the success of the surgical approach is contingent on timely diagnosis and intervention to minimize the risk of irreversible complications distal intestinal obstruction in the neonate pertains to the partial or complete obstruction ruction of the distal portion of the small bowel representing a significant GI challenge this condition often manifests clinically with distinctive features including abdominal distension failure to pass meconium within the first 48 hours after birth and persistent vomiting the nature of the obstruction can vary encompassing both partial and complete obstructions each carrying distinct implications for for clinical management the small ballop struction requires careful assessment and diagnostic scrutiny to identify the underlying calls and determine the appropriate course of intervention a thorough clinical evaluation Often complemented by Imaging studies such as abdominal x-rays or ultrasound AIDS in confirming the diagnosis and guiding subsequent decision-making prompt recognition and intervention are essential in order to mitigate potential complications associated with compromised bowel integrity and function the distal nature of this obstruction implies involvement in the latter segments of the small bowel and the clinical presentation reflects the downstream consequences of impaired intestinal Transit the neonate's inability to pass meconium within the expected time frame underscores the obstructive nature of the condition contributing to abdominal distension and vomiting as accumulating bowel contents en counter resistance imperforate anus A congenital anomaly characterized by the absence or displacement of the anal opening demands immediate attention upon birth due to its potential impact on the neonate's GI and overall health diagnosis is often made in the delivery room where a thorough physical exam reveals the absence of a normal anal opening notably affected infants typically appear asymptomatic at Birth underscoring the need for prompt detection and intervention to prevent potential complications a delay in diagnosing this disease can lead to significant Soliloquy including abdominal distension and perforation highlighting the importance of Swift and accurate identification of this condition to address the immediate concerns associated with imperforate anus essential measures are initiated in the delivery room these include maintaining a Nothing by mouth status to prevent oral intake establishing IV access to provide fluids and placing a nasogastric tube for decompression and intermittent suction the absence of a functional anal opening necessitates careful monitoring and supportive measures to prevent complications and promote the neonate's well-being these interventions address the immediate challenges posed by imperforate anus but also for initiating the appropriate Diagnostic and Therapeutic Pathways that may involve surgical correction to establish a functional anal Passage hrung disease A congenital anomaly characterized by the absence of ganglion cells in a segment of the intestine presents a unique challenge to neonatal GI function the absence of gangan cells leads to the impairment of normal peristalsis resulting in a lack of coordinated intestinal contractions necessary for the propulsion of stool because of this stool accumulates in the affected segment causing a spectrum of clinical manifestations clinically neonates with hrung disease exhibit decreased stooling which is a Hallmark feature indicative of the obstructed nature of the affected bowel segment abdominal distension is a common presentation reflecting the accumulation of stool and gas Upstream of the a ganglionic segment in severe cases where the obstruction is profound the neonate May manifest signs of shock underscoring the potential severity of this congenital anomaly the diagnosis of hrung disease involves various diagnostic modalities such as contrast edema studies and rectal biopsy to confirm the absence of ganglion cells in the effected intestinal segment timely diagnosis and intervention will prevent complications associated with intestinal obstruction and ensure optimal outcomes for affected neonates acute intestinal perforation a critical and emergent condition arises from various etiologies including an obstructed bow necrotizing Intero colitis superpubic bladder aspiration parentesis or spontaneous occurrence this pathological state is characterized by the breach of the intestinal wall leading to The Escape of contents into the peritoneal cavity manifestations of acute intestinal perforation Encompass Progressive abdominal distension respiratory distress hypotention and acidosis reflecting the severity of the underlying pathology when attributable to necrotizing Interac colitis the clinical presentation includes additional features such as abdominal distension feeding intolerance and the presence of grossly bloody stools the combination of these symptoms necessitates prompt recognition and intervention to address the causative factors and mitigate the potentially life-threatening consequences associated with acute intestinal perforation hemat emesis indicative of bleeding from the upper GI tract involves a regurgitation of blood that may be observed in a nasogastric tube aspirate or may accompany episodes of vomiting the blood associated with hemat emesis typically exhibits a bright red Hue signifying its origin from the upper GI structures this clinical presentation suggests an acute hemorrhagic proximal to the ligament of triats the appearance of bright red blood in vomitus or nasogastric aspirat Aids in differentiating upper GI bleeding from lower GI bleeding where the blood is typically darker due to exposure to gastric acids and enzymes the identification of hematemesis serves as a valuable clue for help care providers to initiate prompt Diagnostic and therapeutic interventions to address the underlying cause of upper GI beding and prevent potential complications fabulus characterized by an abnormal twisting of the intestine poses severe risks to affected individuals necessitating urgent medical attention this pathological twisting can result in detrimental consequences such as Gang Green and subsequent death of the affected intestinal segment intestinal obstruction perforation leading to peritonitis and ultimately a life-threatening situation  for the patient recognized as a surgical emergency volvulus demands Swift Intervention when volvulus is suspected immediate measures include maintaining the patient at a state of Nothing by mouth establishing an IV initiating maintenance fluids decompressing the intestines through the insertion of a nasogastric tube and Expediting the transfer of the patient to a surgical center these interventions aim to mitigate the risks associated with volvulus optimize patient outcomes and facilitate timely surgical management interception a condition characterized by the telescoping of one segment of the intestine into an adjacent portion represents a prevalent cause of intestinal obstruction notably affecting children aged between three and six months this pathological telescoping gives rise to a distinctive clinical presentation marked by the passage of bloody stools recognized as a significant concern in Pediatric gastroenterology interception can lead to Bow obstruction aeia and if not promptly addressed potential complications such as necrosis given its propensity to manifest in a specific age group heightened awareness of the symptoms and prompt medical attention allow and ensure an accurate diagnosis and timely intervention often involving non-surgical reduction techniques or in some cases surgical intervention to alleviate the obstruction and prevent further complications diarrhea an uncommon occurrence in neonates is attributed to the presence of maternal immunoglobulin that confer a degree of protection against infectious agents this immunological Safeguard coupled with the relative sterility of the neonatal gut contributes to the Rarity of diarrhea in this population that being said when diarrhea does manifest it necessitates a systematic approach to management maintaining the neonate at a Nothing by mouth status is pivotal limiting the intake of oral feeds to allow the GI tract to rest Sim multaneously establishing intravenous access becomes crucial for the administration of fluid resuscitation to mitigate dehydration and electrolyte imbalances associated with increased fluid losses this approach aims to address the underlying cause of diarrhea and support the neonate's physiological stability during the",
        "Infectious Diseases/Sepsis": "episode infectious diseases and sepsis the susceptibility of neonates to infectious diseases stems from the immaturity of their immune systems neonatal immune defenses are not fully developed rendering these vulnerable infants less capable of mounting robust responses against pathogens consequently when confronted with infection neonates often exhibit a spectrum of clinical signs indicative of symptomatic involvement these signs include diminished activity levels hypothermia hypoglycemia compromised profusion hypotension and episodes of apnea recognizing these manifestations helps for timely identification and intervention given the heightened risk of severe consequences associated with infections in neonates the clinical presentation serves as a prompt for healthc care providers to initiate appropriate diagnostic measures and Institute targeted interventions tailored to the specific infectious etiology to optimize the neonate's chances of recovery as stated neonates face an elevated susceptibility to infection particularly from Group B streptococus and gram negative bacteria which amplifies the risk of sepsis additionally viral infections pose significant threats necessitating prompt and precise management regardless of the Infectious agent the Paramount objective in neonatal sepsis is to fortify the infant's cardiorespiratory stability this involves Vigilant monitoring of vital signs and the maintenance of normothermia to optimize physiological function in cases where signs of shock manifest Swift and judicious fluid resuscitation becomes imperative timely inappropriate interventions are critical in mitigating the adverse effects of neonatal sepsis underscoring the importance of a comprehensive and attentive approach to the care of these vulnerable",
        "Hyperthermia/Hypothermia": "patients hyperthermia and hypothermia hyperthermia in neonates typically results from factors such as over bundling or exposure to elevated ambient temperatures but it can also manifest in the context of a herpes syflex infection or dehydration on the other hand hypothermia is observed across all climates with a higher incidents during winter months notably hypothermia can serve as an early indicator of sepsis underscoring its significance as a potential clinical marker in neonatal care attention to temperature regulation is essential given its diagnostic value and the role it plays in maintaining physiological stability especially in the context of potential infectious etiologies infants owing to their increased surface area to volume ratio exhibit heightened sensitivity to environmental conditions making them prone to Thermal challenges such as hyperthermia or hypothermia in the hypothermic neonate clinical manifest ations Encompass apnea bardia cyanosis irritability weak cry and an overall appearance of lethargy and obtundation additionally Scara characterized by the hardening of the skin with Associated reing and edema may be observed in severe cases hypothermia can lead to complications like thermal shock which is disseminated intravascular coagulopathy and in the gravest instances even death the recognition in prompt management of temperature disregulation in neonates prevents adverse outcomes associated with thermal instability preventative strategies mitigate the risk of temperature disregulation in neonates these measures involve warming the hands before touching the patient employing pre-warm blankets and equipment and ensuring the neonate wears a cap for a critically ill patient once stabilized it is imperative to place them in a pre-warmed incubator or cover them with warm blankets during transport to sustain thermal equilibrium maintaining the infant at the lower margin of normal temperature range typically around 97.5 Dees F prevents both hypothermia and hypothermia contributing to the overall well-being of the patient and reducing the likelihood of associated",
        "Toxic Exposure": "complications toxic exposure toxic exposures of neonates primarily stem from transplacental exposure or intentional Administration by another individual often observed in cases involving children when confronted with such situations a systematic approach is needed for Effective management initiating the assessment with attention to the ABCs it is Paramount to ensure the neonate's vital functions are stable following this establishing IV access is imperative to administer any necessary antidotes or supportive therapies promptly a comprehensive evaluation entails obtaining a detailed history including the circumstances surrounding the exposure and conducting a thorough medical examination this approach enables healthc care providers to identify the specific toxic agent involved assess the extent of the toxicity and Implement targeted interventions to mitigate the potential adverse effects on the neonate's health in cases of toxic exposure leading to respiratory depression such as from narcotics administered during labor the administration of nxone can be considered to reverse the narcotic effects nxen acts as an opioid receptor antagonist rapidly restoring respiratory function however caution must be exercised especially if the mother is a chronic user as an Al lockon Administration in such cases can precipitate seizures and potentially lead to fatal outcomes making it contraindicated in situations where the maternal history is uncertain and acute narcotic intoxication in the infant is suspected ventilator support can be initiated to manage respiratory compromise effectively collabor ation with a poison control center is needed in these scenarios to ensure appropriate guidance and expertise in managing specific toxic exposures and its effects on the",
        "Trauma/Birth Injuries": "patient trauma and birth injuries trauma and birth injuries particularly those involving the head and neck NE are common occurrences during the birthing process While most birth injuries tend to be self-resolving and nonfatal specific conditions may arise vacuum Kut characterized by the accumulation of fluid at the site of vacuum extractor application typically resolve spontaneously within hours additionally Kut cinium a subcutaneous collection of FL fluid in the scalp resulting from pressure during delivery is another transient condition commonly observed these injuries may cause localized swelling but are generally not associated with severe complications continuous monitoring and other clinical observation ensures that these injuries resolve as expected and do not lead to long-term adverse effects on the patient's health serious head and neck injuries during childbirth warrant careful consideration and management subal hematoma characterized by an IL defined mass in the dependent region of the head can also lead to significant blood loss resulting in shock and acute renal failure meanwhile sealo hematoma a sub periostal collection of blood often associated with the linear skull fracture typically resolves over a few months with subsequent calcification a skull fracture identifiable by a slight depression in the skull necessitates attention to prevent complications the management of these head and neck injuries is contingent upon the specific presentation and severity with a focus on addressing potential complications minimizing further trauma and ensuring the overall well-being of the neonate nerve injuries arising during childbirth typically result from hyperextension or overstretching with most instances not necessitating immediate intervention certain nerve injuries demand prompt attention to mitigate potential complications recurrent lenial nerve injury is one such condition that merits treatment due to its potential impact on vocal cords and breathing the intricate nature of nerve function underscores the importance of vigilance in identifying injuries that may compromise neonatal well-being in instances where intervention is required a targeted And Timely approach addresses specific nerve injuries effectively and prevents adverse outcomes particularly in cases where vital functions such as breathing and vocalization are at risk vaginal breach delivery poses a significant risk for spinal cord injury and neonates with the foremost complication being the potential occurrence of nerve injuries this risk is particularly pronounced and the presentation is often marked by distinctive loud snap during delivery in suspected cases a spinal cord injury following breach delivery immediate and prudent measures become imperative the initial step involves a careful immobilization of the neonate's head to minimize further potential damage additionally restraining the infant ensures stability and minimizes the risk of exacerbating the spinal cord injury newborns occasionally experience bone and other injuries during birth with cicular injuries being the most prevalent among these injuries the clavicle or collar bone is susceptible to fracture especially in instances involving a large infant shoulder dyo or the use of delivery instrumentation this fracture when the most common is typically uncomplicated in some cases a clavicular fracture may be accompanied byne thorax warranting additional attention fortunately clavicular fractures generally necessitate minimal intervention healing naturally with limited arm motion within a span of 7 to 10 days birth injuries involving fractures of the humoris or femur necessitate specific management strategies when such fractures occur the limb should be appropriately splinted to prevent further damage and the newborn should be promptly transported to a facility equipped to handle Orthopedic issues intraabdominal injuries although infrequent can manifest with clinical signs such as shock and the development of blue discoloration on the abdominal wall all these cases demand careful evaluation and if identified immediate attention to mitigate potential complications on the other hand soft tissue injuries such as abrasions lacerations and ecosis typically would receive routine care abuse and maltreatment particularly manifested as shake and baby syndrome represent severe forms of trauma and neonates with profound implications for their health shaken baby syndrome a leading cause of mortality in instances of child abuse involves forceful shaking leading to the tearing of bridging veins within the delicate structures of the infant's brain remarkably physical examinations May reveal no overt external signs complicating the detection of this Insidious form of abuse the internal injuries however can be devastating causing life-threatening consequences and longterm neurological impairment the suspicion of child maltreatment particularly in the context of trauma or birth injuries arises when a previously healthy infant exhibits non-specific signs such as feeding intolerance irritability and and vomiting in severe cases the manifestations May escalate to seizures or apnea often indicative of underlying intracranial hemorrhage the spectrum of signs also encompasses blunt trauma to the abdomen Burns bruising and skeletal injuries necessitating a comprehensive evaluation effective management pivots on presentation with the primary objective being the stabilization of the infant's condition and secure transportation to a specialized Treatment",
        "Neurologic Conditions": "Center neurologic conditions differentiating seizures from other motor phenomena such as jitteriness is important in neonatal care seizures characterized by abnormal electrical activity in the brain constitute a medical emergency frequently signaling an underlying medical condition these events can disrupt essential physiological processes affecting cardiopulmonary function feeding and metabolic stability prolonged seizures if uncontrolled may lead to significant brain injury given the potential severity and implications of neonatal seizures prompted accurate identification followed by targeted intervention helps mitigate the risk of associated complications and optimizes the infant's neurological outcomes jitteriness frequently mistaken for seizures is a neurologic phenomenon that poses a diagnostic challenge characteristically jitteriness is a disorder predominantly observed in newborn with infrequent occurrences in older infants this phenomenon is frequently associated with underlying medical conditions such as hypoxic esic and cyop ofy a condition resulting from insufficient oxygenation and blood flow to the brain additionally jitteriness May manifest in the presence of metabolic disturbances including hypocalcemia and hypoglycemia drug with draw especially in infants born to mothers with substance abuse disorders is another common eological factor for jitr the distinctive features and its association with specific medical conditions underscore the importance of a thorough clinical evaluation to differentiate it from True seizure activity seizures in neonates Encompass a spectrum of manifestations including subtle seizures tonic seizures clonic seizures and myoclonic seizures each revealing distinct characteristics subtle seizures are marked by subtle motor activity like apnea eye deviation blinking sucking and rhythmic pedaling of the legs tonic seizures present with a sustained tonic extension of the limbs often accompanied by flexation of the arms and extension of the legs with a higher incidence observed in premature infants clonic seizures involve repetitive localized jerking movements occurring in both full-term and premature infants myoclonic seizures are characterized by rapid and brief flexation jerks affecting the upper and lower extremities distinguishing these seizure types facilitates accurate diagnosis and tailored intervention subtle seizures for instance May manifest as apnea and subtle motor signs while tonic seizures involve more pronounced limb movements seizures and neonates can arise from various underlying causes reflecting the vulnerability of the developing nervous system hypoxic ES schic a consequence of insufficient oxygenation and blood flow to the brain is a common precipitate intracranial hemorrhage characterized by bleeding within the cranial Vault particularly in premature infants is another significant factor intracranial infections such as menitis can provoke seizures as inflammation affects the minies and surrounding structures the developmental defects in the central nervous system May contribute to abnormal electrical activity and seizures metabolic derangements including hypoglycemia and hypocalcemia disrupt the delicate balance required for proper neuronal function potentially leading to seizure activity in the management of neonatal seizures prompt and targeted interventions are essential components of ensuring favorable outcomes immediate recognition and correction of hypoglycemia represent a critical step given its association with seizure activity repeated monitoring of blood glucose levels every 30 minutes allows for ongoing assessment and timely adjustments to maintain glucose homeostasis in cases where apnea is present necessitating respiratory support intubation and ventilatory assistance become crucial particularly during transport pharmacological interventions often involve the administration of anticonvulsants with phenobarbitol and photoin being commonly employed these medications act to stabilize neuronal membranes and prevent the abnormal electrical activity underlying seizures however their use demands careful oversight by a qualified physician to monitor dosage potential side effects and overall efficacy ensuring a tailored approach to each neonate's specific clinical context hypoxic esic encylopedic oxygen delivery or diminished profusion to the brain prolonged periods of aixia prom a redistribution of blood directing more cardiac output to vital organs at the expense of less critical ones this vascular adjustment contributes to the complex pathophysiology associated with hypoxic esic and cyop the aftermath often extends beyond the confines of the CNS manifesting as multiple organ dysfunction further complicating the clinical picture and influencing the infant's overall progress hiie stands as the most prevalent cause of seizures in both term and pre-term neonates with the temporal aspect Associated seizures being noteworthy and typically manifesting within the initial 3 days following birth therefore timely recognition and intervention become important important in addressing hi related complications and optimizing the prospects of neurodevelopmental outcomes lethargy characterized by diminished level of Consciousness and an inability to arouse serves as a critical clinical indicator often pointing towards serious or life-threatening conditions its manifestation can be attributed to a Myriad of underlying factors emphasizing the necessity for a thorough investigation to discern the specific ideology lethargy stands as a clinical red flag prompting urgent attention and intervention due to its association with severe pathological States among the most common culprits leading to lethargy are sepsis severe hypoxia severe hypoglycemia an acute bleeding event such as an intracranial hemorrhage and hypoxic ischemic",
        "Metabolic Conditions": "encylopaedia metabolic acidosis is a physiological disturbance characterized by an abnormal accumulation of cat ions in the bloodstream often involving lactic acid from compromised tissue profusion or toxic byproducts associated with inborn errors of metabolism this condition results from an imbalance between the production and elimination of acid within the body leading to a decrease in blood pH the causitive factors for metabolic acidosis are diverse encompassing conditions such as asphyxia congenital heart disease sepsis inborn errors of metabolism hypovolemia seizures brto cardia hypotention and exposures to certain toxins in the context of NE natal seizures metabolic acidosis can arise as a consequence of the increased metabolic demands during seizure activity the presentation of metabolic acidosis encompasses a spectrum of clinical manifestations each indicative of the underlying disturbance in acidbase Balance compensatory Topia characterized by rapid and shallow breathing is a physiological response aimed at decreasing carbon dioxide levels in an attempt to restore pH modeled or gray skin with delayed capillary refill reflects compromised profusion and oxygenation the clinical picture may also include apnea lethargy and alterations in muscle tone presenting as hypertonia or hypotonia additionally neonates with metabolic acidosis May exhibit feeding intolerance seizures and emesis in managing metabolic acidosis a systematic approach is needed attention to the ABCs ensures adequate oxygenation ventilation and hydration furthermore addressing the root cause of metabolic acidosis is essential as it often of involves targeted interventions to correct the contributing factors hypoglycemia defined as a blood glucose level below 40 milligrams per deciliter constitutes a medical emergency necessitating prompt intervention to prevent potential neurological Soliloquy and mortality the severity is underscored by its capacity to induce brain damage or even lead to fatal outcomes in extreme cases this metabolic derangement is particularly prevalent in specific neonatal populations including infants categorized as either large or small for gestational age those born to mothers with diabetes and infants undergoing stress the clinical presentation of hypoglycemia is characterized by observable signs such as decreased activity jitteriness and notably seizures recognizing these manifestations and promptly addressing hypoglycemia is imperative to mitigate the risk of adverse neurological outcomes and ensure the overall well-being of the neonate hypocalcemia a condition marked by lowlevel of serum calcium is frequently observed in low birth weight infants and may manifest after significant stress as well as an infant's born to mothers with diabetes the implications of severe hypocalcemia extend beyond its mineral homeostasis role posing critical risks such as cardiac arrhythmias seizures and tetany given the role of calcium in neuro transmitter excitability and cardiac function the potential consequences are particularly pronounced in the vulnerable neonatal population hypocalcemia presenting within 1 to two days after birth is a noteworthy phenomenon particularly observed in infants who are fed cow's milk or synthetic formulas characterized by elevated phosphorus content the timing of onset suggests a potential link to the postnatal transition in nutritional sources cow's milk and certain synthetic formulas designed for feeding infants May pose a risk due to their high phosphorus levels which can interfere with calcium absorption and contribute to negative calcium balances in the context of neonatal seizures associated with hypocalcemia specific guidelines for IV calcium Administration are important for infants younger than 24 hours an appropriate intervention involves the administration of an IV infusion of 2 to three Mille equivalents per kilogram per day of calcium d10w during transport this regimen is design designed to swiftly address the immediate Calcium deficiency and mitigate the risk of ongoing seizures on the other hand if the infant is older than 24 hours and Exhibits normal renal function a tailored approach is warranted in these cases providers May opt for the administration of 10% dextrose in 0.25% normal saline supplemented with 10 mil equivalents per kg of potassium chloride all within a 500 ml solution this strategy aims to rectify the hypocalcemic state while concurrently addressing potential electrolyte imbalances and ensuring optimal glucose support during transfer inborn errors of metabolism constitute a heterogenous group of genetic disorders primarily attributed to defects in single genes responsible for encoding enzymes needed to catalyze biochemical reactions these enzymes assist in the conversion of various substances into metabolites that are needed for normal cellular function despite their diversity inborn errors of metabolism are relatively rare occurrences in situations where there is suspicion of such metabolic disorders prompt and precise interventions are imperative one key management strategy involves the cessation of interal feeding recognizing that specific dietary components might exacerbate the underlying metabolic dysfunction simultaneously initiating an IV glucose infusion becomes needed aiming to provide a stable and controlled source of energy this proactive approach implemented before transport aligns with the overarching goal of mitigating the impact of metabolic derangements associated with inborn errors of metabolism congenital adrenal hyperplasia or cah stems from a genetic defect affecting the synthesis of cortisol an adrenal hormone in neonates with cah there may be evident virilizing features reflecting the imbalance of sex hormones due to the disrupted cortisol production sodium loss is a common concern in affected infants manifesting as abnormalities in electrolyte balance and potential dehydration leading to shock in severe cases the acute management necessitates a comprehensive approach focused on normal izing electrolytes and fluid balance this often involves careful monitoring and correction of sodium imbalances to mitigate the risk of shock additionally after a consultation with the physician hydrocortisone replacement therapy is initiated to address the cortisol deficiency aiming to restore hormonal balance and alleviate the symptoms associated with cah",
        "The Transfer Process for a Neonate": "the transfer process for a neonate the process of neonatal transport involves a systematic and well-coordinated approach initiated by The Physician at the referring Hospital the transport request sets in motion a series of essential steps the mode of transportation is carefully selected based on the patient's condition the distance to the receiving facility and the availability of required Services as well as prevailing weather conditions upon the request the transport team comprising Specialized healthc Care Professionals such as a neonatal care provider respiratory therapist and possibly even a physician is mobilized concurrently relevant information is communicated to the critical care transport paramedic assembling necessary equipment for the transport is a critical phase ensuring that the team is well prepared for any emergent situation upon arrival at the referring Hospital the transport team actively engages in further stabilizing the neonate working collaboratively to address the specific needs associated with the infant's seizures and optimize their condition for safe and efficient transportation to the designated medical facility it is imperative for transport Personnel to adhere to rigorous safety precautions if a contagious disease is suspected while focusing on stabilization the transport team diligently gathers essential information and materials including detailed medical records for both the mother and infant radio iaphs laboratory results and information regarding administered medications this collection of this data ensures that the receiving facility is equipped with Comprehensive insights into the patient's medical history and ongoing Care Family communication and support form integral components of the transport process underscoring the need for transparent and compassionate interactions maintaining open communication with the family about the ongoing care and procedures while refraining from providing specific details about the infant's prognosis helps manage expectations and fosters a supportive environment acknowledging the limitations of information and addressing any questions the family may have further contributes to a collaborative and empathetic approach during the challenging situation of of neonatal",
        "Flight Considerations": "transport flight considerations in the context of aeromedical neonatal transport several critical considerations must be addressed to ensure the safety and well-being of the infant with a primary focus on Airway management the establishment of a secure Airway is Paramount before takeoff in instances where inflight intubation becomes necessary attention should be directed towards ensuring optimal ventilation and the proper positioning of the OT tral tube to uphold respiratory function throughout the journey circulatory monitoring during flight is adapted through alternative methods such as assessing cardiac movement or palpating pulsation on a clamped umbilical cord providing valuable insights into the infant's circulatory status oxygenation strategies are modified due to the decreased partial pressure at higher altitudes necessitating careful adjustments to maintain optimal oxygenation saturation levels throughout transport temperature regulation emerges as a critical consideration warranting extra precautions to prevent hypothermia given the potential impact of ambient conditions during flight these key measures collectively contribute to the comprehensive care and safety of neonates during air Medical Transport"
    },
    {
        "The Scoop on Pediatrics": "In This Chapter Understanding the differences between children and adults Assessing pediatric patients in medical and trauma situations Kids are not simply pint-sized versions of adults. Any parent can tell you how different it is to interact with their children as they transition from infant and toddler stages to school-age and teenage form. As an EMT, you need to know what some of these developmental differences are, because they shape your assessment approach for each age group. Anatomical and physiological differences also play a role, not only in the physical findings that you measure but also in the medical and trauma conditions that can be very serious to the child. Many EMS providers find that managing pediatric patients makes them most nervous. Part of the reason is that we see them much less frequently than adult or elderly patients. Especially with infants and toddlers, communication can be a major challenge. Finally, you often have more than one individual to take care of; nervous or frightened parents can present problems of their own. Still, the way to overcome these barriers is to be knowledgeable about pediatric conditions, practice the skills and procedures regularly, engage the caregiver in a way that instills trust, and be confident about your ability to assess and manage the situation.",
        "Sorting Out What Makes Children Different from Adults": "Besides the obvious differences in size and maturity, there are several key differences between children and adults that affect your assessment approach, scene management, and treatment. These differences are developmental, anatomical, and physiological. Developmental differences From the time they are born until they transition to adulthood, children experience rapid physical growth. How they engage with their environment and other humans also changes dramatically. Children can be broadly divided into the following subgroups: Infants: Birth to 1 year Toddlers: 1 to 3 years Preschool: 3 to 5 years School age: 6 to 12 years Adolescent: 13 to 18 years Table 13-1 shows the developmental differences among the groups, as well as their impact upon your assessment and treatment approach. Kids cry when they\u2019re hurt or frightened; this is normal. You should be concerned about a child who is unusually quiet or cries weakly during your assessment and care.",
        "Developmental differences": "From the time they are born until they transition to adulthood, children experience rapid physical growth. How they engage with their environment and other humans also changes dramatically. Children can be broadly divided into the following subgroups: Infants: Birth to 1 year Toddlers: 1 to 3 years Preschool: 3 to 5 years School age: 6 to 12 years Adolescent: 13 to 18 years Table 13-1 shows the developmental differences among the groups, as well as their impact upon your assessment and treatment approach.",
        "Anatomical differences": "There are several major anatomical differences between children and adults that can affect your assessment and treatment. These differences are more pronounced in younger children (infant through preschool age); they begin to disappear as the children age into school age and adolescence. By the time they are 18, most of the changes are complete. Table 13-2 highlights some of these distinctions.",
        "Physiological differences": "Children have incredible demands for oxygen and nutrients as they grow and develop, due to metabolic needs. As a result, children breathe more quickly and their hearts beat faster as compared to adults; blood pressures tend to be lower. Table 13-3 shows the normal ranges in vital signs, based on age. In general, the pediatric patient is usually healthy. Significant problems tend to arise when breathing and/or circulation is compromised. The body attempts to compensate for the problem for as long as possible and then rapidly decompensates when it can no longer do so. You want to be vigilant in observing the child\u2019s level of mentation, breathing ability, and circulatory status, as these may change very quickly.",
        "Managing the Pediatric Patient": "The way that you approach pediatric patients is similar to that of any adult patient \u2014 you evaluate the scene for any safety issues, perform the primary assessment and treat any life-threatening conditions, decide whether the situation is critical enough to require immediate transport, and then perform a secondary assessment. Given what you know about some of the differences between children and adults (see the preceding section), I point out some key differences in the following sections.",
        "Assessment tips": "For children ranging from infant to toddlers, performing the pediatric assessment triangle (PAT) can help you to quickly determine how critical the situation is without rushing right up to the child. As you enter the scene, take a moment to look at the following signs (see Figure 13-1): Appearance: Is the child awake? Crying? Clinging to the caregiver? Those are signs of adequate oxygenation and circulation to the child\u2019s brain. You should be concerned about a child who is quiet, crying weakly, not recognizing the caregiver, or sleepy and hard to arouse. Work of breathing: Keep in mind that fast breathing is fine, so long as the child doesn\u2019t appear tired, anxious, or frightened. Be concerned if the child is working hard to breathe, showing signs of accessory muscle use, or seesaw breathing. Circulation to skin: The skin should have good color. Any mottling, pallor (significant paleness), or cyanosis is a bad sign that requires your immediate attention.",
        "Medical situations": "Several pediatric medical conditions are commonly seen by EMTs. In the majority of cases, your care is supportive \u2014 ensure that problems with airway, breathing, and circulation are identified and managed, and help maintain body temperature and oxygenation during transport. In some situations, you may need to intervene quickly. Table 13-4 provides a list of medical conditions, their signs, and specific treatments.",
        "Trauma situations": "Trauma is the number-one killer of children in the United States. In general, infants and toddlers are most commonly hurt through falls or abuse. In suspected abuse, there may be multiple bruises in various stages of healing. The caregiver may provide a history of the patient being \u201caccident prone.\u201d Injury patterns may be too precise \u2014 scald injuries to just the buttocks and legs of an infant, for example. School-age and adolescent children tend to be hurt through blunt trauma mechanisms involved primarily in automobile crashes or being hit by a motor vehicle while walking or riding a bicycle. Though less frequent, adolescent children are also victims of gunshots and stabbings. Contact sports are another common cause of injuries in children.",
        "Head, brain, and spinal injuries": "Head and brain injuries are common in children due to the relative larger size and weight of the head. Look for signs of injury to the head and scalp, and control any external bleeding. Signs of increasing cerebral pressure (ICP) include altered mental status, headache, and vomiting. Severe ICP may cause the brain to compress, causing unequal pupils and slowing pulse and respiratory rates. Treatment includes providing spinal precautions, preserving airway and breathing, and performing mild hyperventilation in severe ICP.",
        "Chest and abdominal injuries": "The chest wall is more pliable in children than in adults. This pliability provides less protection to the heart, lungs, and upper abdominal organs such as the liver and spleen. If there is a mechanism of injury (MOI) to the chest, evaluate carefully for signs of internal injury, such as respiratory distress and shock. The developing abdominal muscles provide little protection for the organs that lie underneath. As a result, abdominal injuries are more common in children with blunt MOI. Children can mask shock symptoms for some time; evaluate the MOI and assess for possible hidden injuries (as I describe in Chapter 12).",
        "Falls and burns": "As toddlers master the act of walking, falls are common and can sometimes result in bone fractures. Suspect a fracture if the child guards the injury site, can\u2019t put weight on a leg, or is unable to move an extremity without discomfort. Fractures may be incomplete (greenstick fractures) because the child\u2019s bones are more pliable than those of an adult. Splint any possible fracture the same way you would an adult fracture. Burns can be especially harmful to children, as their skin is thinner and offers less protection than adults\u2019 skin. Treat burns as you would in an adult: Extinguish any burning process first, and then dry and cover with dry, clean dressings to help with pain control.",
        "Disaster management for multiple patients": "In disaster management, you can use the JumpSTART method to triage children under the age of 8 years and weighing less than 100 pounds (see Figure 13-2). Patients who can walk are first categorized as \u201cgreen\u201d and sent over to the treatment area, where they can be re-triaged. Patients with a spontaneous breathing rate between 15 and 45 breaths per minute, a palpable pulse, and an appropriate level of consciousness are categorized as \u201cyellow\u201d and are delayed treatment and transport."
    },
    {
        "Introduction": "As technology advances, medicine has become better equipped to extend the life expectancy of individuals who have complex medical conditions. Children with conditions such as hearing impairment, seizures, and extreme prematurity are living with technology that can be both life-sustaining and life-enriching. EMS physicians and prehospital personnel must be familiar with this technology in order to better care for the patients they encounter. According to a recent data query from the Child and Adolescent Health Measurement Initiative, the percentage of children with special needs is on the rise. In 2001, only 12.8% of children in the nation were defined as having \u201cspecial needs.\u201d This number increased to 15% in 2013. Not only are these children increasing in numbers, they also have significant increases in the number of hospitalizations and percentage of hospital days and charges when compared to children without special health care needs. For example, one study showed that this population had an increase in hospitalizations of over 19% from 2004 to 2009, and accounted for 81.7% of the hospital days for all children admitted at 28 children\u2019s hospitals across the country. One study that reviewed hospital discharges from a large pediatric tertiary care center found that 41% of all patients sent home relied on some form of technology. For children included in this retrospective cohort, the most common medical devices were gastrostomy or jejunostomy tubes (10%), central venous catheters (7%), medication nebulizers (7%), ventriculoperitoneal cerebrospinal fluid shunts (2%), and tracheostomies (1%). As this population has grown, there has also been a growing interest in how best to care for these children in the prehospital setting. While focused training programs specifically designed to deal with these patients have been conducted and studied, it is still unclear whether or not they provide a true benefit to either the prehospital provider or the patient. One study reviewing such training programs noted that even in children with special health care needs, simple Basic Life Support (BLS) procedures were much more common than advanced procedures. Such research points out that despite these children\u2019s complex conditions, BLS is likely all that is needed during their prehospital care. While caring for these children, it is important to recognize that the medical and technological complexity of their conditions may greatly compound the likelihood for medical errors to be made. These potential errors range from simple to complex. Something as simple as forgetting to transport a patient with his or her required equipment could pose great problems, not just during the child\u2019s transport but also upon arrival at the health care facility. Of course, more complex errors can be made, such as the failure to distinguish between an obstructed tracheostomy and a ventilator malfunction. Though BLS is what is needed to manage most technology-dependent children in the prehospital setting, familiarity with how to manage common situations in this population is essential for both EMS physicians and field providers.",
        "The caregiver as a resource and the emergency information sheet": "A family member and/or home nurse care for the vast majority of children with special health care needs at home. As such, supplies for their routine care are usually present in the home, and caregivers have a great deal of knowledge with regard to both the child\u2019s medical issues as well as the maintenance and routine functioning of their medical devices. It is essential to recognize the family member and/or caregiver as a vital resource during the prehospital care and transport of these children. However, at least one study showed that over half of caretakers at a specialty clinic visit were unable to report some of the child\u2019s specific diagnoses, and almost 30% could not provide a list of medications. Interestingly, in this same study of 49 caregivers, none of the children wore any medical identification jewelry. While primary caregivers should be considered as the first source for information regarding the child\u2019s care and accompanying medical technology, EMS agencies should also engage with their local hospitals to facilitate the exchange of health information for transported patients. As a result of this potential lack of information on the caretakers' part, especially in times of stress or in their absence, both the American Academy of Pediatrics and the American College of Emergency Physicians have endorsed the use of an emergency information form for children with special health care needs. In addition, many states ask parents to place one in the freezer of the child's home, so that they can be located quickly and easily in the event of a medical emergency. Even when parents are home, the prehospital provider should ask about the emergency information form and verify that it is up to date, since the parent may not be the primary caregiver and/or the person with the child may be distracted in the midst of an emergency situation.",
        "DOPE mnemonic": "DOPE mnemonic When evaluating any device that requires troubleshooting, it is essential to use a systematic approach, such as the DOPE mnemonic. Though this is routinely used with a failing endotracheal intubation, similar concepts can be applied to almost all the devices discussed below. The original DOPE mnemonic reminds us to think about: D - Dislodgment O - Obstruction P - Pneumothorax (for airway) or Peritonitis/Perforation/Pseudocyst (for gastrostomy tubes and ventriculoperitoneal shunts) E - Equipment malfunction",
        "Tracheostomy tubes": "A tracheostomy may become dislodged or obstructed, leading to complications in management of airway and breathing. When tracheostomy tubes are connected to ventilators, pneumothorax and/or equipment malfunction can also lead to respiratory distress or failure. Tracheostomies serve to maintain the airway in a tracheostomy-dependent patient, but they also preserve stoma integrity. Many reasons exist for needing to replace a tracheostomy tube, the most common being difficulty with breathing or ventilation due to a clogged tube, and the second being decannulation, or accidental removal of the tube. The first priority must be maintained airway and breathing for the patient while decisions are made regarding tracheostomy management. EMS providers should assemble appropriate equipment prior to considering replacing a tracheostomy tube. Key equipment includes suction and suction catheters, replacement tracheostomy tube and cannula, if available (families often have their own equipment), and tracheostomy tape or the patient's preferred method of stabilizing the tracheostomy tube. If the child is in distress, first attempt to ventilate via bag and mask, either via the tracheostomy or via the mouth with the stoma site covered. Administering several drops of saline in the stoma prior to suctioning may help to clear debris and/or secretions. If the tracheostomy tube is clogged despite suctioning, remove it with the head and neck slightly hyperextended after releasing the securing ties and deflating the balloon, if present. If the tracheostomy tube is to be reused, cleanse secretions and debris and ensure that the balloon is still functional prior to reinserting it. The tube can be stiffened for reinsertion by inserting the obturator or placing it in cold water. If no replacement tube is available and the old tube is not functional, use an endotracheal tube of similar size by removing the connector portion of the tube, trimming the tube to a similar length as the prior tracheostomy tube, and replacing the connector. Gently insert the lubricated tube, holding it by the flange using pressure in a posterior/inferior direction. Gentle traction above and below the stoma may make passage easier. Once in place, remove the obturator. If unable to pass the tube, a repeat attempt may be tried with a smaller size tracheostomy tube, if available, or a smaller endotracheal tube placed in the stoma. After placement and confirmation, secure it with clean tracheostomy ties or clean stabilization device.",
        "Home oxygen": "Many technology-dependent children require home oxygen. The patient's home oxygen settings can be assessed by observing the flow and FiO2 on an oxygen concentrator and/or oxygen tank in the home. The patient should be transferred over to the ambulance oxygen supply for the transport, but any personal tanks should be brought with the child as they may be needed for the return trip home.",
        "Ventilators": "Children with tracheostomies may require ventilator support for part of the day, if not 24 hours a day. These ventilators generally have battery packs; however, the ventilator should be placed on the ambulance's power supply for transport. The settings should remain standard per the caregiver's instructions, unless concerns for poor O2 saturations, or other signs of poor oxygenation and/or ventilation, are present. For example, if the oxygen saturation is lower than what is normal for the patient or breath sounds are unequal, pneumothorax or equipment failure may be present. Also, if the airway pressures are higher than normal on the ventilator, this may be a sign of airway obstruction. With any of these situations, the prehospital provider should consider maintaining oxygenation and ventilation with a bag-valve attached to the tracheostomy rather than the ventilator. Noting chest rise and an age-appropriate respiratory rate is important in these situations.",
        "Gastrostomy/gastrojejunostomy tubes": "Many technology-dependent children require a method of obtaining nutrition other than by mouth. Most of these children have surgically created stomas into the stomach (a gastrostomy tube) or both the stomach and jejunum (a gastrojejunostomy tube). These tubes can present with a number of complications, but most commonly present with either displacement or obstruction. The more quickly the tube is found to be out, the more likely the success of replacing the gastrostomy tube (G-tube). Families often have replacement G-tubes, or previous G-tubes can be cleansed in gentle solution, rinsed well, and reused. Inspect the site to ensure the stoma is open and no tear is present, and cleanse the site of secretions or debris. Check the G-tube, making sure the balloon is intact and functional. If the tube is in place but seems obstructed, attempt to flush it with 5\u201310 mL of a carbonated beverage (soda, soda water, or sodium bicarbonate solution). If it is dislodged and a replacement tube is unavailable, a Foley catheter can be used in its place. Once the G-tube or Foley catheter is lubricated, gently insert it using light pressure into the stoma. If resistance is met, repeat the attempt with a red rubber catheter. If successful, remove the red rubber catheter and reattempt placement of G-tube or Foley. If still unable to pass, replace the red rubber catheter or use a smaller Foley. Inflate the balloon with 3\u20135 mL of saline or water and once in, check placement by pulling back with a syringe for gastric contents, followed by instillation of air while auscultating with a stethoscope.",
        "Vagus nerve stimulators": "A vagus nerve stimulator (VNS) is a small device that is surgically implanted under the skin. Typically, it is placed near the patient\u2019s clavicle and can be felt with palpation. The device has a wire that leads from the device to the vagus nerve. It is then programmed to deliver a weak electrical current, similar to a pacemaker, which travels along the vagus nerve to the brain. These signals help prevent seizures. In addition, an external magnet can be passed over the device if the patient is seizing or if the patient feels he or she is about to seize, in an effort to abort the seizure. The prehospital provider may be required to pass this magnet over the device, in order to stimulate the device to prevent or stop a seizure. However, despite the presence of a VNS, prehospital providers should continue to provide the same level of care and perform the same general interventions they would normally perform for a seizing patient.",
        "Cochlear implants": "A cochlear implant is generally located behind and above the external ear and aids individuals with significant auditory impairment. In general, these should be left in place and not adjusted or removed during prehospital care. However, the presence of this hardware means that patients with these implants are at higher risk for meningitis, mastoiditis, and intracranial abscesses. So these complications should be considered in the setting of fever, neck stiffness, headache, vomiting, or severe ear pain.",
        "Ventriculoperitoneal shunts": "A ventriculoperitoneal (VP) shunt is placed in children with obstructive hydrocephalus. Obstructive hydrocephalus is common in patients with neural tube defects, such as spina bifida, meningocele, and myelomeningocele. Since the cerebrospinal fluid (CSF) in the ventricles of the brain does not adequately drain, a VP shunt is placed to prevent ventricular swelling, brain herniation, and death. The VP shunt tubing leads from the ventricle and generally courses behind one ear, down the neck, and into the peritoneal space, where the fluid is deposited and reabsorbed by the body. While other types of shunts exist that lead the CSF into various places (ventriculoatrial, ventriculopleural), the VP shunt is the most common. Patients with VP shunts can present with various complications including infection or malfunction, due to blockage or a break in the tubing. Infection may be associated with fever, and both infection and malfunction can be associated with headache, nausea, vomiting, altered mental status, or focal neurological deficits. There is almost never a need for the prehospital provider to access this tubing, but being able to identify it on exam may provide great insight into what may be affecting the patient.",
        "Central venous catheters": "Central venous catheters can exist in a variety of places with varying levels of permanence. If the child has one of these present and it is currently in use, it can be used emergently to deliver intravenous medications and fluids, if a peripheral IV or intraosseous access cannot be obtained first. Patients with central venous catheters are prone to bacteremia and sepsis, so when these children have fever and tachycardia, the prehospital provider should strongly consider giving rapid IV fluids.",
        "Conclusion": "While technology-dependent children are not the most common patients encountered in the prehospital setting, becoming familiar with commonly used devices can increase one's confidence significantly. In addition, EMS agencies should identify patients who are technology dependent in their local area in order to know their individual needs prior to an emergency. Remembering to use the caregiver as a resource and to ask for an emergency information form can provide providers with valuable information regarding the patient's specific medical conditions. Finally, relying on home equipment during transport can ensure an uneventful transport with the necessary supplies for a safe arrival."
    },
    {
        "Introduction": "Injury is the leading cause of death and disability in children, and adolescents, young adults, and pediatric patients constitute 25% of all injured patients in the United States. While overall mortality is one-third the rate of trauma deaths in adults, case fatality rates for children are higher. In other words, for equivalent trauma severity, children are more likely than adults to die during transport and resuscitation. Although prehospital encounters with pediatric patients represent a small fraction of EMS transports, traumatic injury is the most common chief complaint for EMS response in the pediatric age range. Most injuries in children fall into the category of minor trauma, such as contusions and lacerations, and typically require straightforward application of the basic tenets of wound care, splinting, and immobilization. However, being prepared to manage major multisystem pediatric trauma involves a thorough understanding of the unique anatomical and physiological characteristics of the pediatric patient, as well as a working appreciation of pediatric growth and development. The effect that these factors can bring to bear upon injury presentation and patient assessment, and thus the establishment of resuscitation and treatment priorities, is significant. The following discussion is organized around a system-based inventory of what makes children different and an analysis of how these differences can affect the approach to the pediatric trauma patient. The clinical implications of these unique attributes are highlighted in the context of the trauma survey. Also important is a basic appreciation of injury mechanisms in children, as they differ from those in older patients. The recognition of particular injury patterns can be important clues in the field assessment and management of the pediatric trauma patient.",
        "Anatomical and physiological considerations": "There are several key anatomical and physiological characteristics unique to the pediatric patient of which the prehospital professional needs to be aware when evaluating an injured child. These characteristics can affect the presentation of traumatic injuries, especially in young children, and require a heightened index of suspicion during the trauma survey for subtle signs and symptoms of occult injury.",
        "General": "Because of a child's smaller body size, traumatic forces can be distributed over a larger area, thus making multisystem trauma the rule rather than the exception with childhood injuries. Children often sustain internal injuries with little or no external evidence of trauma. Thus, as a general rule, internal injury cannot be ruled out in a child merely based on the absence of external signs of trauma. Children also have a large surface area to body mass ratio and are particularly vulnerable to thermoregulatory derangements from prolonged environmental exposure. Particularly in infants, the relatively large head can be a source of significant unrecognized heat loss in a trauma resuscitation situation. The simple placement of a cap on the head of an infant during transport and turning up the heat in the ambulance can help to obviate this problem.",
        "Head": "Head injury is the most common cause of serious trauma in children. The disproportionately large head in young children functions like a 'lawn dart,' causing them to lead head-first during falls or rapid deceleration mechanisms, such as car crashes. More than 80% of multisystem pediatric trauma cases involve the head and nearly one-third of all childhood injury deaths result from head injury. Among the highest priority early interventions in the management of multisystem pediatric trauma are those directed at limiting the severity of traumatic brain injury and preserving brain function.",
        "Airway": "The pediatric airway has several unique anatomical features with which the prehospital professional must be familiar to ensure successful airway management. These features are usually present until about 8 or 9 years of age when the airway assumes more of an adult configuration. Because of the relatively short neck, particularly in young children, the larynx is more cephalad and far more anterior than what would be visualized on direct laryngoscopy of an adult patient. In fact, the cricoid pressure provided by the Sellick maneuver is not only necessary to occlude the esophagus during endotracheal intubation, but is often required to actually bring the airway into view. The diameter of the pediatric airway is obviously much smaller than the adult airway and is far more vulnerable to compromise from relatively small amounts of obstructive material, blood, or edema. The tongue is a relatively larger structure within the mouth and is actually the most common cause of upper airway obstruction in the young child. The epiglottis is a floppier, U-shaped structure that generally requires use of the straight Miller blade to control it directly and provide adequate visualization during intubation. The narrowest part of the pediatric airway is the subglottic region, below the vocal cords, as opposed to at the cords themselves. This 'physiological cuff' obviates the need for cuff inflation or for cuffed endotracheal tubes altogether before 8 years of age. Children are obligatory abdominal breathers and depend on sufficient diaphragmatic excursions to ventilate properly. Swallowing air, or aerophagia, with subsequent gastric distension is common in the trauma resuscitation setting. Gastric decompression with an orogastric or nasogastric tube is required to prevent disruption of ventilatory mechanics.",
        "Spinal column": "Although vertebral injuries in children are uncommon, the cervical spine has a high injury risk potential due to the large head being supported by relatively weak neck muscles and elastic supporting ligaments. Through the age of 8, anatomically, the pediatric c-spine has a higher fulcrum (C1-C2) compared to adults upon extreme flexion-extension of the neck. Therefore disruption of innervation to the diaphragm (phrenic nerve) and accompanying ventilatory impairment must be a consideration in high-energy mechanisms in which neck injury with vertebral fracture is a possibility. Compression fractures to the thoracolumbar vertebral bodies are a possibility in rapid deceleration from a motor vehicle crash when a child hyperflexes over a lap belt which is improperly positioned across the abdomen. This circumstance is typically the result of young children being prematurely advanced to adult restraint systems when they still require the use of belt-positioning booster seats.",
        "Cardiovascular": "The cardiovascular response to hemodynamic instability from bleeding in young children is one of rapid and accentuated vasoconstriction with limited stroke volume boosting capacity. The ability to increase cardiac output is almost entirely dependent on the capacity to increase heart rate because of the diminished compliance of the immature ventricular myocardium. Tachycardia is the earliest and most sensitive sign of impending hemorrhagic shock in children and must always be explained in the evaluation of any injured child. The prehospital professional must also appreciate that normal ranges for pediatric vital signs are age dependent, and that convenient access to a reference guide is prudent. The total circulating blood volume in a child is 70\u201380 cc/kg and children will maintain compensatory vasoconstrictive mechanisms in the face of hemorrhage until 25% blood volume loss, after which uncompensated shock rapidly ensues. Particularly in young children, relatively small volumes of blood loss can precipitate hemorrhagic shock and it is incumbent upon the prehospital professional to note external evidence of blood loss on the scene and maintain a high index of suspicion for occult blood loss, especially in the face of tachycardia. Even an isolated laceration to the highly vascularized scalp of an infant can produce significant enough blood loss to warrant volume resuscitation.",
        "Musculoskeletal, chest, and abdomen": "The pediatric musculoskeletal system is generally more pliable and elastic than an adult's and, therefore, less likely to yield fractures in response to equivalent mechanical force. For example, significant blunt force trauma can be distributed to the intrathoracic cavity without evidence of rib fractures. Therefore, injuries like flail chest are uncommon in children, yet high-energy transfers can exert significant injury directly to the heart and lungs. The mediastinum in a child is hypermobile and can be significantly displaced, for instance, by a tension pneumothorax with concomitant kinking of the great vessels. Loss of pulses or other sudden change of vital signs should raise suspicion for this possibility. The ribcage itself is more horizontally oriented than in adults, exposing the liver and spleen which themselves are poorly protected by underdeveloped abdominal muscles and by the absence of a fat pad. This same orientation is responsible for excursion of the diaphragm on full exhalation as high as the nipple line with concomitant presentation of underlying abdominal organs high in the thoracoabdominal cavity. The clinical implication is that injuries to abdominal organs can occur after chest trauma alone. In the developing long bones, the ligamentous structures are actually stronger than the nearby growth plates, explaining why fractures at the epiphyseal-metaphyseal region, the weak cartilaginous areas, are more common in children.",
        "Injury patterns": "Children in the United States are far more likely to sustain blunt trauma than are adults; blunt force mechanisms represent nearly 90% of the pediatric injury burden. Motor vehicle occupant injuries remain the leading cause of death in the pediatric age group. Although penetrating injury mechanisms are far more typical of adult patients, firearm injuries among children, especially unintentional, are a growing concern, as are intentional firearm injuries among adolescents for whom gun violence is the most common cause of penetrating trauma. Children are typically injured as a function of their activity or location. Thus, being aware of common patterns of injury based on mechanism as part of the assessment of the pediatric trauma patient is important. Three examples are Waddell's triad, handle bar injuries, and the lap belt complex. Waddell's triad refers to the multisystem injury pattern seen when a child pedestrian is struck by a vehicle. This mechanism can produce lower extremity (femur) fractures from direct contact with the bumper, chest and abdominal trauma caused by being thrown onto the hood, and, finally, head injury when the child strikes the pavement, as described above, lawn dart style. Bicycle falls produce a range of injuries from minor abrasions and contusions to major head injury in unhelmeted riders. However, contact with the bicycle handle bars during a fall can cause intraabdominal trauma, such as a duodenal hematoma, which, clinically, may be very subtle and notoriously late-presenting. The prehospital professional must have a high index of suspicion for such injury when soliciting a history that reveals this mechanism. The lap belt complex refers to a constellation of signs and possibly symptoms associated with hyperflexion over the top of an abdominally positioned lap belt during rapid deceleration in a motor vehicle crash. The presence of an ecchymotic bruise across the abdomen can be an important clue to underlying intraabdominal (especially hollow viscus) injuries, as well as vertebral compression fractures to the thoracolumbar spine. These injuries can also have a delayed clinical presentation, thereby making recognition of the mechanism and associated injury pattern essential. The prehospital professional may encounter traumatic injuries that seem inconsistent with the developmental motor capability of a young child to have sustained as a result of an unintentional mechanism. This circumstance should be a red flag for suspected intentional injury or child abuse. Child abuse is the most important cause of visceral injuries in children under the age of 3.",
        "Pain management": "Due to the wide range of developmental and communication variability in assessing pain in children and unfounded concern about masking injury, pediatric trauma patients are frequently undertreated with analgesics. Recent national efforts to define an evidence-based approach to pain management in all injured patients strongly support weight-based opioid dosing, with either intravenous morphine sulfate, 0.1 mg/kg, or intranasal or intravenous fentanyl, 0.1 \u03bcg/kg. Redosing if pain persists upon 5-minute reassessment is also strongly recommended.",
        "Resuscitation and management priorities": "The approach to the trauma survey is basically the same as in adults. The sequencing of the steps in assessment of the injured child must be primarily attendant to the integrity of the airway and adequacy of ventilation, along with protection and immobilization of the cervical spine as necessary. Controlling bleeding, establishing vascular access, and supporting circulation are also primary management priorities. As the prehospital professional completes the trauma survey and head-to-toe secondary assessment, there are several pitfalls and caveats based on the aforementioned unique characteristics that must be kept in mind. Failure to recognize the subtle signs of early shock. Tachycardia is the most sensitive measure of compensated traumatic shock, usually hemorrhagic, in an injured child and should never be dismissed. Also crucial is understanding that responsiveness inconsistent with expected developmental stage suggests a derangement in sensorium secondary to early shock and compromise of cerebral perfusion. Failure to suspect abdominal injury in multiple trauma. Small size, greater surface to mass ratio, poor protection of viscera by muscle or fat, and compliant musculoskeletal system all contribute to the widespread internal distribution of kinetic energy forces in multisystem trauma. The absence of external signs of injury should never rule out intrathoracic or intraabdominal injuries. Acute gastric dilation mimics visceral injury. Swallowed air with gastric distension can not only mimic injury but may interfere with diaphragmatic excursion and thus impair ventilation. Decompression with passage of an orogastric or nasogastric tube will ameliorate this preventable complication. Inadequate pain management. Oligoanalgesia, or underdosing of pain medications in the field, may be more common in pediatric patients due to communications challenges in the way that children manifest and express pain and/or in the way that providers may subjectively interpret it. Appropriate weight-based dosing of opioid analgesics (morphine or fentanyl) should always be offered in the management of moderate-to-severe pain associated with traumatic injury.",
        "Field triage": "The Centers for Disease Control and Prevention's 2011 Guidelines for the Field Triage of Injured Patients introduced a modification to the Step 1 criteria that recognizes that patients requiring ventilatory support, independent of respiratory rate, require immediate transport to a trauma center. This revision is particularly appropriate for pediatric patients acknowledging that adults and children in need of ventilatory support, including both bag-mask ventilation and intubation, represent a high-risk group, whether or not their respiratory rate falls outside the specified ranges of <10 or >29 breaths per minute (<20 in infant aged <1 year)."
    },
    {
        "Introduction": "For the past several decades, most prehospital research has been conducted with adult participants, largely because it is difficult to access and study the pediatric patient population. In addition, the original models for EMS were focused on trauma (primarily from military experience) and cardiac emergencies, both populations and experiences that did not include children. However, decades of research focusing only on adults have left gaps in the epidemiology of EMS calls for children and on critical treatment information for children. This is disturbing because approximately 5\u201310% of EMS calls are for children. Pediatric emergency medicine is a relatively young field; as recently as the late 1970s, there were no pediatric emergency medicine textbooks or journals. In addition, although the quantity of research conducted in pediatric emergency care has increased considerably over the past 25 years, there is still little evidence on which to base the prehospital treatments for children as most data are hospital based or extrapolated from adult data. Gaps in knowledge include such basic information as developing the EMS system to include consideration for pediatric patient care, pediatric assessment, and key training aspects for providers. Further, many of the treatments and management strategies practiced by EMS providers today are not supported by scientific evidence. The lack of adequate data and limited research funding are among the most serious barriers to the advancement of research in pediatric emergency care. Despite an increase in the amount of pediatric emergency care research in the past two decades, and a corresponding increase in pediatric prehospital research due to the efforts of several very committed researchers, centers, and networks such as Pediatric Emergency Care Applied Research Network (PECARN), research to guide optimal prehospital treatment of children for most conditions remains minimal, research directed at outcome measures versus process measures is scarce, and research on the key aspects of effectively teaching providers how to care for children and both establishing and maintaining competency is lacking. The reasons for this deficiency are numerous. One obvious issue is that conducting pediatric prehospital research involves navigating the barriers imposed by conducting prehospital research as well as those obstacles related to conducting pediatric research and those related to educational research. This chapter will build on other chapters on prehospital research by discussing issues unique to conducting pediatric prehospital research.",
        "The need for pediatric prehospital care research": "Children represent one-fourth of the US population, which translates to more than 73 million infants, toddlers, school-aged children, and adolescents. Furthermore, each age group has very different emergency care needs. For example, the Ontario Prehospital Advanced Life Support (OPALS) study group found that pediatric cardiopulmonary arrest patients were more likely to have unwitnessed cardiac arrests and receive no bystander cardiopulmonary resuscitation (CPR). The most common arrest etiologies reported were trauma, sudden infant death syndrome, and respiratory disease. Studies such as OPALS provide important information about pediatric patient demographics and the epidemiology of the illnesses and injuries encountered by EMS providers, which is essential to the design and conduct of more in-depth pediatric prehospital care research. Although some of this preliminary research has been done, basic questions still remain. For example, the age distribution of patients treated by EMS, their typical illnesses and injuries, and preexisting medical problems are poorly understood. This type of descriptive research could assist in designing prehospital systems and could also provide baseline data for future analyses by allowing researchers to determine areas of potential study, feasibility of the study within a system, and study planning information such as sample size calculation data. An additional area for which research is needed is the field of pediatric critical care transport. While neonatal transport might be considered one of the earlier areas of prehospital care, it only represents a small fraction of pediatric critical care transport. Despite being in existence for decades, the actual research on indications for transport, education of providers, and validation of outcomes provided during transport unique to the prehospital environment is scant. The view traditionally has been transport using in-hospital providers with validated in-hospital therapies. The assumption that this will work and its application when in-hospital providers are not used is questionable. With advances in neonatal and pediatric critical care, children who in the past may have not survived are now surviving initial resuscitation and/or are candidates for further care. Therefore research on when it is appropriate to use these scarce pediatric critical care interfacility transport resources, which interventions during transport improve outcomes, and how to effectively educate providers is vitally needed.",
        "Challenges unique to pediatric prehospital researchers": "Many challenges must be overcome when conducting pediatric prehospital research. Many of these are similar to those barriers encountered when conducting general prehospital research and have been covered in other chapters. In addition to these, however, the research population itself presents some challenges which are unique to EMS but which are also common to any pediatric research activity. These include defining a \u201cpediatric\u201d patient, the limited numbers of pediatric patients seen by a typical EMS agency, and the different ethical standards to which pediatric research is held. Specifically, compared to adult studies it can be more difficult to recruit pediatric research participants, to obtain community support for exception from informed consent, and to obtain assent from parents/guardians.",
        "Status of pediatric prehospital research": "The Institute of Medicine\u2019s (IOM) 2006 report Emergency Care for Children: Growing Pains focused on how pediatric emergency services are (and are not) integrated into the nation\u2019s health care system. Among the issues discussed were emergency care planning, preparedness coordination, funding for pediatric emergency care, training of pediatric emergency care professionals, unique characteristics and needs of pediatric populations, and pediatric emergency care research. The report indicated that, although some progress has been made since the first IOM report on EMS for children was published in 1993, there is still a long way to go to improve the accessibility, quality, and cost of emergency care for children in this country. In addition in its 2009 interim report, the National Commission on Children and Disasters found \u201cdeath rates due to pediatric injury have dropped by 40 percent since the EMSC program was established. Despite this progress, the gap between adult and pediatric emergency care on not only a day-to-day, but also a disaster basis, is sufficiently large as to require substantial increases in funding for EMSC\u201d and \u201cA significant amount of improvement must still be made to ensure that the emergency care system is prepared for the care of children in both everyday emergencies and disasters.\u201d From the development of the National EMS Research Agenda in 2001 to the publication of the National EMS Research Strategic Plan in 2005, there has been an exponential increase in prehospital research, yet there is still little research that has been conducted on the prehospital care of children. The 2006 IOM report characterizes the state of pediatric emergency care as a multifaceted crisis, affecting all aspects of emergency care. To drive continued improvements in care, the report asserts that pediatric prehospital care research must become a priority. While its own discipline, the intersection of disaster medicine and public health preparedness with prehospital medicine, is clear, the need to understand the role and interventions provided in disasters, terrorism events, and public health emergencies is imperative. The research base for pediatric issues in disaster medicine is severely limited based on the same barriers as other areas of pediatric research combined with the challenges of research in disasters. It is important to note the progress made by the development of some federally funded research networks with the mission of conducting high-quality multicenter collaborative research throughout the United States. One is PECARN, initially funded in 2001; another is the NIH-funded Resuscitation Outcomes Consortium (ROC). Although these networks can potentially conduct pediatric prehospital research, little has emerged to date.",
        "Defining the \u201cpediatric\u201d patient population": "In order to conduct any research, one must define both inclusion and exclusion criteria. For the inclusion criteria, basic definitions and biographical/demographic information are key. One can easily understand that a clear definition of the age groups under investigation is critical for anyone conducting quality pediatric prehospital research. One must be clear on how the term \u201cpediatric\u201d or \u201cchild\u201d will be defined. Whereas the legal definition of a minor in the United States is a person younger than 18 years of age, the definition of \u201cadult\u201d versus \u201cchild\u201d can be highly variable in both the hospital and prehospital settings. The definition can range from as young as 8 to as old as 18 and there may different ages for classifying as adult or pediatric based on presentation, such as one for trauma patients and one for all other patients. There may also be variability even within the same EMS system due to individual hospitals having different criteria for what they consider a pediatric versus adult patient. In addition, within pediatrics some studies would require further subcategorization, such as neonatal, toddler, school age, or adolescent. Another problem which often occurs is that although most prospective prehospital trauma studies limit inclusion to adult patients, the definition of \u201cadult\u201d can vary from individuals 15 and older up to those aged 18 years and older. The Centers for Disease Control and Prevention (CDC) statistics, hospitals, and others often use data in which children are considered \u201cadult\u201d at age 15, 14, or even 13. However, the federal Emergency Medical Services for Children (EMSC) program defines \u201cchildren\u201d as ages 0 through 21 years, in accord with the American Board of Pediatrics, which defines the field of pediatrics as encompassing patients 0 through 21 years of age. There is no common age-based definition of pediatric, which hinders researchers\u2019 ability to compare findings across studies. It is therefore important for the prehospital researcher to very clearly define the study population and, even more importantly, be prepared to address the need when aggregating data to exclude ages which do not meet their inclusion or aggregate some adult data. The upper age range for pediatrics is the source of most debates over inclusion criteria. Although heterogeneity in age may confound a study\u2019s findings due to anatomical, physiological, and developmental differences, it is important to note that postpubertal patients between 15 and 20 years of age, while psychologically different from an adult, are physiologically and anatomically almost identical to young adults. It may be even more important for an investigator to recognize that as a child matures toward mid-adolescence, he or she undergoes many developmental, anatomical, and physiological changes which may make this small age range for some studies very heterogeneous. Therefore, studies must often be stratified by age so that developmental differences do not bias the study results. Also, if there is sufficient sample size, a multivariate analysis could be conducted with age included in the model as a continuous variable.",
        "Sample size": "When planning for any well-designed research study, and especially a randomized controlled trial or population-based study, the researcher must recognize that no single hospital or EMS agency is likely to have access to sample sizes large enough to answer important questions about critically ill or injured children. The few existing studies on pediatric EMS demographics have shown that these patients account for approximately 10% of EMS call volumes, of whom only 10\u201320% actually have critical complaints. This presents researchers with a problem in obtaining a sample size sufficiently large to conduct a meaningful study. This challenge is not unique to pediatric prehospital research, however, because it occurs in most pediatric research. One solution is research networks using multicenter study methodologies; when researchers from different institutions pool data, these challenges are successfully met. The large numbers of patients included in the networks allow researchers to carry out trials designed to evaluate rare conditions or complications. The problem is that solutions such as multisite research or establishing collaborative research networks are challenging in any environment, but even more so in prehospital research. Although pediatric emergency medicine networks do exist, true pediatric prehospital research collaborative groups do not. Therefore, there is really no preexisting mechanism to support the multisite research needed to achieve the numbers required for a research study. As a result, researchers frequently must establish their own multisite collaborative networks. Because the accessible sample for pediatric research is limited and multicenter mechanisms are limited at best, it is imperative that, whenever possible, pediatric prehospital researchers use standard definition sets and variables. This will permit combination of data sets and allow metaanalyses to be conducted so that while a single study may not reach significance, the aggregation using metaanalysis methodology could reach significance. One data definition standard that could be used for pediatric prehospital research is the Pediatric Utstein Style. This consensus document is an attempt to provide an organized method of reporting pediatric resuscitation data in the out-of-hospital, emergency department, and in-hospital settings. Further work is needed to establish broader data definition standards for pediatric EMS research.",
        "Epidemiology": "While it is vital to define what is the pediatric population, it is also key to conducting research to know the epidemiology of the population studied. Information such as sex, age ranges, disease and injury prevalence, ethnic variation, and types of requests for prehospital assistance is essential. This information allows the researcher to determine areas where research may be needed. It is also vital to determine whether a study is feasible. For example, if one knows the epidemiology of the population one wishes to study, one can perform calculations such as power analysis to determine if there is even the possibility of the research results reaching significance and whether it can be conducted within that system or, as described above, may require multicenter studies. Lastly, this information allows one to know whether the study population is a true reflection of the actual population and thus can be extrapolated.",
        "Institutional review board approval": "Other chapters cover the issue of obtaining institutional review board (IRB) approval and the unique obstacles faced by prehospital researchers. Ethical issues regarding pediatric patients can be even more controversial and challenging. For example, a child younger than 18 years of age cannot legally give consent as a research participant; the child must give his or her assent to participate and have a parent or guardian provide consent. Further, when children are research participants, IRB members may be more hesitant to approve studies that involve waiver of or exception from informed consent. This is ostensibly because pediatric subjects are considered a more vulnerable population, but there may also be an element of cultural and moral reluctance to \u201cexperiment on children.\u201d In addition, expedited review processes often preclude a study population involving children due to them being considered a vulnerable population. Lastly, in some prehospital research where consent is not feasible, while a difficult hurdle, researchers may use mechanisms allowed for consent in emergency situations. As other chapters have described, this approach includes many specific processes including community consultation and significant exclusion provisions. While not technically impossible, obtaining such an approval for a study involving children who are considered by IRB rules a vulnerable population and who in community perception should not be \u201cexperiments\u201d is in actuality almost impossible.",
        "Informed consent \u2013 pediatric assent": "Pediatric studies requiring consent are more complicated than adult studies because subject assent is necessary in addition to the consent of a participant's legal guardian. This means that, at a minimum, two groups of people must agree to participate in the study. Similar to consents, assent documents must be submitted to the IRB for approval. Depending on the age of the children involved in the study, there may need to be several forms available that are appropriate for each age group. It is also recognized that not all children have the developmental ability to provide assent; children who are too young may not need to give formal written assent. For those who can understand the issues addressed and questions asked, obtaining the child\u2019s assent must be part of the process. Further, the assent document may be more detailed for adolescents than it is for younger children.",
        "Priority areas of research": "One could ask many questions when conducting pediatric prehospital research. Several groups have tried to prioritize questions to direct researchers to first answer what are considered the most important ones for the field. Examples of these attempts include the Pediatric Emergency Medicine Research Agenda, EMSC priorities, and recent research highlights in the 2006 IOM report. Some examples of areas that are priorities for research include but in no way are limited to the following. Although pediatric skills deteriorate quickly without practice, continuing education in pediatric care for many EMTs is not required by law or standard practice, or availability is extremely limited. The ability of prehospital providers to acquire pediatric skills, the training needed, and the ability to retain these skills has not been widely studied. All prehospital pediatric protocols are based on the assessment by the prehospital provider, yet there are no studies of the accuracy of such assessments. Many medications prescribed for children are \u201coff-label,\u201d meaning they have not been adequately tested or approved by the US Food and Drug Administration for use in pediatric populations. Further study is needed to verify that these medications, including some used in the prehospital setting, are safe and effective in children. Pediatric treatment patterns vary widely among emergency care providers. Many of these providers do not properly stabilize seriously injured or ill children, many undertreat children in comparison with adults, and many fail to recognize cases of child abuse. Investigations into the occurrence of these issues and efforts to mitigate the deficiencies are needed. Many of the challenges faced in pediatric prehospital care are exacerbated in rural areas, where dedicated, well-intentioned prehospital providers often lack any specialized pediatric training or resources. Research into the abilities and effectiveness of those not specifically trained in pediatric care is needed. Traditional hospital-based providers and thus hospital data were used to guide the early development of pediatric neonatal and critical care transport. Much research is needed in this field, on such issues as the criticality of the patients transported, the use of non-hospital-based providers, predictors of when transport is appropriate and will alter outcome, which techniques can be provided during transport and change outcome, and how we effectively educate providers and assure competency. Recognizing the needs of prehospital systems and providers to be prepared and to act in times of disasters, terrorism, and public health emergencies, it is vital that research on the unique needs of children in these situations be undertaken. Finally, in a 2008 publication addressing a PECARN-specific research agenda, Miller et al. provide a ranked list of 16 multicenter EMSC research topics. Priorities for PECARN researchers included respiratory illnesses/asthma, prediction rules for high-stakes/low-likelihood diseases, reduction of medication errors, injury prevention, and acuity scaling. These are all topics that can be answered through the multicenter network and it is hoped will provide answers to some of the important clinical questions they represent.",
        "Moving forward: challenges and opportunities": "Clearly the researcher who addresses the prehospital care of children has opportunities to gain knowledge and improve care that far outweigh the challenges posed by the nature of this diverse, vulnerable, and complicated population. Several key gaps still remain, most of which have been identified in the IOM reports and, more recently, by PECARN research agenda. In pediatrics as well as in other prehospital research, there are times when traditional clinical research methods based on directed questions and conducted in a limited number of sites to control all the factors do not translate well to the uncontrolled, multitasking EMS environment. Unfortunately, in some cases the inability to conduct research has led to the use of treatments and practices that have never been studied. However, there are now several resources and some databases available to research teams. These include assistance from professional associations such as the American Academy of Pediatrics, American College of Emergency Physicians, National Association of EMS Physicians, and Emergency Nurses Association as well as academic institutions, state departments of health and EMS, federal agencies (e.g. the federal EMSC program housed at the Maternal and Child Health Bureau, the Agency for Health Care Research and Quality, the CDC\u2019s National Center for Health Statistics and National Center for Injury Prevention and Control, and the National Institute for Child Health and Human Development), and federally funded resource centers and research collaborations (e.g. PECARN). There are fewer excuses in the 21st century to exclude children from prehospital research and myriad compelling reasons to include this population and improve the care of children in the prehospital setting."
    },
    {
        "Introduction": "Approximately half of the EM responses to calls for pediatric patients are for medical complaints. Calls for medical complaints outnumber traumatic calls in patients under 5 years. Seizures and respiratory distress are common pediatric medical complaints. Other less common conditions, such as shock, cardiac arrest, and apparent life-threatening events (ALTE), require careful education and training. Controversies exist over management of the pediatric airway, and there is still a need to address the research agendas calling for improved evidence for out-of-hospital pediatric care.",
        "Respiratory and airway problems": "Cardiopulmonary arrest in the majority of infants and children is respiratory in origin. Appropriate and timely treatment of a child in respiratory distress may prevent respiratory and subsequent cardiac arrest. Many respiratory diseases are unique to children; however, the underlying treatment is the same as for adults: maintenance of the airway and adequate oxygenation and ventilation. Evaluation of the very young patient with respiratory complaints should take place in the parent\u2019s/guardian\u2019s arms if possible. The respiratory rate can increase with fear, and an anxious child may resist therapy and become more distressed. Signs of respiratory distress include a child in tripod position or refusing to lie down, nasal flaring or retractions, and grunting or head bobbing in infants. Interventions may be accomplished more easily with the parent\u2019s assistance. Moving a child from a position of comfort might worsen the respiratory distress. During transport, a child in respiratory distress should be safely restrained in an upright position, unless specific treatments require the supine position. All children in respiratory distress require supplemental high-flow oxygen, such as a face mask at 12\u201315L/min. The 'blow-by O\u2082' method administers oxygen by holding the face mask 1\u20132 inches in front of the child\u2019s face, and is useful when a face mask increases the child\u2019s agitation and work of breathing. If the child is cyanotic, oxygen with assisted bag-valve-mask (BVM) ventilation may be required. The airway should be managed in the least invasive way possible \u2013 supraglottic devices and endotracheal intubation (ETI) should be used only if BVM ventilation fails. Anatomical differences in infants and children affect airway management. The occiput is proportionally larger and causes neck flexion in the supine position. Placing a towel roll under the shoulders can improve airway alignment. The tongue is large relative to the oral cavity and is a source of upper airway obstruction. Children have larger tonsils and adenoids. Attempts at nasopharyngeal airway placement or intubation may cause bleeding. During endotracheal intubation, the straight blade is preferred to the curved blade due to the weaker hyoepiglottic ligament and relatively large and floppy epiglottis. The trachea is narrow, increasing the effect of even small decreases in the airway size due to secretions, edema, or external compression. The subglottic region and the non-distensible cricoid cartilage are the narrowest portion of the pediatric airway, unlike in adults, where the vocal cords are the narrowest portion. Wheezing is a frequent EMS pediatric encounter. First-line treatment for acute asthma episodes includes bronchodilators, such as the beta-agonist albuterol, and the anticholinergic ipratropium. Other therapy may include corticosteroids, IV magnesium sulfate, and epinephrine (nebulized or IM injection). Continuous positive airway pressure (CPAP) should be administered for severe respiratory distress of any cause. Bag-valve-mask ventilation should be utilized in children with respiratory failure. It is very difficult to manage ventilation in asthmatic patients who are intubated; therefore, intubation should only occur when high-quality BVM ventilation fails. Other respiratory processes such as bronchiolitis, pneumonia, and airway foreign bodies can cause wheezing. Bronchiolitis is associated with a large amount of mucus production and airway edema, and neonates are at risk of apnea. The airway should be maintained by suctioning the nose and/or mouth when excessive secretions are present. Bronchodilators may be ineffective in bronchiolitis but albuterol should be administered to all children in respiratory distress with signs of bronchospasm. Nebulized epinephrine should be administered if the above treatments fail. Pneumonia usually presents with fever and cough, associated with dyspnea, tachypnea, chest pain, and/or vomiting. Prehospital interventions include oxygen and ventilatory support by the least invasive means. IV access should be obtained if the patient\u2019s status warrants treatment of dehydration with IV fluids. Suspected foreign body airway obstruction is managed according to AHA/ILCOR guidelines. Laryngotracheobronchitis, or croup, causes a characteristic barking cough and can present with stridor. Nebulized epinephrine should be administered to all children in respiratory distress with signs of stridor and can be repeated with unlimited frequency for ongoing distress. Patients who receive nebulized epinephrine should be transported to a receiving facility for continued observation. While key history and physical exam findings can lead the provider to the correct treatment guideline, a key principle should be to treat respiratory distress first, by ensuring an open airway and providing supplemental oxygen, and then consider the differential diagnosis.",
        "Controversies over airway management": "The current literature highlights shortcomings associated with prehospital pediatric ETI. Few studies show improved outcomes, and several studies describe worsened outcomes. ETI and intubation medications may inadvertently interact with other physiological processes key to resuscitation. Adverse events and errors are frequent. Significant system-level barriers limit training and clinical experiences for prehospital providers and students, and ETI is a complex procedure, requiring a significant amount of training to learn and maintain proficiency. Fortunately, few situations necessitate prehospital ETI. One review documented that ETI was attempted in only 0.7% of all calls for children less than 15 years of age. Paramedics were unable to intubate 18% of these patients. A review from a largely rural state documented that fewer than half of the state\u2019s paramedics attempt at least one pediatric intubation per year; only 2% of providers attempted any pediatric intubation during the 5-year study period. A large prospective controlled trial comparing BVM ventilation to ETI in pediatric medical and trauma patients under 13 years of age demonstrated no survival or neurological outcome benefits in the ETI group. The ETI group had longer scene and total prehospital times. In a review of the National Pediatric Trauma Registry, mortality and abnormal functional outcome scores were more likely in children who were intubated in the prehospital setting versus the hospital setting, controlling for injury severity scores. Observed versus expected rate of mortality was higher for patients intubated in the prehospital setting across all injury severities. Supraglottic airway devices have not been studied in pediatric patients in the prehospital setting; however, use by prehospital providers on pediatric high-fidelity simulators has been studied. Of the available devices, the laryngeal mask airway is available in a range of sizes that allows its use in all ages, including neonates. The King airway device (KingSystems, Noblesville, IN) is limited in pediatric use due to available sizes. The smallest size is recommended for patients as small as 3 feet tall or 12 kg, making them unavailable for patients under the age of approximately 2 years. One key fact remains: proficiency in pediatric BVM ventilation is mandatory for all prehospital providers. The method of airway support used in the system should be based on the skill level of the providers, equipment and medications available, ongoing training and experience, transport times, and medical oversight.",
        "Apparent life-threatening events": "Apparent life-threatening events (ALTE) may present as a call to 9-1-1 from a frantic parent stating that his or her child has stopped breathing or turned blue. The child may have already recovered to baseline status. An ALTE is defined as 'an episode that is frightening to the observer and that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging. In some cases, the observer fears that the infant has died. Apparent life-threatening event is a diagnosis usually reserved for infants up to age 12 months. ALTE has a reported incidence of 1\u20139 infants per 1,000 live births, but accounts for 7.5% of infant EMS encounters, 2% of hospitalized children, and 0.7% of infant ED visits. ALTE is more common in younger infants less than 3 months. The literature reports mortality associated with ALTE as being anywhere between <1% and 6%. Greater than 80% of these patients will recover quickly and be well-appearing at the time of evaluation, with no signs of distress. Nearly all will have normal vital signs. The on-scene evaluation for children with ALTE should include close examination of the patient and surroundings for evidence of occult trauma, and a blood glucose measurement. Despite the patient\u2019s well appearance, all those with a chief complaint consistent with ALTE should be transported to the hospital. At least 75% of patients presenting to the ED with ALTE are admitted to hospital. Thirteen percent may need significant intervention during hospitalization. It is prudent to recommend contact with direct medical oversight for caregivers who are refusing medical care and/or transport. The differential diagnosis of ALTE is broad, encompassing gastrointestinal, respiratory, neurological, cardiac, and metabolic disorders. Serious illness causing an ALTE is difficult to exclude during a brief EMS evaluation. Of the very serious causes of ALTE, child abuse has been found in as many as 11% of cases, metabolic disease in 1.5%, ingestion of drugs or toxins in 1.5%, meningitis in 0.5\u20131%, and cardiac problems in 0.8%. One study noted that a call to 9-1-1 for ALTE was associated with an almost five times greater odds of abusive head trauma being diagnosed as the cause of the ALTE, clearly emphasizing the high index of suspicion EMS providers must have when responding to these calls. Long-term prognosis for infants with ALTE is generally very good. Recurrence of ALTE has been reported as being as high as 24%. ALTE has not been shown to be a risk factor for subsequent sudden infant death syndrome (SIDS).",
        "Seizures and seizure mimics": "Seizures account for 10% of pediatric calls to 9-1-1. They often are associated with anxiety on the part of the family and bystanders. The EMS physician should be concerned about the cause of the seizure as well as field treatment; however, providers should not diagnose the cause of the seizure before initiating appropriate therapy and transport. For actively seizing patients, a blood glucose level should be measured. A blood glucose of <45 mg/dL in neonates or <60 mg/dL in infants, children, and adolescents should be treated with IV dextrose or IM glucagon. Hypoglycemic pediatric patients should be transported to the hospital, even if they return to baseline mental status after treatment. Febrile seizures occur in 5% of the population and are strictly defined as occurring between ages 6 months and 6 years. Simple febrile seizures are generalized seizures lasting less than 15 minutes and not associated with focal neurological findings. Complex febrile seizures, defined as focal, lasting longer than 15 minutes, or recurring within 24 hours, carry a higher association with serious bacterial infection. Fever associated with seizures can be the result of heat illness or toxin exposure. Patients with epilepsy have a lower seizure threshold during the course of a febrile illness and may have breakthrough seizures at that time. If a high fever is suspected as the cause of seizure, the child can be cooled with wet towels en route, not with ice or cold packs. A list of conditions that mimic seizures can be found in Table 54.2. Notable pediatric-specific conditions include breath-holding spells, which are common in toddlers and usually associated with a painful or temperamental episode. In the neonatal period, benign myoclonus, sleep myoclonus, and jitteriness or exaggerated Moro reflex can mimic motor seizures. Sandifer syndrome is episthotonic posturing associated with gastroesophageal reflux.",
        "Shock": "Many providers equate shock with hypotension, which may be useful for adults but presents problems when caring for children. Normal blood pressure varies with age and restoring adequate intravascular volume by the administration of 20 mL/kg of a crystalloid (normal saline or Ringer\u2019s lactate) should be initiated quickly (over 5\u201320 minutes). This can be accomplished by using a 30\u201360 mL syringe to push fluids through an IV or IO line. If a child\u2019s weight is unknown, a length-based resuscitation tape should be used for fluids, drug dosing, and equipment size. Patients in hypovolemic shock may require up to 60 mL/kg of crystalloid fluid resuscitation. If cardiogenic shock is suspected, smaller fluid boluses of 5\u201310 mL/kg should be used. In diabetic ketoacidosis with compensated shock, a bolus of 10\u201320 mL/kg should be administered over 1 hour. If signs of pulmonary edema or worsening tissue perfusion are noted during fluid resuscitation, IV fluids should be stopped. Serum glucose should be measured. A major difficulty in these situations may be the ability of the provider to establish IV access. It has been demonstrated that it is very difficult and time-consuming to establish IV access in young ill children. In some situations, rather than waste precious moments of transport time, it may be useful to 'load and go' and search for access en route. Another method is to limit the number of attempts or time allowed for IV access before IO cannulation is attempted in the appropriate patient. In children with cardiac lesions, where there is mixing of the pulmonary and systemic circulations, careful attention must be directed to the child\u2019s clinical response to interventions. While oxygen is considered empiric therapy for patients in shock, supplemental oxygen relaxes pulmonary vascular resistance and can lead to increased left-to-right shunting. This decreases systemic blood flow, worsening metabolic acidosis. Providers must ascertain from caregivers what the patient\u2019s baseline oxygen saturations are, and should not provide supplemental oxygen that raises saturations above the patient\u2019s baseline. Obtaining an accurate blood pressure in a child can be difficult. Due to children\u2019s unique physiology, when hypotension is present, the body\u2019s compensatory mechanisms have failed and providers should recognize that the child is in a critical condition and at significant risk of death. While compensated shock may persist for hours, once the patient is hypotensive, cardiopulmonary failure may occur within only minutes. Heart rate, initially and on repeated assessments, is the key parameter for recognition of compensated shock. Tachycardia without fever, anxiety, or hypoxia requires immediate intervention. Heart rate varies with age and knowledge of the norms is needed. Assessing pulse quality and comparing peripheral to central pulses is an easy clinical assessment of stroke volume. Delayed capillary refill (>2 seconds) and skin that appears pale, mottled, cool, or diaphoretic are also common signs of shock. A change in the level of consciousness demonstrates the effects of shock on the brain. Although this may be subtle, in children as young as 2 months, irritability or failure to recognize the parents is a sign of cerebral hypoperfusion. A decreasing level of consciousness is an ominous sign. Other parameters to assess include muscle tone and pupillary responses. Shock in children tends to result from hypovolemia, which most commonly occurs in gastroenteritis/dehydration and trauma. Other forms of shock include distributive (maldistribution of blood as occurs in sepsis, anaphylaxis, or spinal cord injury), cardiogenic (resulting from an arrhythmia, congestive heart failure, congenital heart disease, or post arrest), and obstructive (impaired cardiac output due to obstruction of blood flow as from a tension pneumothorax or cardiac tamponade).\n\nRestoring adequate intravascular volume by the administration of 20mL/kg of a crystalloid (normal saline or Ringer's lactate) should be initiated quickly (over 5-20 minutes). This can be accomplished by using a 30-60 mL syringe to push fluids through an IV or IO line. If a child\u2019s weight is unknown, a length-based resuscitation tape should be used for fluids, drug dosing, and equipment size. Patients in hypovolemic shock may require up to 60 mL/kg of crystalloid fluid resuscitation. If cardiogenic shock is suspected, smaller fluid boluses of 5-10 mL/kg should be used. In diabetic ketoacidosis with compensated shock, a bolus of 10-20mL/kg should be administered over 1 hour. If signs of pulmonary edema or worsening tissue perfusion are noted during fluid resuscitation, IV fluids should be stopped. Serum glucose should be measured.\n\nA major difficulty in these situations may be the ability of the provider to establish IV access. It has been demonstrated that it is very difficult and time-consuming to establish IV access in young ill children. In some situations, rather than waste precious moments of transport time, it may be useful to \u201cload and go\u201d and search for access en route. Another method is to limit the number of attempts or time allowed for IV access before IO cannulation is attempted in the appropriate patient.\n\nIn children with cardiac lesions, where there is mixing of the pulmonary and systemic circulations, careful attention must be directed to the child\u2019s clinical response to interventions. While oxygen is considered empiric therapy for patients in shock, supplemental oxygen relaxes pulmonary vascular resistance and can lead to increased left-to-right shunting. This decreases systemic blood flow, worsening metabolic acidosis. Providers must ascertain from caregivers what the patient's baseline oxygen saturations are, and should not provide supplemental oxygen that raises saturations above the patient's baseline.",
        "Cardiac arrest": "Out-of-hospital cardiac arrest (OHCA) is a rare occurrence in childhood, with an incidence of 2.6\u201319.7 annual cases per 100,000 pediatric population. Survival rates for children who suffer OHCA are 6\u201312%, and overall intact neurological survival is reported to occur in 4%. In contrast to adults, cardiac arrest in infants and children is usually the end result of respiratory failure or shock, and not of primary cardiac etiology. It is important to emphasize this principle when considering all pediatric prehospital emergencies and educating providers. Despite recent AHA recommendations to teach 'Circulation-Airway-Breathing,' when treating children, airway and ventilation skills are critical to preventing the need for cardiopulmonary resuscitation (CPR). Sudden cardiac arrest (SCA) is much less common in children than in adults. Predisposing conditions for SCA in children include anatomical anomalies, genetic mutations causing channelopathies, and myocarditis, though these may not be diagnosed at the time of SCA. Blunt trauma to the chest and drug intoxication are also associated with SCA. Many cases of SCA in children occur during exercise. SCA in children should be treated as in adults, with immediate high-quality CPR and early defibrillation. The highest incidence of pediatric OHCA occurs in infants, where the majority of cases are unwitnessed. Survival to hospital discharge is higher for patients with witnessed arrests: 13% versus 4.6% for unwitnessed arrest. Favorable neurological outcomes are more common in adolescents than in younger children and adults. Return of spontaneous circulation (ROSC) is achieved in 30% of children with OHCA. Survival to hospital discharge after ROSC is 31\u201338%, with 31\u201354% of these survivors having good Cerebral Performance Category scores. The initial rhythm in pediatric cardiac arrest is asystole in 78\u201380%, pulseless electrical activity (PEA) in 12\u201313%, and ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in only 4-8%. The most common first documented rhythm in traumatic cardiac arrest is PEA, and in adolescent arrests is VT/VF. Traumatic cardiac arrest is associated with higher morbidity and mortality than non-traumatic cardiac arrest, although survival to hospital discharge is 5\u201318%, and neurologically favorable outcomes occur in 1\u20138%. Bystander CPR rates for pediatric patients in cardiac arrest vary greatly (8\u201385%), but average 30%. A Japanese nationwide prospective study of pediatric cardiac arrest compared patients receiving traditional CPR versus chest compression-only CPR from bystanders. Forty-seven percent of patients received bystander CPR; these patients had significantly higher rates of favorable neurological outcome 1 month after OHCA. Traditional CPR was associated with five times higher odds of a favorable outcome for OHCA from non-cardiac causes and had similar outcomes to chest compression-only CPR for OHCA from cardiac causes. American Heart Association Pediatric Advanced Life Support guidelines recommend early defibrillation for VF and pulseless VT. A dose attenuator is recommended for use with an automated external defibrillator (AED) for children up to 25 kg (approximately 8 years of age). In infants <1 year of age, an AED with a dose attenuator may be used but a manual defibrillator is preferred. If neither is available, a regular AED may be used. There is insufficient evidence to make a recommendation for or against the use of vasopressin for cardiac arrest in children. Therapeutic hypothermia has not been proven to be of benefit in pediatric cardiac arrest. Review of 18 non-randomized studies showed no effect on mortality or good neurological outcome. Ongoing randomized controlled trials may provide definitive evidence in the future. Until there is evidence showing benefit of hypothermia after pediatric cardiac arrest, EMS should not routinely cool children after ROSC. There is evidence that hypothermia improves survival and neurodevelopment in newborns with moderate-to-severe hypoxic ischemic encephalopathy from intrapartum asphyxia. It has been shown that paramedics are uncomfortable terminating CPR in children. Decisions on if and when to terminate resuscitation in the field should be determined by the medical director, ideally with consultation from local pediatric providers. A model offline protocol for termination of resuscitation in children does not exist, and there are very few resources to help guide the medical oversight of this difficult situation. No reliable predictors of outcome have been identified to guide when to terminate resuscitative efforts. Some variables associated with survival are duration of CPR, number of doses of epinephrine, age, witnessed versus unwitnessed arrest, and the first rhythm.",
        "Conclusion": "Although pediatric calls account for only a small percent of EMS runs, they cause anxiety for providers. Some factors, such as training and appropriate equipment, can be addressed beforehand; other aspects cannot. The physician's level of comfort when providing direct medical oversight on pediatric calls will be discerned by the prehospital care providers. Patient assessment skills are the cornerstone of therapy because treatment and triage decisions are based on this information. Providing oxygen is basic but decisions regarding IV access, medications, and airway interventions should be based on the age of the child, transport time, and the information related by the prehospital care providers. Frequent reassessment should be performed en route; in many cases, a child will be stabilized on arrival in the ED due to prehospital care and expertise."
    },
    {
        "Epidemiology of prehospital pediatric care": "Despite the fact that pediatric calls account for only 13% of ambulance runs, they provoke a disproportionate degree of concern and anxiety for prehospital care providers and, in turn, medical oversight physicians. A recent study by the Pediatric Emergency Care Applied Research Network (PECARN) from 14 EMS ground agencies across 11 states found that the most common chief complaints were traumatic injury (29%), general illness (10%), respiratory distress (9%), behavioral/psychiatric disorder (8.6%), seizure (7.45%), pain/non-chest/non-abdomen (6.5%), abdominal pain/problems (4.5%), and asthma (3.9%). Prehospital care providers may be uncomfortable with pediatric patients. This can be due to limited knowledge and skills obtained during initial training, infrequent field experience, or a lack of continuing education. It can also be due to weight-based drug doses and equipment size variations in children. In addition, empathy in treating ill and injured children plays a large role. NAEMSP model pediatric protocols were developed so they would not have to be started from scratch in each system. The particular protocol or algorithm chosen should be based on several factors including the structure of the system (e.g. one-tiered versus two-tiered; EMT versus paramedic), scope of practice decisions, transport times, continuing education requirements, skills retention, system quality improvement, and, of course, resources.",
        "Evaluation of children": "Evaluation is an area in which children are truly different. An accurate assessment of a pediatric patient is the key to proper field evaluation and treatment and, in turn, appropriate direct medical oversight. Evaluation should be tailored to each child in terms of age, size, and developmental level.",
        "Pediatric Assessment Triangle": "A useful learning tool that may be beneficial for providers is the Pediatric Assessment Triangle (PAT), which looks at Appearance, work of Breathing, and Circulation \u2013 a variation on the classic ABCs of primary assessment. This tool was developed by the Pediatric Education for Paramedics Task Force and has been incorporated into the Pediatric Education for Prehospital Professionals (PEPP) program and Advanced Pediatric Life Support (APLS) course. The PAT allows the prehospital provider to develop a general impression of the child and determine if life support is needed urgently. The three parts of the triangle are done by watching and listening to the patient and do not require equipment. They can be accomplished from across the room and can be completed in 30\u201360 seconds.",
        "Appearance": "This is the most important component as it determines the severity of injury or illness. It consists of five characteristics, the TICLS mnemonic: Tone, Interactiveness, Consolability, Look/gaze, and Speech/cry. Assessment of tone includes: Is the child moving vigorously or is he limp? Interactiveness reflects how alert the child is: does she react to a voice or an object? Does the child reach for a toy or is he uninterested? Is the child consolable; can she be comforted? Look/gaze: Does the child look at the EMS provider or caregiver, or does the child have a blank expressionless face? Speech/cry: Is the cry or voice strong or weak?",
        "Work of Breathing": "This portion of the tool can give the provider a quick indication of oxygenation and ventilation and can be done without a stethoscope. The characteristics to note include: abnormal airway sounds such as grunting, wheezing, or muffled phonation; abnormal positioning such as the tripod position, sniffing position, or refusing to lie down; presence and location of retractions; presence of nasal flaring.",
        "Circulation to the skin": "This helps determine the adequacy of perfusion to vital organs, using three characteristics: pallor, which reflects inadequate blood flow; mottling, which is due to vasoconstriction; cyanosis, which is blue coloration of the skin and mucous membranes. If there is an abnormality in one or more aspects of the triangle, this can help the provider decide how severely ill or injured the child is and the most likely physiological abnormality. For example, abnormal appearance and breathing point to a respiratory problem, whereas abnormal appearance and circulation point to a circulatory disorder. Abnormalities in all three areas point to a critically ill child who requires rapid scene interventions.\n\nThe next step in patient assessment is the ABCDEs: A \u2013 Airway: Assessment of the patient\u2019s airway should include: Is it patent? Is the child maintaining his or her own airway or is assistance needed in the form of airway positioning: jaw thrust, chin-lift, oral airway, nasal airway, bag-mask, or endotracheal (ET) tube? B \u2013 Breathing: Respiratory rate varies with age and can be very difficult to obtain in a crying child. Children in respiratory distress will usually breathe fast but as they tire, the rate will decrease, which is an ominous sign. When one listens to the chest, are there any adventitious sounds (grunting, stridor, wheezing, rales, rhonchi) or no sounds (no air movement)? Depending on available equipment, the use of a pulse oximeter can help determine oxygen saturation and the need for supplemental oxygen and/or assisted ventilation. C \u2013 Circulation: Determining heart rate and strength of peripheral pulses (radial) can be accomplished together. Heart rate varies with age and can also increase with fever and anxiety, but a heart rate below the normal range is worrisome and can imply hypoxia or pending arrest. If peripheral pulses are weak, central pulses should be checked as a means of assessing circulation. Capillary refill, which should be less than 2 seconds, can be assessed with the evaluation of the temperature and color of the extremity. Cold, blue, pale, or mottled extremities indicate poor circulation and shock. Although obtaining a blood pressure is part of the vital signs, in children it is often inaccurate because of the wrong size cuff or a fighting child. A normal blood pressure in the face of some of the above abnormalities should not make a prehospital care provider comfortable. In fact, hypotension in a child is a late finding of shock. D \u2013 Disability: This is a brief assessment of level of consciousness (mental status). The key is a quick assessment done initially as general appearance, so this is a recheck. It is not necessary to memorize a pediatric Glasgow Coma Scale, as a rapid assessment uses the mnemonic AVPU: Awake, responsive to Voice, responsive to Pain, and Unresponsive. E \u2013 Exposure: Although parts of the ABCDEs require that parts of the body be exposed for a complete assessment, it is necessary to ensure that all of the child\u2019s body has been examined to fully evaluate any abnormalities. At the same time, it is also important to prevent heat loss and hypothermia.",
        "Vital signs": "One of the most challenging aspects for prehospital care providers in the assessment of infants and children is that their vital signs change with age, so it is difficult to remember what is within a normal range. Having a table with appropriate vital signs for age is an easy way to solve this problem.",
        "Heart rate": "A child\u2019s heart rate decreases with age. Counting an infant\u2019s very fast heart rate can be difficult by auscultation in a screaming child. It is often easier to feel the pulse as this is not as threatening. In an infant, the brachial pulse can be used while in a child or adolescent, the radial pulse is useful. While counting the pulse, one can also assess pulse quality (strong versus weak). A fast heart rate can be due to fever, pain, anxiety, or fear but can also be due to shock or hypoxia. Watching the trend of the heart rate is also useful once you intervene, to see if the patient is improving. Any heart rate >220 in an infant or >180 in a child deserves prompt action. While this may be due to sinus tachycardia, it is also important to determine if this is supraventricular tachycardia. A slow heart rate (<60) in a symptomatic child (altered mental status, hypoxia, poor pulse quality) should prompt cardiopulmonary resuscitation (CPR).",
        "Respiratory rate": "A child's respiratory rate also decreases with age. When counting respirations, especially in infants, it is important to count for 30 seconds, then double the number, as very young infants may have periodic breathing (short periods of apnea of 5 seconds, followed by rapid breathing). Try to count respirations when the child is calm, as crying does not provide an accurate respiratory rate. A child's respiratory rate can be elevated due to fever, pain, fear, or anxiety, as well as respiratory distress. It is important to assess the respiratory rate with additional information provided by the PAT such as signs of increased work of breathing (e.g. retractions, abnormal airway sounds). Beware of a slow respiratory rate, as this can signal respiratory failure.",
        "Blood pressure": "Blood pressure determination is often difficult in a child due to lack of proper cuff size or agitation of the child caused by the cuff tightening. The proper size cuff has a width two-thirds the length of the upper arm (or thigh). In children under age 3 years, it may be difficult to obtain an accurate blood pressure, so use of other information such as heart rate, pulse quality, and capillary refill time (normally less than 2\u20133 seconds) can provide needed information about the child's condition. (An infant or young child with a rapid heart rate, weak pulses, and delayed capillary refill is in shock whether the blood pressure is normal or not.) In a child, it is often difficult to obtain both the systolic and diastolic blood pressure due to movement, so obtaining a systolic pressure by palpation (rather than auscultation) is useful. For children older than 1 year of age, the systolic blood pressure should be greater than 70 + (2 \u00d7 age of child in years). If it is less than this, there is hypotension.",
        "Pain": "Pain is now considered the fourth vital sign but once again, assessing pain in children is not easy. A crying infant can be in pain, hungry, or just wet. A toddler may not understand the word \u201cpain\u201d but recognize \u201cboo-boo\u201d or \u201cowie.\u201d In older children, use of self-reporting scales such as the visual analog scale (VAS) (e.g. 0 no pain to 10 the worse pain in my life) is possible; however, language barriers may prevent understanding. The Wong-Baker FACES scale has been used in hospital settings. There are other scales, including the FLACC observational scale and CHEOPS, which use observations on the infant/child\u2019s cry, facial expression, and leg movement to provide a total score. The Oucher and Faces Pain Scale-revised use a 0\u201310 score that has the child match his or her facial expression, similar to the Wong-Baker FACES scale. No matter which scale is used, once pain is assessed and treated, it should be reassessed to see if the pain has decreased.",
        "Weight measurement": "While parents may know their child\u2019s weight in pounds, medication dosing in children is by kilograms. While it is possible to mentally divide the weight in pounds by 2.2 to get kilograms, it may be easier and more reliable to use a calculator or phone application. If the parent does not know the child\u2019s weight or no parent/caregiver is available, there are a few tools one can use. The easiest is a length-based tape that takes the child\u2019s length and provides a weight in kilograms. The Broselow Pediatric Emergency Tape is the one commonly in use. This tape goes from 3 to 36 kg and should be placed with the red portion at the child\u2019s head, and the weight is measured at the child\u2019s heel. A benefit of this device is that it provides equipment size as well as medication doses in mg, except for resuscitation medications that are in mL. Other formulas for weight include: 1\u201310 years: (age \u00d7 2) + 10 (kg), or for those >10 years: (age \u00d7 2) + 20 kg, and Luscombe and Owens (3 \u00d7 age + 7). The midarm circumference formula (weight (kg) = (mid-arm circumference [cm]\u221210) \u00d7 3) was useful to estimate body weight in Chinese children. Another device called the MERCY Tape is based upon weight estimation using the mid-upper arm circumference and humeral length, and estimates weight more accurately in obese children than the Broselow tape. A recent concern is that the Broselow tape underestimates a child\u2019s weight due to the obesity epidemic in the US. The length-based tape assumes lean body mass, and the weight given is the 50th percentile for any measured length. Resuscitation drugs (epinephrine) have a small volume of distribution and clearance, which is associated with lean body mass, not the actual body weight. Lean body weight is similar to ideal body weight, so these drugs are best dosed by ideal body weight. Those drugs that are lipid soluble are best dosed by actual body weight, but if a child is overweight, toxicity can occur if the drug has a narrow therapeutic window. In realistic terms, if the calculated drug dose for an obese child is greater than the adult dose, use the adult dose. In addition, length is the best predictor of equipment size needed as well, so adding a few kilograms to the weight estimated by the Broselow tape is not recommended!",
        "Specialized equipment needs": "As mentioned above, children of different ages and sizes require different sized equipment. The length-based tape or computer or telephone applications can provide this information, but they are all useless unless you have the right equipment in your ambulance. Numerous organizations, including NAEMSP, recently revised the 2009 Policy Statement: Equipment for Ground Ambulances. This new policy includes a list of core equipment for both BLS and ALS ambulances, for adults and children. While states may mandate equipment or allow EMS regions or medical directors to dictate what equipment is carried based on scope of practice and other factors, this consensus document represents the latest guidelines.",
        "Developmental approach": "Another important consideration in taking care of pediatric patients is the various developmental levels. A 6-month-old crying infant cannot tell you where it hurts while an injured 15 year old can, but may not disclose important information in front of his or her parents or friends. Understanding some of the developmental characteristics of children can assist you in your evaluation of the patient.",
        "Infants": "Infants under 2 months have a very limited repertoire. They cannot tell the difference between you and their caregivers by sight, but may turn to their mother's voice. When evaluating them, it is important to keep them warm, allow the parents to hold them if possible, and speak in a soothing voice. Those from 2 to 6 months can make eye contact and recognize their caregivers. They are also more active, and those older than 3 months can roll over. They may follow objects or light with their eyes, and they bring objects to their mouths, so don't offer anything small! Once again, evaluate them in a parent's lap, and try to get down to their level (squat down or evaluate them when you are on your knees). Those between 6 and 12 months are gaining gross motor skills, which include going from sitting by themselves to crawling, to cruising (walking while holding onto an object), and some can walk by 12 months. Their verbal skills are still limited, saying only a few simple words (mama, dada). A key development during this time is that they experience stranger anxiety. This means that they know you are not their parent/caregiver, and do not like to be separated from them. Once again, during your evaluation keep the child with the parents and, if possible, during transport, keep the parents in eyesight or within voice range. Other tips for evaluating infants is allowing parents to offer a pacifier, toy, or blanket, and allowing the parents to remove or lift the infant's clothes. Evaluate them based on their activity level: if they are calm, listen to the heart rate and respiratory rate first. If not, save this for later as they become more accustomed to you. Perform the most uncomfortable or distressing part of the exam last.",
        "Toddlers": "Toddlers are considered ages 1\u20133, and are gaining verbal and fine and gross motor skills rapidly. They can walk, run, play with toys, and feed themselves. Some say only a few words but others speak in phrases, and definitely say \u201cno\u201d They are very fearful of strangers, curious but not aware of danger, and very opinionated. On the other hand, they are playful and enjoy make-believe. During your evaluation, use the toddler\u2019s name and talk to them in a friendly tone of voice. Use distraction and play to gain their confidence and cooperation. Ask the parent/caregivers to help with the exam. Speak in simple terms and give the patient limited choices. If there is a critical portion of the exam, do that first, then work from toes to head. Despite their small size, they can put up quite a fight during your exam and therefore a combination of patience and parental assistance may be needed.",
        "Preschoolers": "Preschoolers include those 3\u20135 years of age. They are very mobile, speak in sentences and have a large vocabulary. They are creative thinkers but also illogical. They have many misconceptions about bodily functions and illness, and fear being left alone. Evaluation tips include distraction (use one of their toys to demonstrate what you will be doing), choosing your words carefully, and allowing the patient to participate in the exam (hold the stethoscope or let them listen to their heart).",
        "School-aged children": "School-aged children are those who attend elementary and middle schools. They are independent, talkative, and have a fair understanding of illness and injury. They fear being different from friends and being separated from parents and friends, and do not like loss of control. When ill or injured, this independence is threatened, so the child may be angry and put up resistance to evaluation, especially in front of friends. It is important to establish trust with the patient and explain to them in simple terms what you are going to do, but don\u2019t negotiate. It may be beneficial to give the patient privacy by completing the evaluation in the ambulance, and praise them for their cooperation. You can perform the evaluation in a head-to-toe manner.",
        "Adolescents and teenagers": "Adolescents can be rational and can express themselves well. They often like to take risks, even though they may understand the possible consequences. Friends take a front seat to parents and they like to appear independent of their parents. When evaluating adolescents, use their name and respect their modesty and privacy. They may not provide all past medical information in front of their friends, and may not divulge drug or alcohol use in front of their parents. Speak directly to them, explain what you are going to do, and be honest. If they are uncooperative, friends may be able to provide some assistance.",
        "Children with special health care needs": "One of the most important aspects of evaluating a child with special health care needs is to ask a parent or caregiver their developmental level and baseline activities. The child may have physical disabilities but be developmentally normal for age, or have severe impairments in speech and mental abilities. This affects not only their baseline vital signs, weight, and size, but their response to illness and injury. Evaluation includes asking the parent/caregiver what is different from normal, asking them the best approach to the child, and enlisting their help. Ask if they have a special emergency information form, which can provide EMS with past medical history, allergies (especially latex allergy), medications, and where they usually receive their medical care. Ask the parent if they have a \u201cgo bag\u201d which has all the special equipment they need for transport and hospital visits. In many cases, these children obtain their care at a children\u2019s hospital farther than the local hospital, and that is where the parents are most comfortable. EMS personnel may need to contact medical oversight for approval if transport to the preferred hospital is outside their protocols.",
        "Consent issues": "When taking care of pediatric patients, consent issues may arise. While parents commonly provide consent for treatment, if an injury occurs without them, several legal issues can arise. Obtaining informed consent is required by law but children cannot provide informed consent, because they are considered to be minors (less than 18 years of age), unless they are emancipated minors. Emancipated minor laws vary from state to state but in most states, emancipated minors include those who are married, have a child, are pregnant, are on active military duty, or are not living at home and are self-supporting, no matter what their age. The emancipated minor can consent to treatment as well as refuse treatment by EMS. There are emergency situations when no parent or legal guardian is available and the child needs medical care and transport. In this case the emergency exception rule/implied consent is in effect, but the following four conditions must be met: the child\u2019s legal guardian is unavailable or unable to provide consent for treatment or transport; the child is suffering from an emergency condition that places his or her life or health in danger; treatment or transport cannot be delayed until consent can be obtained; only treatment for the emergency condition is administered by EMS. In cases where implied consent is used, excellent documentation is required, including that attempts were made to contact the guardian, the nature of the injury and treatment provided, and why it was an emergency. The EMS provider should contact medical oversight if guardians are not available or if unsure about transporting the patient. Mature minors are those who have been declared adults by the court. The age also varies by state but is usually older than 14 years. A mature minor can refuse treatment and transport for him or herself, as long as he or she is not on a psychiatric hold and is competent to make the decision to refuse. If the guardians refuse transport of a child, a few conditions should be met. They must be alert, mentally competent, and oriented. In these cases, the EMS provider should contact medical oversight to either have a physician control speak to the parent to convince him or her to allow treatment and transport, or get approval for the refusal. If medical oversight feels that emergency treatment and transport are needed, or if the parent is not competent, law enforcement may be needed to take temporary protective custody of the child. Each state differs somewhat in who can take temporary protective custody but law enforcement is one of the groups in all states. A key fact is that, if temporary protective custody is taken, this allows EMS to transport the child to a hospital for a medical evaluation but not to treat a non-life-threatening illness or injury."
    },
    {
        "Introduction": "Child maltreatment is a serious public health problem. In 2011, an estimated 3.4 million referrals involving approximately 6.2 million children were made to Child Protective Service (CPS) agencies nationally. An estimated 676,569 children were determined to be victims of abuse or neglect. Of these, 78.5% experienced neglect, 17.6% were physically abused, 9.1% were sexually abused, and approximately 9% experienced emotional or psychological abuse. An estimated 1,570 children died of abuse or neglect in 2011, with a rate of 2.10 per 100,000 in the total US population. Although any child may fall victim to child abuse, the most vulnerable groups are infants, preverbal children, and children with chronic diseases and disabilities.",
        "Role of the prehospital provider": "Emergency medical services physicians and personnel play an important role in recognizing and reporting child maltreatment. They frequently have the opportunity to assess the scene and home environment as well as the interactions between the child and the caregiver(s). If there are any suspicions for maltreatment, it is vitally important that appropriate interventions are implemented to protect the child as mortality is known to be significantly higher in children who experience repeated episodes of non-accidental trauma. Observations made by prehospital providers can be invaluable to physicians, nurses, other health care providers, child welfare workers, and law enforcement personnel who are charged with evaluating and investigating child maltreatment.",
        "Child maltreatment": "Child maltreatment involves acts of commission and omission that result in harm or threat of potential harm to a child. Acts of commission involve physical, psychological, and sexual abuse. Acts of omission (neglect) may involve failure to provide adequate food, shelter, medical and dental care, and education. A caregiver may also fail to provide adequate supervision or may expose a child to a dangerous or injurious environment, which may be considered neglect.",
        "Assessment and general approach": "Providing the appropriate level of medical care is the first priority when responding to any illness or injury. This priority does not change when responding to children who are victims of maltreatment. BLS and ALS measures should be implemented as indicated after provider safety is assured. Scene assessment and investigation, although very important in understanding mechanisms of injury and the relationship to real or potential maltreatment, should not impede the delivery of expedient and appropriate medical care. Pediatric ABCs and the primary survey are discussed elsewhere and will not be specifically addressed in this chapter.",
        "Secondary survey: signs and symptoms suggestive of abuse or neglect": "The secondary survey should involve a careful examination of the child, especially the skin surfaces. The most common manifestations of child abuse are cutaneous injuries; therefore, a detailed physical examination is essential in identifying suspicious findings. Bruising, burns, and bite marks are often observed in children who have sustained physical abuse. However, children may have no obvious cutaneous findings and still be victims of physical abuse. For example, the presence of bruising with inflicted rib and extremity fractures has been shown to be uncommon.",
        "Bruising": "The age and developmental level of the child should be considered when understanding mechanisms and resulting injuries. Bruising is rare in infants before they begin to walk or crawl. When bruising is identified in this age group and a credible history is not obtained from the caregiver, abuse should be considered and the child should receive an appropriate medical evaluation. For mobile children, accidental bruising is more common to certain areas of the body. Skin overlying bony prominences is more likely to bruise from accidental causes such as play activities or falls. Areas over the knees, anterior tibial area, forehead, hips, lower arms, and spine commonly demonstrate bruising from accidental causes. However, this does not guarantee that bruising over these areas cannot result from inflicted trauma. Bruising over more protected areas such as the upper arms, medial and posterior thighs, hands, torso, cheeks, ears, neck, genitalia, and buttocks is more frequently associated with inflicted trauma. The observation of bruising over these areas should raise suspicions for maltreatment. However, bruising over these areas can also occur accidentally; therefore, obtaining a careful history regarding the injuries that may have led to the bruising becomes important in assessing whether or not the injuries are compatible with the caregiver's account and the child\u2019s developmental abilities. Observations that increase concerns for inflicted trauma include multiple sites of bruising and bruising that demonstrates a pattern. Research has shown that dating of bruises (e.g. by the progression of colors) is unreliable. A finding of multiple bruises over the body of a child should increase concerns for inflicted trauma.",
        "Burns": "Burns are common injuries in children and may occur from both accidental and inflicted causes. Abusive burns represent about 10% of pediatric burns. Most common abusive burns will be scald burns such as immersion burns. Abusive burns may also occur from contact with hot thermal sources, chemicals, electricity, and even microwaves. Obtaining information concerning the history of the burn, to include the mechanism and timing, is important in understanding if an abusive or neglectful injury may have occurred. The history should be correlated not only with the physical presentation of the injury but also with the developmental level of the child if the caregiver is reporting an action on the behalf of the child that led to the burn. Any mismatch with respect to the reported history, a changing history, mechanism, appearance and developmental level of the child should be documented. Delays in seeking care for burns may also represent abuse and neglect, and therefore documenting the reported timing of the burn is important.",
        "Fractures": "It is estimated that 11\u201355% of pediatric fractures are the result of physical abuse. Younger children are particularly at risk for sustaining abusive fractures: 55\u201370% of all abusive fractures occur in infants less than 1 year of age. With respect to orthopedic injuries, a careful history and secondary survey are vital when assessing the young child. EMS providers do not have the advantage of radiography in determining if a child has a fracture. Some children may not exhibit signs such as guarding, deformity, swelling, or pain, thus creating difficulty in making safe and accurate assessments.",
        "Transport decisions": "Before determining that a child does not require EMS transport, careful consideration should be given to the age of the child, the ability to adequately determine if a fracture or other injury exists, and the history given by the caregivers. Any child with a suspicious or concerning history surrounding the injury should be transported to medical care.",
        "Scene survey": "Emergency medical services providers are in an excellent position to provide valuable information about the scene and circumstances of the call. In many instances, they will be able to observe and confirm or refute the details provided by the caregiver and communicate these to the medical providers. This type of information becomes very important when determining the credibility of the history and the injuries sustained by the child.",
        "Obtaining the history": "Obtaining a concise and detailed history will obviously depend on the acuity of the child\u2019s condition. The ability of the child to respond to questions is contingent on age and developmental level as well as the degree of injury. A verbal child may be able to answer simple questions such as \u201cwhat happened?\u201d but he or she may not be able to answer questions relating to how, where, or when. The following questions should be asked of the caregiver. \u2022 How did the injury occur? \u2022 Where did the injury occur? \u2022 When did it happen? \u2022 Who witnessed the event? \u2022 What is the child\u2019s medical history? \u2022 Who is the child\u2019s regular medical provider? The provider should think about the responses to the questions in terms of a credible explanation for the observed injuries. \u2022 Is the explanation credible? Does the injury pattern fit the manner in which the caretaker describes the incident? \u2022 Does the scene assessment support the alleged mechanism of injury? \u2022 Was there a long delay before seeking medical attention? \u2022 If there are histories from more than one source, are they consistent? \u2022 Was there adequate supervision of the child? \u2022 Does the child have preexisting medical, psychological, or developmental problems? \u2022 Does the child have a current health care provider? When was the last time the child saw a health care provider? Has this child been seen by EMS for a previous concern?",
        "Communicating with the child and caregivers": "Method and style of communication are very important when dealing with situations surrounding possible child maltreatment. Judgmental and accusatory questioning may only serve to threaten the caregiver and incite defensiveness or aggression. Maintaining objectivity is very important in managing interactions with the child and caregiver. The provider should avoid challenging the child or caregiver on the proposed history and mechanisms for observed injuries.",
        "Documentation": "Accurate, detailed, and concise documentation of the scene, a complete physical examination of the child, and history from the caregiver and child are vitally important. Responses and statements made by the child and the caregiver should be placed in quotes. Conflicting histories should be noted. The objective findings documented by the prehospital provider frequently become very important in the investigation of suspected child maltreatment. Concerns should be carefully communicated to the hospital personnel taking over care of the patient from the EMS providers.",
        "Medical conditions that may be confused with child abuse": "Numerous medical conditions may present with signs and symptoms that may be confused with child maltreatment. Some of these conditions may have already been identified in the child's history. For example, a child with a blood clotting disorder such as hemophilia is more prone to bruising; however, this should not be interpreted to mean that these children have not been abused. Young children may have skin markings that have the appearance of purplish bruising but are congenital melanosis. These markings are usually found on the lower back and buttocks but can also be on other parts of the body. The caregivers are usually able to give a history of these markings as being present since birth.",
        "Sexual abuse": "Sexual abuse represents the third most common form of child maltreatment. Research and statistics describing EMS response to child sexual abuse calls are minimal; therefore, it is unknown how frequently these types of calls are encountered in the pre-hospital environment and under what conditions. Because it is rare for an acute case of child sexual abuse to present to medical care, it is reasonable to expect that EMS response will also be relatively rare. EMS providers may respond to a call only to find that there is no medical emergency. A caregiver may call EMS not knowing what other action to take or may simply have no transportation options to access medical care for the child. It is important to understand the dynamics of how child sexual abuse is often disclosed in order to respond appropriately. Children frequently do not disclose abuse when it happens. It may be weeks, months, or even years before a child is able to disclose being sexually abused. Smith et al. found that almost half of all women they interviewed who had sustained rape as a child did not disclose the rape within 5 years of the assault and 28% had never disclosed to anyone until surveyed in their study. Children who are verbal often do not disclose sexual abuse due to threats or other manipulation by the abuser, who is often a trusted relative or friend. One of the more common concerns a caregiver may mention is that the child's genital area appears red or irritated. Other concerns may involve a caregiver or other family member observing suspicious contact or inappropriate touching of the child. Once there is an EMS response to a child sexual abuse call, it becomes vital that the medical, psychosocial, and safety needs of the child and family are addressed. This is a very complex process and requires a multidisciplinary and specialized approach. It is impossible for the EMS responder to address the many issues surrounding this type of event. Some communities have established protocols to address this type of response. When there is no local medical protocol, the best course of action is to transport these children to medical care. Acute medical and forensic interventions are seldom indicated due to the rarity of immediate disclosure or discovery of child sexual abuse. Locales and communities may also have differing time-frames for defining acute for the purposes of immediately evaluating child sexual abuse (72\u201396 hours is more common but some may consider acute up to 120 hours). However, the presence of any of the following within the established acute time-frame warrants having the child medically evaluated: \u2022 discovery or disclosure of suspected sexual abuse occurring within the specified acute time-frame \u2022 anogenital pain, bleeding, discharge \u2022 contact with the suspected perpetrator within the specified acute time-frame \u2022 other extragenital findings concerning for trauma such as bruises, abrasions, etc. \u2022 a distressed child and/or caregiver. The greatest responsibilities for the EMS provider are identification of concerns, crisis intervention, and careful documentation. If at all possible, the history from the caregiver should not be taken in front of the child if the child is verbal and capable of understanding. If possible, it is preferable to talk with the child alone. Many issues concerning the credibility of the child's history and disclosure of sexual abuse will arise as the child moves through the medical, social, and legal systems. A limited interview of the child should be conducted to ascertain areas of discomfort or pain. Probing questioning of the disclosure and details surrounding the abuse are better left to professionals who are skilled in the area of child interviewing for the purposes of documenting and diagnosing sexual abuse. If a child spontaneously begins to give the history, allow him or her to do so, and document the history as carefully as possible. Use quotes to differentiate the child\u2019s verbatim words from other documentation because the response and the record may become a vital document in legal proceedings. With acute events, preservation of any evidence on the child\u2019s body should be attempted by carefully handling the child and any clothing the child is wearing. Articles such as diapers, clothing, and the child\u2019s bedding and blankets may yield the best source of recoverable evidence and should be protected and preserved. If law enforcement is at the scene, officers should take possession of these items. If law enforcement is not present then the EMS provider should place each item in a separate brown paper bag, labeling each bag with the patient\u2019s name, date, time of recovery, and provider\u2019s signature. The items may then be turned over to the appropriate medical or hospital staff on arrival to medical care. The EMS provider should document the evidence recovered and to whom it was turned over.",
        "Responding to intimate partner violence calls": "It is not unusual for EMS to respond to calls involving intimate partner violence (IPV). Concerns for child maltreatment should always be considered when responding to calls where IPV is occurring and children are part of the family unit. Children who reside in homes in which IPV is present are at increased risk of being maltreated and neglected, as well as suffering significant emotional and psychological harm from witnessing the abuse. Appropriate measures should be undertaken to address safety concerns for these children and should involve collaboration with law enforcement, child welfare services, and medical oversight.",
        "Medicolegal duties": "All states and territories in the United States require reporting suspicions of child abuse. Prehospital providers should have a good understanding of how legal requirements guide reporting in their respective states or jurisdictions. Accurate and detailed written documentation is vital in conveying important information to which the prehospital provider may be privileged based on his or her unique position in the continuum of care. A thorough summary of the assessment and suspicions should be relayed to receiving physicians, nurses, and social workers.",
        "Conclusion": "Emergency medical services providers are in an excellent position to provide valuable information in the recognition, documentation, and ultimate intervention in cases of child maltreatment, but it is likely that prehospital personnel need more training in recognizing and managing child maltreatment than is typically provided. Field personnel frequently have the opportunity to observe the home and/or the scene and note consistencies or inconsistencies that accompany the history provided by caregivers. EMS providers often see or hear things at the scene or en route that are suspicious and need follow-up or further investigation. Accurate documentation of the history and observations made is vital in the comprehensive assessment of child maltreatment."
    },
    {
        "Key Terms": "Adult: For the purpose of providing emergency medical care, anyone who appears to be approximately 12 years old or older., Apparent life-threatening event (ALTE): A sudden event in infants under the age of 1 year, during which the infant experiences a combination of symptoms including apnea, change in color, change in muscle tone and coughing or gagging., Child: For the purpose of providing emergency medical care, anyone who appears to be between the ages of about 1 year and about 12 years; when using an automated external defibrillator (AED), different age and weight criteria are used., Child abuse: Action that results in the physical or psychological harm of a child; can be physical, sexual, verbal and/or emotional., Child neglect: The most frequently reported type of abuse in which a parent or guardian fails to provide the necessary, age-appropriate care to a child; insufficient medical or emotional attention or respect given to a child., Croup: A common upper airway virus that affects children under the age of 5., Epidemiology: A branch of medicine that deals with the incidence (rate of occurrence) and prevalence (extent) of disease in populations., Epiglottitis: A serious bacterial infection that causes severe swelling of the epiglottis, which can result in a blocked airway, causing respiratory failure in children; may be fatal., Febrile seizures: Seizure activity brought on by an excessively high fever in a young child or an infant., Fever: An elevated body temperature, beyond normal variation., Infant: For the purpose of providing emergency medical care, anyone who appears to be younger than about 1 year of age., Pediatric Assessment Triangle: A quick initial assessment of a child that involves observation of the child\u2019s appearance, breathing and skin., Respiratory failure: Condition in which the respiratory system fails in oxygenation and/or carbon dioxide elimination; the respiratory system is beginning to shut down; the person may alternate between being agitated and sleepy., Retraction: A visible sinking in of soft tissue between the ribs of a child or an infant., Reye\u2019s syndrome: An illness brought on by high fever that affects the brain and other internal organs; can be caused by the use of aspirin in children and infants., Seizure: A disorder in the brain\u2019s electrical activity, sometimes marked by loss of consciousness and often by uncontrollable muscle movement; also called a convulsion., Shaken baby syndrome: A type of abuse in which a young child has been shaken harshly, causing swelling of the brain and brain damage., Status asthmaticus: A potentially fatal episode of asthma in which the patient does not respond to usual inhaled medications., Sudden infant death syndrome (SIDS): The sudden death of an infant younger than 1 year that remains unexplained after the performance of a complete postmortem investigation, including an autopsy, an examination of the scene of death and a review of the care history., Thready: Used to describe a pulse that is barely perceptible, often rapid and feels like a fine thread.",
        "INTRODUCTION": "In an emergency, you should be aware of the special healthcare or functional needs and considerations of children and infants. Knowing these needs and considerations will help you better understand the nature of the emergency and provide appropriate care. A young child may be scared or nervous due to the circumstances of the emergency, because they are being assessed by a stranger, a combination of those reasons or some other reason. Being able to communicate with and reassure children and infants can be crucial to your ability to care for these patients effectively.",
        "ANATOMICAL DIFFERENCES": "It is important to be aware of the anatomical differences among adults, children and infants. The most significant of these differences involve the airway and breathing. Children and infants have proportionately larger tongues than do adults, so it is easier for the tongue to block the airway. Placing pressure under the chin, which can occur during the head-tilt/chin-lift or jaw-thrust (without head extension) maneuvers, can cause the tongue to be pushed back and block the airway. Newborns and infants prefer to breathe through the nose and may not open their mouths when their nose is blocked, so they are more likely to develop respiratory distress if the nose is blocked. Additionally, the epiglottis is much higher in children and infants than it is in adults. A newborn\u2019s trachea is also very narrow, only about 4 or 5 mm wide, so swelling, for example due to inhaling toxic fumes, can become life threatening very quickly. Children and infants younger than age 5 also breathe at a rate two to three times faster than that of adults, and their breathing is shallower, as less volume and pressure are needed to ventilate the lungs.",
        "Determining the Age Group of the Patient for the Purpose of Providing Emergency Medical Care": "At times, care must be provided according to the age of the patient and it is not always easy to determine exact age. The American Red Cross follows established age categories for emergency care that are based on epidemiological patterns of injury including care needed, while at the same time being easy to recognize based on the patient\u2019s appearance. Always follow local protocols and medical direction when deciding how to care for a child versus an adult. In general, children and infants predominantly suffer respiratory emergencies, which, if untreated, can lead to cardiac emergencies. Adolescents and adults will often suffer primarily cardiac events. Lastly, an individual can generally look at a patient and determine if the patient is an adult, a child or an infant. At times, a small 13 month old may be categorized as an infant, or a small 13 year old as a child. However, the difference between the perceived age category and the actual age would not have any significant impact on care. Additionally, the easy recognition of a perceived age category helps to provide appropriate care quickly, a benefit that far outweighs any age discrepancy. Based on this physiological, epidemiological and recognition approach, the following general age groups have been developed:\nInfant\u2014Anyone who appears to be younger than about 1 year of age.\nChild\u2014Anyone who appears to be between the ages of about 1 year and about 12 years. For automated external defibrillator (AED) purposes, based on U.S. Food and Drug Administration (FDA) approval of pediatric-specific devices, a patient who is between the ages of 1 and 8 or weighs less than 55 pounds is considered a child. If precise age or weight is not known, the responder should use best judgment and not delay care to determine age.\nAdult\u2014Anyone approximately 12 years old or older.",
        "CRITICAL FACTS": "It is important to be aware of the anatomical differences among adults, children and infants. The most significant of these differences involve the airway. In general, children and infants predominantly suffer respiratory emergencies, which, if untreated, can lead to cardiac emergencies. Anyone who appears younger than 1 year of age should be considered an infant, 1 to 12 years a child, and 12 and older an adult. Based on this physiological, epidemiological and recognition approach, the following general age groups have been developed: \uf0a7 Infant \u2014Anyone who appears to be younger than about 1 year of age. \uf0a7 Child \u2014Anyone who appears to be between the ages of about 1 year and about 12 years. For automated external defibrillator (AED) purposes, based on U.S. Food and Drug Administration (FDA) approval of pediatric-specific devices, a patient who is between the ages of 1 and 8 or weighs less than 55 pounds is considered a child. If precise age or weight is not known, the responder should use best judgment and not delay care to determine age. \uf0a7 Adult \u2014Anyone approximately 12 years old or older.",
        "CHILD DEVELOPMENT - Infants (Birth to 1 Year)": "Infants\u2019 inability to do anything for themselves and their inability to communicate where there may be pain or discomfort makes them among the most vulnerable of children and patients. After the first few weeks of birth, an infant can usually recognize a parent\u2019s or caregiver\u2019s voice. After a few months, facial recognition becomes possible. The quality of crying usually differs according to the cause, but the subtleties of the differences may only be recognized by the parent or caregiver. Crying could be triggered by hunger, the need for diapers to be changed, pain, fear or for unknown reasons.",
        "CHILD DEVELOPMENT - Toddlers (1 to 3 Years)": "Toddlers can readily recognize familiar faces and may be fearful of strangers. They may not be cooperative when dealing with an unknown person, even if the parent or caregiver is in the room. Toddlers may also fear being separated from the people they know. Crying makes it difficult for them to communicate. Some toddlers relate well to stuffed animals, to help them calm down and demonstrate what the problem may be. When dealing with an unknown emergency with a toddler, keep in mind that toddlers\u2019 curiosity about the world around them makes poison ingestion a common injury.",
        "Preschoolers (3 to 5 Years)": "Preschoolers communicate their ideas more effectively than toddlers, but they may have difficulty with certain concepts. They may have difficulty understanding complex sentences that contain more than one idea, so speak in simple terms. Children at this stage often feel that bad things are caused by their thoughts and behaviors. Their fears may seem out of proportion to the events. The sight of blood may be disturbing, but often a dressing or bandage can help calm the situation.",
        "School-Age Children (6 to 12 Years)": "Children of school age have been exposed to more unfamiliar faces and are more likely to cooperate with strangers. With reassurance from familiar faces (parents, caregivers, guardians, teachers), they are likely to understand the situation once it has been explained, and are able to cooperate with emergency responders. This age group is often fascinated with the topic of death and may have strong fantasies or imaginary ideas. Children of school age need continual reassurance.",
        "Adolescents/Teens (13 to 18 Years)": "The characteristics of adolescents and teens vary quite a bit from the beginning of the age group (age 13) to the end (age 18). Thirteen year olds are just leaving the school-age group, and 18 year olds are on the cusp of adulthood and already may have had to take on adult responsibilities. Generally, adolescents are more able to provide accurate information and cooperate with emergency responders. However, they may be apt to fall into mass hysteria, in which multiple adolescents feel they are all experiencing the same problems or symptoms. This requires understanding and tolerance on behalf of the emergency responder. Generally, this group is quite modest and will require privacy. They are also aware of the potential for fatality or permanent disability and often fear they will experience this.",
        "ASSESSING PEDIATRICS - General Considerations": "Assessing an injured or sick child is similar to assessing an adult, with a few differences. Primary assessments on a conscious child should be done unobtrusively, so the child has time to get used to you and feel less threatened. Try to carry out as many of the components of the initial evaluation by careful observation, without touching the child or infant. Approach the parent or caregiver, if possible, as the child will see you communicating with them and subsequently may feel more comfortable with your exam and treatment. If appropriate, a parent or caregiver may hold the child during assessment and treatment. Observe the young patient to assess for breathing, the presence of blood, movement and general appearance. If the child is showing signs or symptoms of a serious injury or illness, start the assessment using the head-to-toe approach. If the child is agitated or upset and there are no signs or symptoms of a serious injury or illness, the assessment can be done toe to head, which allows the patient to get used to you rather than have you in their face from the start. When treating children, remember that you are also treating their parent or caregiver as they, too, are likely to be scared or stressed. Reassess continuously as you wait for more advanced medical support to arrive. Document and report all your findings to more advanced medical personnel when they arrive.",
        "ASSESSING PEDIATRICS - Scene Size-Up": "Begin observing the scene from the moment you arrive. The big picture will allow you to assess the situation and may give clues to other issues, such as child abuse. As usual, also assess the scene for personal safety. Be alert for any signs that may indicate poisoning (empty bottles, for example) and look for signs of child abuse. Are the adults responding in an appropriate manner? Are they appropriately concerned, or are they angry or indifferent? Does the child seem frightened of them and/or their reactions? Does the parent or caregiver answer your questions directly? Is the environment safe for a child? While noting how the patient was found (position and location), keep in mind that the child may have been moved by well-meaning adults. Be sure to ask as part of your patient history. If you have confirmation that the patient has been moved, ask the adults where the child was and how the child was found.",
        "Pediatric Assessment Triangle": "The Pediatric Assessment Triangle is a quick initial assessment of a child that takes between 15 and 30 seconds and provides a picture of the severity of the child\u2019s or infant\u2019s injury or illness. This is done during the scene size-up as part of forming your general impression and before beginning the primary assessment. It does not require touching the patient, just looking and listening. You should observe three components in the child\u2014appearance, work of breathing and skin: Appearance: Does the child appear to have normal muscle tone? Is the child crying, talking or moving about? Is the child able to interact with you or other adults in the area? Is the child able to make eye contact or be consoled? \nBreathing: Does the child appear to be breathing? Does breathing require great effort (flaring nostrils, indrawn area just below the throat or use of abdominal muscles)? Is the child leaning forward in an attempt to breathe? Is any noise coming from the child, such as wheezing or any other abnormal sound?Skin (Circulation): When looking at the child, is the skin pale, mottled or cyanotic (bluish)? Are any signs of trauma or bleeding present?",
        "CRITICAL FACTS 1": "Assessing an injured or sick child is similar to assessing an adult, with a few differences. Primary assessments on a conscious child should be done unobtrusively, so the child has time to get used to you and feel less threatened. Try to carry out as many of the components of the initial evaluation by careful observation, without touching the child or infant. Observe the young patient to assess for breathing, the presence of blood, movement and general appearance. Unless the child is agitated or upset, start the assessment using the head-to-toe approach. The Pediatric Assessment Triangle is a quick initial assessment of a child that takes between 15 and 30 seconds and provides a picture of the severity of the child\u2019s or infant\u2019s injury or illness. This is done during the scene size-up and before beginning the primary assessment. It does not require touching the patient, just looking and listening.",
        "Equipment for Assessing and Caring for Children and Infants": "As children come in all different sizes, so does the equipment used to assess them. A wide range of sizes should be available for assessing children, to provide optimal care. Essential equipment and supplies include: \uf0a7 Bag-valve-mask (BVM) resuscitators with oxygen reservoirs. \uf0a7 Oxygen masks. \uf0a7 Non-rebreather masks. \uf0a7 Airway adjuncts. \uf0a7 Bulb syringe. \uf0a7 Portable suction unit with regulator. \uf0a7 Suction catheters. \uf0a7 Cervical immobilization devices. \uf0a7 Backboard and other extrication devices. \uf0a7 Extremity splints. \uf0a7 Stethoscope for pediatrics. \uf0a7 Blood pressure cuffs. \uf0a7 Thermal blankets. \uf0a7 Water-soluble lubricant. A new, clean stuffed animal and references for the Glasgow Coma Scale and Pediatric Trauma Score are also recommended.",
        "Airway": "An airway that is open, even if only partially open, will allow the child to cough, cry or breathe. Even with an open airway, the child should be observed closely for any change in status. A child whose airway becomes compromised or shows signs or symptoms of inadequate breathing or a lack of oxygen will need immediate care. A child\u2019s airway can be blocked by anatomical or mechanical obstructions. For example, illness can cause constriction of the bronchi and upper airway as in status asthmaticus (asthma) or anaphylaxis (anatomical). Infection and trauma can also cause swelling and block the airway. Children are prone to airway obstruction caused by small objects as well as food (mechanical). Choking hazards among children include small objects such as coins, buttons, small toys and parts of toys and balloons, as well as certain food items. While hazardous for all children, these objects generally pose a larger threat to children under age 4. If a solid object is blocking the child\u2019s upper airway, oxygen may not enter the lungs. This situation requires immediate care for a conscious choking child or infant; a combination of skills may be needed to clear the airway including abdominal thrusts and back blows for a child, or back blows and chest thrusts for an infant. If secretions are blocking the airway, suctioning will help remove them. The suction may need to be repeated frequently to maintain an open airway, so the child should be monitored at all times.",
        "Ventilation/Oxygenation": "A child who is in respiratory distress may be agitated or drowsy. Agitation results from trying to get air; drowsiness is the result of insufficient oxygenation. The breathing effort increases in many cases, but as respiratory failure sets in, the breathing effort may decline considerably as the child weakens. Additionally, a combination can occur; the child may breathe with great effort for periods, followed by declining efforts as the child tires. If the child is not breathing adequately or is not breathing at all, ventilation and/or oxygenation will be required. Signs of the need for this assistance would be agitation or drowsiness, limp muscles, inability to respond and a pale or cyanotic appearance.",
        "Circulation": "Circulation in a child is similar to that of an adult, though the average child\u2019s pulse is more rapid than an adult\u2019s. Observe the child for signs and symptoms of shock, which include restlessness; cold, clammy, pale or ashen skin; rapid or irregular breathing; falling blood pressure; altered mental status; rapid, weak or thready pulse; delayed capillary refill; and an absence of tears if the child or infant is crying. Place the child in the supine position (flat on their back). A child who is in shock or is at risk of going into shock must be kept from getting chilled or overheated. Place a blanket over the child to help maintain the body temperature. Monitor the child closely for any changes in status.",
        "Determining the Level of Consciousness": "Using the AVPU scale, you can start to determine the child\u2019s level of consciousness (LOC). The AVPU scale is a mnemonic that describes stages of awareness: Alert (the patient can respond to questions and is aware of the surroundings), Voice (the patient responds to verbal stimuli), Pain (the patient only responds to painful stimuli) and Unresponsive (the patient does not respond to any stimuli). The AVPU scale is covered more thoroughly in Chapter 7. Another way to determine the LOC is pupil assessment, which involves checking to see if the pupils react to light. Shine a flashlight or penlight quickly into and then out of the child\u2019s eye. In a normal reaction, the pupil constricts in response to the light and then dilates again after the light is removed. Movement is another good indication of LOC. Observe the child. A fully alert child will have spontaneous movements and as LOC diminishes, so will the movement.",
        "Exposure": "Despite the need to keep the child covered if you are concerned about shock, you must be able to assess the child properly and thoroughly, barring any life-threatening situation. Check the child for any other injuries or signs of trauma. You do not need to uncover the child completely. You may remove the top part of the blanket to examine the upper body, cover the child and then remove the lower part of the blanket to examine the lower body. Be swift and cover the child as quickly as possible. Because a large proportion of body heat is lost through the head and neck, cover the child\u2019s head to minimize the loss of body heat.",
        "SAMPLE History": "When taking a child\u2019s SAMPLE (signs and symptoms, allergies, medications, pertinent medical history, last oral intake and events leading up to the incident) history, you will need the parent\u2019s or caregiver\u2019s cooperation. Encourage this cooperation by remaining respectful and polite during the conversation, even if the adult is difficult or if you suspect child abuse or child neglect. Ask questions that require detailed answers, not yes-or-no questions. If the child is young but wants to participate, welcome this. An older child, particularly an adolescent, may want to speak with you privately. Keep this in mind if you must ask sensitive questions about topics such as sexual activity or drug use. If you are not sure that the answers you receive are accurate or contain enough information, try asking the question in another manner, using different phrasing. Use feedback, repeating the answers as you make note of them, to be sure you heard correctly.",
        "Symptoms and Duration": "Ask the parent, caregiver, or child, if appropriate, about the symptoms, any changes (worsening or easing) and how long they have been present. While obtaining a patient history, inquire about: \uf0a7 Fever. \uf0a7 Unusual activity level. \uf0a7 History of eating, drinking and urine output. \uf0a7 History of vomiting, diarrhea and abdominal pain.",
        "Allergies": "Ask the parent, caregiver or child, if appropriate, if they have any allergies. While obtaining a patient history, inquire about allergies to: \uf0a7 Medications. \uf0a7 Food. \uf0a7 Environmental elements, such as dust, pollen or bees.",
        "Medications": "Ask the parent or caregiver about medications the child might take. Does the child take any prescription medications or has the parent or caregiver given any over-the-counter medications recently? Does the child have any allergies to medications? Could the child have gotten into someone else\u2019s medications?",
        "CRITICAL FACTS 3": "You will need the parent\u2019s or caregiver\u2019s cooperation while taking a child\u2019s SAMPLE history. Be respectful and polite, even if you suspect child abuse or neglect. Avoid asking yes-or-no questions. Allow a child to participate; older children may want to talk privately, especially if you must ask sensitive questions concerning sexual activity or drug use.",
        "Pertinent Past Medical Problems or Chronic Illnesses": "Ask the parent or caregiver if something like this has ever occurred before. If so, what caused it before and what happened in the long run? Does the child have any chronic illnesses, such as asthma or diabetes? Has the child been ill lately with any other type of illness?",
        "Last Oral Intake": "Ask the parent or caregiver when the child last had something to eat or drink and what it was.",
        "Events Leading Up to the Injury or Illness": "Ask the parent or caregiver what specifically was going on when the injury or illness was first noticed. What was the environment like (where did it happen)? What was the child doing? What was the child\u2019s reaction?",
        "Physical Exam": "Conducting a physical exam of a child or an infant requires some special handling. Try to have only one individual deal with the child, to reduce the anxiety of being handled by multiple strangers. If you can, crouch down to the child\u2019s eye level. Speak calmly and softly and maintain eye contact. Be gentle and never lose your temper. Involve people who are familiar to the child, if possible. For preschoolers, save frightening tools like stethoscopes until the child has had a chance to get used to you. When examining a child, the standard procedure is to go from head to toe. For a very agitated child, however, the exam may be more successful if it is performed toe to head. A head-to-toe exam involves the following components: \uf0a7 Head: Look for bruising or swelling. \uf0a7 Ears: Look for drainage suggestive of trauma or infection. \uf0a7 Mouth: Look for loose teeth, identifiable odors or bleeding. \uf0a7 Neck: Look for abnormal bruising. \uf0a7 Chest and back: Look for bruises, injuries or rashes. \uf0a7 Extremities: Look for deformities, swelling or pain on movement.",
        "COMMON PROBLEMS IN PEDIATRIC PATIENTS - Airway Obstructions": "Some of the most common airway problems you may encounter with small children and infants are airway obstructions. Airway obstructions may be categorized as either partial or complete. Signs of a partial airway obstruction in a child or an infant who is alert and sitting up include: \uf0a7 Abnormal high-pitched musical sounds, crowing or noisy respirations. \uf0a7 Retraction . \uf0a7 Drooling. \uf0a7 Frequent coughing. Keep the child or infant in a position of comfort, possibly sitting on a parent\u2019s or caregiver\u2019s lap. The child can stay there while you administer supplemental oxygen based on local protocols. A complete airway obstruction is a life-threatening situation. A partial airway obstruction in a child or an infant who is showing signs of cyanosis should be treated as a complete airway obstruction. Signs of a complete airway obstruction include: \uf0a7 Inability to cough, cry or speak. \uf0a7 Cyanosis. \uf0a7 Loss of consciousness. \uf0a7 Altered mental status. Care includes clearing the airway and attempting ventilation using the mouth-to-mask technique. For more information on clearing airway obstructions in children and infants, refer to Chapter 11.",
        "COMMON PROBLEMS IN PEDIATRIC PATIENTS - Breathing Emergencies": "Respiratory distress is apparent when the child or infant begins to experience difficulty breathing. If uncorrected, respiratory distress can lead to respiratory failure.",
        "Anatomic and Physiological Differences in Children": "Anatomical differences among adults, children and infants can change their susceptibility to respiratory difficulties and affect how to provide emergency care: \uf0a7 In children and infants, the tongue is larger in relation to the space in the mouth than it is in adults. This can increase the risk of the tongue blocking the trachea.\n\uf0a7 In children, the airway is smaller, resulting in more objects, such as different types of solid foods, being a choking hazard. Their smaller airway can make children more prone to developing infections or amassing liquid secretions. This also affects the choice of ventilation equipment used.\n\uf0a7 In children, the trachea is not as long as it is in adults, so any attempt to open the airway by tilting the child\u2019s head too far back will result in blocking the airway.\n\uf0a7 Children breathe using their diaphragm, so ensure nothing is pressing on the abdomen to prevent this. Also, if possible, allow the child to sit up.\n\uf0a7 Young children and infants do not usually breathe through their mouth; they breathe through their nose. Ensure that the nose is as clear as possible for breathing.",
        "Pathophysiology": "The process of respiratory emergencies usually follows the pattern of respiratory distress, followed by respiratory failure, which is then followed by respiratory arrest if emergency interventions are not attempted or are not successful.\nRespiratory distress occurs when the child is having trouble breathing but is visibly able to breathe. A child in respiratory distress may be mentally alert and/or agitated. The patient\u2019s breathing effort is increased and the skin color may be normal or pale.\nRespiratory distress preceding respiratory failure is characterized by:\n\uf0a7 In infants, a respiratory rate of more than 60 breaths per minute.\n\uf0a7 In children, a respiratory rate of more than 30 breaths per minute.\n\uf0a7 Flaring of the nostrils.\n\uf0a7 Use of neck muscles and muscles between and below the margin of the ribs to aid in breathing.\n\uf0a7 Abnormal, high-pitched sounds when breathing.\uf0a7 Cyanosis.\n\uf0a7 Altered mental status.\n\uf0a7 Grunting.\nRespiratory failure occurs when the respiratory system is beginning to shut down. The child may be sleepy and lethargic, or may alternate between being agitated and sleepy. Muscle tone is generally limp, breathing is usually visible, and breathing can decrease or alternate between increased and weak effort as the child becomes tired. The skin is usually pale, mottled or cyanotic.\nRespiratory arrest occurs when the respiratory system shuts down. The child is unconscious and completely limp. Signs of breathing may be slight, but are most likely absent, and the skin color is cyanotic.\nThe importance of recognizing early signs of respiratory distress cannot be emphasized enough. Early recognition of respiratory emergencies can make the difference between life and death. More information on the recognition and care of breathing emergencies can be found in Chapters 10 and 11.",
        "Assessing Breathing Emergencies": "The child\u2019s ability to breathe adequately must be assessed by checking the mental status, muscle tone, breathing movement, breathing effort and skin color. Once you have made your assessment, be sure to frequently perform follow-up assessments to note if there are any changes in the child\u2019s respiratory status.",
        "CRITICAL FACTS 2": "Certain problems are unique to children, such as specific kinds of injury and illness. Some of the most common airway problems the emergency responder may encounter with small children and infants are airway obstructions.\nAnatomical differences among adults, children and infants can change their susceptibility to respiratory difficulties and affect how to provide emergency care.",
        "Common Respiratory Problems in Children": "Although many types of breathing problems can affect children, some will be seen by emergency responders more often than others, such as croup, epiglottitis, asthma and choking on an obstruction.\nCroup is a common upper airway virus that affects children younger than 5. The airway constricts, limiting the passage of air, causing the child to produce an unusual sounding cough that can range from a high-pitched wheeze to a barking cough. Croup occurs most often during the evening and night hours. A child with croup may progress quickly from respiratory distress to respiratory failure. Children with croup may benefit from humidified oxygen. If you are transporting the child to the hospital, you may see an improvement in the child once exposed to cool air outdoors.\nEpiglottitis: Epiglottitis is a bacterial infection that causes severe swelling of the epiglottis. While it is extremely rare, the symptoms may be similar to croup; it is a more serious illness and can result in death if the airway is blocked completely. If the child is older, you may see the tripod position, where the child is sitting up and leaning forward, perhaps with the chin thrust outward. Other signs are drooling, difficulty swallowing, voice changes and fever. A child with epiglottitis can move from respiratory distress to respiratory failure very quickly without emergency care. With epiglottitis, keeping the child as calm as possible is vital. Do not examine the throat using a tongue depressor or place anything in the child\u2019s throat, as these can trigger a complete airway blockage. Asthma: Asthma is a common illness and can be triggered in many children by exposure to allergens. Air is drawn into the lungs, but as the bronchioles constrict during an asthma attack, they also may fill with mucus, blocking the air in the lungs from exiting. This blockage results in the characteristic wheeze when the patient exhales. Ask the parent or caregiver if the child is known to have asthma and, if so, if any rescue medications are available. If medications have been administered, find out what has been taken and how often up to the time of your arrival. The status of a child with asthma can change very quickly, so constant monitoring is necessary. The typical signs of asthma include rapid respirations that take effort as respiratory distress develops, but the breathing may seem to become less labored. This does not indicate improvement, but rather deterioration in respiratory status. Choking: Choking is a common emergency in young children, particularly once they become mobile and are able to explore on their own. Your interventions will be based on your assessments as to whether the child has a partial or complete airway obstruction.",
        "Providing Care for Breathing Emergencies": "Treatment of all respiratory emergencies is generally the same. Use equipment that is properly sized for the child, particularly if using an oxygen mask. The mask should fit the child and should deliver the appropriate amount of oxygen. Monitor the airway and breathing continuously, and arrange for transport as quickly as possible.",
        "Circulatory Failure": "As with adults, undetected and uncorrected circulatory failure in children and infants can cause cardiac arrest. Signs and symptoms of circulatory failure include: Increased heart rate (but can also be decreased). Unequal pulses (femoral compared with radial). Delayed capillary refill. Changes in mental status. Unlike adults, children seldom initially suffer a cardiac emergency. Instead, they suffer a respiratory emergency that develops into a cardiac emergency. Motor-vehicle collisions, drowning, smoke inhalation, poisoning, airway obstruction and falls are all common causes of respiratory emergencies that can develop into a cardiac emergency. A cardiac emergency can also result from an acute respiratory condition, such as a severe asthma attack. Always be prepared for the possibility of circulatory failure when dealing with a respiratory emergency. Care for circulatory failure includes identifying problems through assessment; assisting attempts to breathe by opening the airway, removing obstructions or providing ventilation; and observing for signs of cardiac arrest, performing CPR and using an AED. More information on the identification and care for circulatory failure can be found in Chapter 13.",
        "Seizures": "A seizure is a disorder in the brain\u2019s electrical activity, sometimes marked by loss of consciousness and often by uncontrollable muscle movement; also called a convulsion. A chronic condition, such as epilepsy, or an acute event may cause seizures. In children, febrile seizures are the most common type of seizure. These seizures occur with a rapidly rising or excessively high fever, higher than 102\u00b0 F (38.9\u00b0 C). Febrile seizures may have some or all of the following signs and symptoms: \uf0a7 Sudden rise in body temperature \uf0a7 Change in LOC \uf0a7 Rhythmic jerking of the head and limbs \uf0a7 Loss of bladder or bowel control \uf0a7 Confusion \uf0a7 Drowsiness \uf0a7 Crying out \uf0a7 Becoming rigid \uf0a7 Holding the breath \uf0a7 Rolling the eyes upward",
        "Assessing Seizures": "When obtaining a history from the parent or caregiver, you need to know several things to assess what type of seizure the child may be having and what may have caused it. Ask questions such as: \uf0a7 Has the child ever had seizures before? If so, does the child have medications for them? If not, is there a family history of seizures? \uf0a7 Does the child have diabetes? If so, what type of insulin/medication is being used and when was the last time it was given? Does the parent or caregiver monitor the blood sugar level? If so, what was the child\u2019s blood sugar level when it was most recently monitored? \uf0a7 Has the child begun taking any new medications lately? If the child takes medications, is it possible there may have been an overdose? Could the child have taken someone else\u2019s medication? \uf0a7 Did the child have access to anything poisonous? \uf0a7 Has the child had an injury, particularly a head trauma, recently? \uf0a7 Has the child seemed sick or had a high fever, stiff neck or recent headache? \uf0a7 What did the seizure look like? Did it involve the child\u2019s whole body, or only one half of the body? Did it start in one area and progress to the rest? Did the child fall when the seizure began and if so, was it possible the child\u2019s head struck an object or the floor?",
        "Managing Seizures": "The general principles of managing a seizure are to prevent injury, protect the child\u2019s airway and ensure that the airway is open after the seizure has ended. Call for more advanced medical personnel for a child or an infant who has had a seizure and for a young child or an infant who experienced a febrile seizure brought on by a high fever. Do not put anything in the child\u2019s mouth and do not restrain the child. Ensure that the environment is as safe as possible to prevent injury to the child during the seizure by moving away any furniture or other objects. Place the child in a side-lying recovery position during the seizure, if it is possible and safe to do so. After the seizure, ensure the child\u2019s airway is open and administer supplemental oxygen, based on local protocols. Suctioning the airway may be necessary to remove excessive fluids. Also, after the seizure, assess the patient for any injuries that may have been sustained as a result of the seizure. If you have not already done so, position the child or infant on their side so that fluids (saliva, blood, vomit) can drain from the mouth. Care for a child or an infant who experiences a febrile seizure is much the same as for any other seizure. Most febrile seizures last less than 5 minutes and are not life threatening. However, immediately after a febrile seizure it is important to cool the body if a fever is present. See Chapter 14 for more information on managing seizures.",
        "Fever": "Fever is defined as an elevated body temperature. It signifies a problem and, in a child or an infant, can indicate specific problems. Often these problems are not life threatening, but some can be. A high fever in a child often indicates some form of infection. In a young child, even a minor infection can result in a rather high fever, which is often defined as a temperature higher than 102\u00b0 F (38.9\u00b0 C). If a fever is present, call for more advanced medical help at once. Your initial care for a child with a high fever is to gently cool the child. Never rush cooling down a child. If the fever has caused a febrile seizure, rapid cooling could bring on another seizure. Parents or caregivers often heavily dress children with fevers. Remove the excess clothing or blankets. Do not use an ice water bath or rubbing alcohol to cool down the body. Both of these approaches are dangerous, and parents and caregivers should be discouraged from ever using them. Do not give children or infants aspirin or products that contain aspirin when they show flu-like symptoms including fever, or if they may have a viral illness such as chicken pox, as this may result in an extremely serious medical condition called Reye\u2019s syndrome. Reye\u2019s syndrome is an illness that affects the brain and other internal organs. Ask the parent or caregiver what medications they may have given the child so you can inform more advanced medical personnel.",
        "Poisoning": "Poisoning can cause many types of emergencies, from seizures to cardiac arrest. Unintentional poisoning is a leading cause of unintentional death in the United States for adolescents, children and infants. Just under half of exposure cases managed by Poison Control Centers involve children younger than 6. Children in this age group often become poisoned by ingesting medications (typically those intended for adults) and household products, such as laundry detergent pods and solid objects, like batteries, particularly the watch-sized batteries found in many children\u2019s toys.",
        "Shock": "Shock is the body\u2019s reaction to a physical or emotional trauma in both adults and children. Physical trauma could include loss of blood. In small children, the loss of blood may be much more significant than in adolescents or adults. This adds to the increased risk of shock and the speed with which it may develop. Children can go into shock very quickly, regardless of the cause, and may go into cardiac arrest much faster than adults.",
        "Causes of Shock in Children": "In addition to trauma, shock may also be caused by infection. Infections can send the body into shock because of the body\u2019s reaction to the infection. The risk of shock increases with the severity and centrality of the infection. Among children, the most common cause of shock is vomiting or diarrhea. As they lose fluid from the vomit and/or diarrhea, their body fluid volume becomes depleted and their blood pressure drops.",
        "Assessing Shock": "When assessing shock, watch the child\u2019s mental status, including any changes that have occurred since you arrived on the scene. Some children may experience a change in mental status so pronounced that it makes them unable to recognize their parent or caregiver. This altered mental status is a strong indicator that shock is developing quickly and may result in cardiac arrest. Other signs and symptoms of shock include: \uf0a7 Cold, clammy, pale or ashen skin, particularly in infants, as they are less capable of regulating body temperature. \uf0a7 Rapid, weak or thready pulse. \uf0a7 Rapid or irregular breathing. \uf0a7 Lack of tears when crying. \uf0a7 Low or lack of urine output. \uf0a7 Falling blood pressure.",
        "Providing Care for Shock": "Lay the child flat if possible, but do not force it if the child is too agitated or upset. Constantly monitor the child\u2019s respiratory and circulatory status. Have equipment available should the child go into cardiac arrest.",
        "Altered Mental Status": "Altered mental status in children and infants is another medical condition you may encounter. This can be caused by low blood sugar, poisonings or overdoses, seizures, infections, trauma, decreased level of oxygen and the onset of shock. When assessing altered mental status, use the AVPU scale, which is covered more thoroughly in Chapter 7. When arriving on the scene, determining the cause of the alteration in mental status right away is not essential. Your role is to support the patient by maintaining an open airway and administering supplemental oxygen based on local protocols. Any information you can gather from the parent, caregiver or bystanders will help you care for the patient.",
        "Trauma": "Injury is the number-one cause of death for children in the United States. Many of these deaths are the result of motor-vehicle collisions. The greatest dangers to a child involved in a motor-vehicle crash are airway obstruction and bleeding. Ensure an open airway and control severe bleeding as quickly as possible. A relatively small amount of blood lost by an adult is a large amount for a child or an infant. Because a child\u2019s head is large and heavy in proportion to the rest of the body, the head is the most frequently injured part of the child\u2019s body. A child injured as the result of force or a blow may also have sustained damage to the organs in the abdomen and chest. Because children have very soft, pliable ribs, such damage can cause severe internal bleeding. Care for a child with a chest injury involves keeping an open airway, assessing the chest for rise and fall, and administering supplemental oxygen based on local protocols. In a car crash, a child only secured by a lap belt may have serious abdominal or spinal injuries. You may need to rely on bystanders\u2019 reports of what happened, as a severely injured child may not immediately show signs of injury. Laws requiring children to ride in safety seats or wear safety belts have been enacted to stop some of the needless deaths of children associated with motor-vehicle crashes. As a result, children\u2019s lives are being saved. However, you may have to check and care for an injured child or infant while the child is in a safety seat. A safety seat does not normally pose any problems when checking a child or an infant. Leave the child or infant in the seat if the seat has not been damaged. If the child or infant is to be transported to a medical facility for examination, the child can often be safely secured in the safety seat for transport. Care for extremity injuries in a child or an infant in the same way as for adults. When providing care for an injured child or infant, use equipment of the proper size. If equipment of the proper size is not available, manually stabilize extremity injuries until additional help arrives. Information on the general management of extremity injuries can be found in Chapter 22. Try to comfort, calm and reassure the child and family members while waiting for additional emergency medical services (EMS) resources.",
        "Child Abuse and Neglect": "You may at some point encounter a situation involving an injured child in which you believe or have reason to suspect child abuse or neglect is involved.",
        "Types of Abuse": "Child abuse , or non-accidental trauma, is the physical, psychological or sexual assault of a child resulting in injury and emotional trauma. Child abuse involves an injury or pattern of injuries that do not result from a mishap. You might suspect child abuse if the child\u2019s injuries cannot be logically explained or a caregiver or parent gives an inconsistent or suspicious account of how the injuries occurred. Perpetrators of child abuse may often be evasive or volunteer very little information. One type of abuse is shaken baby syndrome , which is the result of a young child being shaken harshly\u2014hard enough to cause brain swelling and damage. Signs and symptoms of shaken baby syndrome include unconsciousness, lethargy/decreased muscle tone, extreme irritability, difficulty breathing, seizures, inability to lift head, inability of eyes to focus and decreased appetite. Child neglect  is insufficient attention given to or a lack of respect shown to a child who has a claim to that attention. Neglect is the most common type of child abuse reported. Signs and symptoms include: \uf0a7 Lack of adult supervision. \uf0a7 A child who appears underfed or malnourished. \uf0a7 An unsafe living environment. \uf0a7 Untreated chronic illness; for example, a child with asthma who has no medications available despite being issued a prescription.",
        "Epidemiology of Child Abuse and Neglect": "Epidemiology  studies show that child abuse is not limited to a certain sector of society but may occur in any part. Every year in the United States, almost 700,000 children are victims of child abuse and neglect, and more than 1,600 children die from the abuse and neglect at a rate of 2.25 per 100,000 children. Of those, 75.3 percent were neglected, 17.2 percent were physically abused and 8.4 percent were sexually abused.",
        "Assessing Child Abuse and Neglect": "Upon arriving on the scene, note anything in the child\u2019s history or at the scene that causes concern or suspicion of abuse or neglect. Watch the caregiver\u2019s behavior, which may be evasive; the caregiver (usually a parent) may not volunteer much information or may contradict information already given. Also observe for particular physical signs and symptoms: \uf0a7 Injury that does not fit the description of what caused it\uf0a7 Patterns of injury that include cigarette burns, whip marks and handprints \uf0a7 Obvious or suspected fractures in a child younger than 2 years of age \uf0a7 Any unexplained fractures \uf0a7 Injuries in various stages of healing, especially bruises and burns \uf0a7 Unexplained lacerations or abrasions, especially to the mouth, lips and eyes \uf0a7 Injuries to the genitalia \uf0a7 Pain when the child sits down \uf0a7 More injuries than are common for a child of that age \uf0a7 Repeated emergency calls to the same address",
        "Managing Child Abuse and Neglect": "When caring for a child who may have been abused, your first priority is to care for the child\u2019s injuries or illness. An abused child may be frightened, hysterical or withdrawn. Abused children may also be unwilling to talk about the incident in an attempt to protect the abuser or for self-protection. If you suspect abuse, explain your concerns to the responding police officers or emergency medical technicians (EMTs), if possible. When answering a call where you suspect abuse, you must ensure your own safety. Do not place the child in the awkward position of having to tell you things that may cause tension with a parent or caregiver. Focus on treating the child and making your assessments. Never  confront the parent or caregiver about your suspicions, as this could put you and/or the child at risk. If you need to transport the child out of the environment, the parent\u2019s or caregiver\u2019s support is essential.",
        "Legal Aspects of Child Abuse and Neglect": "If you have reasonable cause to believe that abuse has occurred, you can report your suspicions to a community or state agency, such as the Department of Social Services, the Department of Children and Family Services, or Child Protective Services. You may be afraid to report suspected child abuse because you do not wish to get involved or are afraid of getting sued. You do not need to identify yourself when you report child abuse, although your report will have more credibility if you do. In some areas, certain professions are legally obligated  to report suspicions of child abuse as a mandated reporter.",
        "Documenting Child Abuse and Neglect": "As with all emergency calls, you must document your observations and actions and the patient\u2019s response objectively. When dealing with suspected child abuse or child neglect, remain objective in your documentation. Do not write any supposition or theories. If there is later legal action, your notes may be used in court. Your notes have a better chance of being useful if they are thorough and objective.",
        "Sudden Infant Death Syndrome": "Sudden infant death syndrome (SIDS), which used to be called crib death, is the unexplained sudden death of an infant younger than 1, but it occurs most often between the ages of 4 weeks and 7 months. SIDS almost always occurs while the infant is sleeping. This condition does not seem to be linked to any disease. Because the cause or causes of SIDS are not yet understood, parents do not know if their child is at risk. SIDS is sometimes mistaken for child abuse because of the unexplained death of an otherwise healthy child and the presence of bruise-like blotches that sometimes appear on the infant\u2019s body. However, SIDS is not related to child abuse. SIDS is also not believed to be hereditary, but it does tend to recur in families.",
        "Epidemiology and Risk Factors": "The rate of SIDS occurrence is significantly lower now than prior to 1992, when parents and caregivers were first told to put infants to sleep on their back or side. Even so, unfortunately, SIDS still causes a significant number of deaths in infants younger than 1, and thousands of babies die of SIDS in the United States each year. Parents and caregivers should not place anything in the crib, including pillows, blankets or toys, and should try to ensure that the infant is not exposed to any secondhand smoke. Babies who die of SIDS are most often reported to have been perfectly healthy, although some reports indicate some infants had a cold prior to their death.",
        "Assessing and Managing SIDS": "When called for a SIDS death, unless the infant is very obviously dead (rigor mortis has set in), attempt resuscitation with CPR as per infant protocols. Follow local EMS protocols for death in the field, and notify the appropriate authorities. If possible, try to obtain the following information:\n\uf0a7 When was the infant last checked on or put to bed and seen to be breathing?\n\uf0a7 Who discovered the infant and what brought the person into the room (concern of infant sleeping too long, time to get up, etc.)?\n\uf0a7 How was the infant lying in the crib, in what position?\n\uf0a7 Was anything else in the crib?\n\uf0a7 Were any other adults or children in the house while the infant was sleeping?\n\uf0a7 What was the infant\u2019s state of health?\n\uf0a7 Did the infant seem different, uncharacteristically quiet or cranky, for example, when last put in the crib?\n\uf0a7 Did the infant have any illnesses or allergies?\n\uf0a7 Was the infant given any medications?\n\uf0a7 Were any medications or toxic substances nearby?\n\uf0a7 How warm was the bedroom?\nBy the time the infant\u2019s condition is discovered, the infant will likely be in cardiac arrest. Ensure that someone has called more advanced medical personnel, or call for help yourself. Give the infant CPR until more advanced medical personnel take over.",
        "Support for SIDS": "Because of the circumstances of the death, the parents, caregivers and possibly siblings may be your patients as much as the infant. Shock can result from a severe emotional trauma, so observe the parent or caregiver closely for signs and symptoms of shock. When more advanced emergency personnel take over the infant\u2019s care, you can focus on the family. Encourage them to accompany the infant. If they are concerned about leaving other children behind, see if a neighbor or friend is able to stay with their children.",
        "Lowering the Risk for SIDS": "Because it cannot be predicted or prevented, SIDS makes many new parents feel anxious. However, there are several things they can do to lower the risk for SIDS. The American Academy of Pediatrics has guidelines for safe sleep, which include the following for the first year of an infant\u2019s life:\n\u2022 Always place an infant on their back for every sleep time including naps.\n\u2022 Always use a firm sleep surface. Car seats and other sitting devices are not recommended for routine sleep.\n\u2022 The infant should sleep in the same room as the parents or caregivers, but not in the same bed.\n\u2022 Bed sharing is not recommended for any infants.\n\u2022 Keep all soft objects or loose bedding out of the crib. This includes pillows, blankets, bumper pads and toys.\n\u2022 Wedges and positioners should not be used.\n\u2022 Do not smoke during pregnancy or after birth.\n\u2022 Offer a pacifier at nap time and bedtime.\n\u2022 Avoid covering the infant\u2019s head or allowing the infant to become overheated.\n\u2022 Do not use home monitors or commercial devices marketed to reduce the risk of SIDS.\n\u2022 Supervised, awake tummy time is recommended daily to facilitate development and minimize the occurrence of positional plagiocephaly (flat head).\n\u2022 Make sure an infant has received all recommended vaccinations. Evidence suggests that immunization reduces the risk for SIDS by 50 percent.\n\u2022 Breastfeeding is associated with a reduced risk for SIDS and is recommended.\nFor more information on the guidelines for sleep position for infants and reducing the risk for SIDS, visit healthychildren.org/safesleep. Additional information can be found on the National Institutes of Health website at nichd.nih.gov/sids.\nSource: American Academy of Pediatrics: Ages & stages: Reduce the risk of SIDS. healthychildren.org/safesleep. Accessed December 2016.",
        "Apparent Life-Threatening Events": "An apparent life-threatening event (ALTE) is a sudden event in infants younger than 1, characterized by apnea, change in Lowering the Risk for SIDS color, change in muscle tone, and coughing or gagging. About half the time, ALTE is linked to an underlying digestive, neurologic or respiratory health problem, but it remains unexplained in half of all cases. When linked to certain other conditions, ALTE is thought to be a risk factor for SIDS. At one time it was believed these two conditions were more strongly linked and it was questioned whether ALTE was simply a \u201cnear-miss\u201d case of SIDS, but experts no longer believe this is the case.",
        "Considerations for Children with Special Healthcare or Functional Needs": "In addition to the more common problems any child may have, a child with special healthcare or functional needs may have additional health concerns. When called to a scene with a child with special healthcare or functional needs, the parent or caregiver can generally provide you with the most information, because they are the most familiar with the medical equipment the child may use. Pieces of equipment may include:\n\uf0a7 Power wheelchairs.\n\uf0a7 Ventilators.\n\uf0a7 Communication systems.\n\uf0a7 Feeding apparatus.\nWhile making your assessments, the parent or caregiver can provide valuable insight into the problem. They may suspect a specific issue, or perhaps a similar situation occurred previously.\nWhile assessing breathing and pulse, take into account that if a child is on a respirator or ventilator, the problem may not be with the child, but with the machine. You may need to manually give ventilations with a BVM or other device while the machine is being checked.\nWhen caring for children, you depend on your assessment skills to determine the child\u2019s age and maturity level. When dealing with children who have special healthcare or functional needs, the child\u2019s age and maturity level may not be as straightforward, depending on the child\u2019s disability. Do not assume a child\u2019s mental capacity if the child is unable to express thoughts or words. Ask the parent what the child is capable of understanding, and speak directly to the child as you would to any other child. Do not speak to the parent or caregiver as if the child is not in the room.",
        "THE EMERGENCY MEDICAL RESPONDER\u2019S NEEDS": "Dealing with emergency situations can be difficult for many emergency medical responders (EMRs). The difficulty can be compounded when the emergencies include children, particularly if they involve suspected child abuse or SIDS. The death of a child, especially if declared on the scene of an incident, can be very difficult for any responder.\nWhile you are on scene, caring for the child and interacting with the parent, caregiver and/or bystanders, maintain a professional demeanor and control your emotions. This is easiest if you focus on the task at hand and only the task. However, once you are away from the scene, your professional \u201cmask\u201d may be removed as you deal with your own thoughts and emotions.\nAs a person, you are entitled to your own thoughts and emotions, be they anger, pain or sorrow. Feeling anxious and helpless is common and normal after such events. However, these feelings must be put in context so they do not overwhelm you and interfere with your professional and personal life.\nMost emergency response teams have resources available to help responders following a critical event. More information on this topic can be found in Chapter 2.",
        "PUTTING IT ALL TOGETHER": "Caring for children is similar in many ways to caring for adults, but differences exist, both physical and emotional. Caring for a child often also means providing support and care to the parent or caregiver, who are often stressed and anxious.\nAssessing breathing and pulse in children is, for the most part, the same as assessing the same things in adults. For both adults and children, breathing and pulse are your priority and must be assessed before all else. Although the airway must be patent in both adults and children, it is smaller and shorter in children, and their respirations are generally more rapid than those of an adult. When assessing circulation, a child who is bleeding may go into shock more rapidly than an adult because of the lower quantity of blood circulating in a child\u2019s body.\nCaring for children may also involve potentially anxiety-provoking situations, such as child abuse or neglect. If you suspect child abuse or neglect, you must perform your duties as a professional, and keep your personal feelings to yourself.You are not, however, helpless; you can report concerns of child abuse if you feel they are warranted. Finally, as an EMR, you will likely face death on occasion, and dealing with a child\u2019s death may have an especially strong impact. Although you must remain professional while on the job, you also must recognize that\u2014as a person\u2014you have the right to feel upset, anxious, angry or any other emotion. Take care of yourself so that these emotions do not overcome you and affect your life."
    },
    {
        "Introduction": "Sudden illnesses and medical emergencies are common in children and infants. This chapter covers the special knowledge and skills you will need to assess and treat children and infants. This chapter also covers the differences between the anatomy of an adult and a child and highlights the special considerations for examining pediatric patients. It describes how the pediatric assessment triangle gives you a first impression of the severity of the child\u2019s illness or injury. Respiratory care for children is extremely important. This chapter reviews the following respiratory skills: opening the airway, basic life support, suctioning, and relieving airway obstructions. It explains the signs of respiratory distress, respiratory failure, and circulatory failure in children and infants. It is important that you learn some basic information and treatment for the following conditions: altered mental status, asthma, croup, epiglottitis, drowning, heat illnesses, high fever, seizures, vomiting and diarrhea, abdominal pain, poisoning, and sudden infant death syndrome. Because trauma is the leading cause of death in children, this chapter covers patterns of injury and the signs of traumatic shock in children. Finally, it is important for you to be able to recognize some of the signs and symptoms of child abuse and sexual abuse of children so you can take the appropriate steps to get help from the proper authorities.",
        "General Considerations": "Managing a pediatric emergency can be one of the most stressful situations you face as an emergency medical responder (EMR). The child is frightened, anxious, and usually unable to communicate the problem to you clearly. The parents are anxious and frightened. In an atmosphere where everyone involved is tense, you must remain calm and behave in a controlled and professional manner. Emergency medical services (EMS) personnel often have mixed feelings when treating a child. In some situations, the child reminds them of someone they know. Even the most experienced personnel respond emotionally to a seriously ill or injured child. Unless you are prepared, your anxiety and fear may interfere with your ability to deliver proper care.",
        "The Parents": "The child\u2019s parents or caregivers can be either allies or a potential problem. You must respond to them as much as to the child, although in a different way. Talk to both the parents and the child as much as possible. Parents are understandably concerned about their child\u2019s condition, especially if they do not clearly understand the situation or if they think the situation is more serious than it is. For example, imagine a parent\u2019s reaction to a bleeding laceration on his or her child\u2019s forehead. You know that scalp wounds can bleed profusely, but you also know that you can easily control such bleeding with direct pressure. However, many parents are not aware of this fact and may become emotionally distressed by the large amount of blood. Other parents can be extremely helpful. They know the child well and can tell you how the child\u2019s behavior is different from his or her usual behavior.\n\nChildren get many of their behavioral cues from their parents; therefore, if you calm the parents, talk with them, and ask for their assistance in calming the child, it is likely that the child will become less agitated. It is a good idea to allow a parent to hold the child if the illness or injury permits. If the injury is such that the parent cannot hold the child on his or her lap, let the parent hold the child\u2019s hand or keep the parents where the child can see them.\n\nQuickly try to develop a rapport with the child. Tell the child your first name, find out what the child\u2019s name is, and use the child\u2019s name as you explain what you are doing. Do not stand over the child. Squat, kneel, or sit down to place yourself at the level of the child and establish eye contact. Ask the child simple questions about the pain and ask the child to help you by pointing to (or touching) the painful area.\n\nBe honest with the child. For example, if you must move an arm or leg to apply a splint, tell the child what you are going to do and explain that the movement may hurt. In talking to the child, you can also request his or her help, asking the child to help you by being calm, lying still, or holding a bandage. The level of understanding and cooperation you can receive from an ill or injured child is often remarkable and may surprise you. Some emergency service agencies provide the child with a trauma teddy bear to hold while being examined.",
        "Pediatric Anatomy and Function": "Children and adults have the same body systems that perform the same functions. However, there are certain differences, particularly in the airway, that you need to understand. A child\u2019s airway is smaller in relation to the rest of the body. Therefore, secretions or swelling from illnesses or trauma can more easily block the child\u2019s airway. Because a child\u2019s tongue is relatively larger than the tongue of an adult, a child\u2019s tongue can more easily block the airway if the child becomes unresponsive. Because a child\u2019s upper airway anatomy is more flexible than that of an adult, you must remember to avoid hyperextending (overextending) the neck of an infant or child when attempting to open the airway. Position the head in a neutral or slight sniffing position, but do not hyperextend the neck. Hyperextension of a child\u2019s neck can occlude the airway. For at least the first 6 months of their lives, infants can breathe only through their noses. If mucus blocks an infant\u2019s nose, the infant cannot breathe through the mouth. Therefore, it is important to clear the nose of an infant to enable breathing.\n\nThe anatomy of a child\u2019s airway differs from that of an adult. The tongue is proportionally larger and can more easily block the airway. Also, the back of a child\u2019s head is larger, so head positioning requires more care.\n\nWhen the demands on a child\u2019s respiratory system change, the child is able to quickly compensate by increasing his or her breathing rate and breathing efforts. However, these compensatory mechanisms will function for only a short period of time, because the child will become exhausted. When this happens, the child may begin to show signs of severe respiratory distress and rapidly progress into respiratory failure if left untreated. Therefore, it is important for you to perform a thorough patient assessment and monitor the child\u2019s vital signs at least every 5 minutes when caring for seriously ill or injured pediatric patients.\n\nInfants and children also have limited abilities to compensate for changes in temperature when compared with adults. Children have a greater surface area relative to the mass of their body. This means that they lose relatively more heat than adults do. Therefore, you need to keep the body temperature of children as close to normal as possible and warm them if they become chilled.",
        "Examining a Child": "It is important for you to perform a thorough and systematic assessment of a child to determine the extent of his or her illness or injury. The examination of a child should consist of the same five steps used in the patient assessment sequence that you learned for adult patients. First, perform a scene size-up to ensure that the scene is safe for you and for the patient. Then complete a primary assessment to form a general impression of the patient; to determine the patient\u2019s level of responsiveness; and to assess the status of the airway, breathing, and circulation (ABCs). Next, complete a secondary assessment by examining the child from head to toe. Obtain a medical history. Finally, perform reassessments as needed.",
        "The Pediatric Assessment Triangle": "It is important for you to be able to quickly determine when a child is seriously ill or injured. The pediatric assessment triangle (PAT) was developed to help you quickly form a general impression of a pediatric patient\u2019s condition as part of your primary assessment. It does not change the steps of the patient assessment sequence you already learned. The PAT is a valuable tool that allows you to quickly form a general impression of the child using only your senses of sight and hearing. It provides you with an accurate initial picture of the functioning of the child\u2019s airway, breathing, circulation, and level of responsiveness. It will help you begin to identify whether the child is experiencing a serious condition. It will help you assess a child from a distance and determine what steps to take first. The three components of the PAT are: (1) the child\u2019s overall appearance, (2) the work of breathing, and (3) circulation to the skin. Each of these three components is discussed in this section.",
        "The three components of the PAT": "include appearance, work of breathing, and circulation to the skin.",
        "Appearance": "The first element of the PAT is appearance. Does the child appear to be ill or injured? The child\u2019s general appearance is important when you are trying to determine the severity of the child\u2019s illness or injury. The general appearance is an indicator of how well the heart and lungs are working. Appearance is also a good indication of how well the central nervous system is working. As you assess a child, compare his or her appearance and actions with what you would expect from a healthy child of the same age.\n\nLook at the child to see whether he or she has good muscle tone. Is the child crying or able to speak? Infants and young children normally cry in response to fear or pain; a child who is not crying may have a decreased level of consciousness, an upper airway infection, or swelling in the airway. If the child is crying, does the cry sound like a normal, healthy cry or is it a subdued whimper? Does the child have a blank, unfocused stare or does he or she look at others? Carefully evaluate a child who is unresponsive, lackluster, and appears ill, because lack of activity and interest can signal serious illness or injury. Is the child able to interact in a manner that is age appropriate? If the child is conscious, it is better to start your assessment from across the room than to disturb the child by removing him or her from the caregiver\u2019s arms. A child with good eye contact, good muscle tone, and good color would seem to be normal. \n\nA child who makes poor eye contact and is pale and listless should be of concern to you. As you evaluate the initial appearance of a child, keep in mind that the child\u2019s appearance can change quickly. Therefore, you need to Reassess the child\u2019s appearance regularly.",
        "Characteristics of Appearance": "**Table 17-1: Characteristics of Appearance** outlines differences between healthy and unhealthy reactions in children. In terms of **movement**, a healthy child moves vigorously, whereas an unhealthy child may appear limp, listless, or flaccid. Regarding **interaction**, a healthy child reaches for a toy or reacts to a person or sound, while an unhealthy child shows little interest in playing or engaging. In the area of **reassurance**, a healthy child is comforted by caregivers, but an unhealthy child may remain crying or agitated and be unrelieved by gentle reassurance. For **eye movement**, healthy children track the movement of a person or toy with their eyes, whereas an unhealthy child may have a glassy-eyed stare. When assessing **speech**, age-appropriate speech is a sign of a healthy reaction, while garbled or confused speech indicates an unhealthy one. Lastly, in terms of **crying**, a strong cry is typical of a healthy child, while a weak or high-pitched cry may signal distress or an unhealthy condition.",
        "Work of Breathing": "The second element of the PAT is the work of breathing. In children, assessing the work of breathing is a more accurate indicator of a child\u2019s condition than merely determining the rate of respirations. You can determine the child\u2019s work of breathing by measuring four factors: (1) abnormal breath sounds, (2) abnormal positioning, (3) retractions of the neck or chest, and (4) flaring of the nostrils. Abnormal breath sounds include noisy breathing, snoring, crowing, grunting, or wheezing. Abnormal positioning includes leaning forward while supporting themselves with their arms and a refusal to lie down. Retractions can occur above the collarbone or between the ribs. Flaring of the nostrils occurs during inspiration. Assess these four factors to determine the work of breathing. You can perform this assessment from across the room without touching the child.",
        "Characteristics of Work of Breathing": "**Table 17-2: Characteristics of Work of Breathing** lists observable signs that may indicate respiratory distress. **Abnormal breath sounds** include noisy breathing such as snoring, crowing, grunting, or wheezing. **Abnormal positioning** is seen when a patient leans forward while using their arms for support, often referred to as the tripod position. **Retractions** are visible indentations above the collarbone or between the ribs that occur when a person is struggling to breathe. **Flaring** involves the flaring of the nostrils, which is another sign of labored breathing.",
        "Circulation to the Skin": "The third element of the PAT is circulation to the skin. The three characteristics for determining circulation to the skin are paleness, mottling, and cyanosis. Check the child\u2019s skin for paleness or pallor. White or pale skin indicates an inadequate blood flow to the skin. The second characteristic of circulation to the skin is mottling, a patchy skin discoloration that is caused by too little or too much circulation to the skin. The third characteristic used in assessing the skin is cyanosis. Cyanosis is a blue discoloration of the skin caused by low levels of oxygen in the blood. You can establish the status of the circulation to the skin without touching the child. \n\nBased on the findings of the PAT, you should now be able to form a general impression of a pediatric patient and determine the severity of the child\u2019s illness or injury. Use the PAT with the other parts of the patient assessment sequence that you learned in Chapter 9, Patient Assessment. This helpful tool allows you to quickly obtain valuable information without touching and agitating the child, and it helps set the priorities for further assessment and treatment.",
        "Characteristics of Circulation to the Skin": "Pallor is characterized by white or pale skin or mucous membranes. Mottling appears as patchy skin discoloration caused by too much or too little blood flow to the skin. Cyanosis is identified by blue discoloration of the skin and mucous membranes.",
        "Respirations": "To calculate the respiratory rate of a child, count respirations for 30 seconds and multiply by two. Counting for less than 30 seconds can cause inaccurate results because children often have irregular breathing patterns. As you examine children, look to see how much work they are doing to breathe. This work of breathing will help to determine whether they are in respiratory distress. Look for abnormal breath sounds such as noisy breathing, snoring, crowing, grunting, or wheezing. Look to determine whether they are holding themselves in an abnormal position. Are they supporting themselves with their arms while leaning forward (known as the tripod position) or do they refuse to lie down? Check for retractions of the neck or chest. Look for flaring of the nostrils. These signs and symptoms of breathing difficulty are the same as the ones you use to assess breathing difficulty as part of the PAT. The presence of any of these signs indicates that the child is having some difficulty breathing and may be experiencing respiratory distress. Respiratory distress is discussed in the section on respiratory care.",
        "Special Populations": "From birth to about 6 months of age, children are 'nose breathers.' They have not yet learned to breathe through their mouths.",
        "Pulse Rate": "The normal pulse rate of a child is faster than an adult's normal rate. For a child younger than 1 year, palpate a brachial pulse, which is located halfway between the shoulder and the elbow on the inside of the upper arm or directly over the heart.",
        "Table 17-4 normal vital signs for children at various ages.": "Newborns (0 to 1 month) have a heart rate of 90\u2013180 beats per minute and respirations of 30\u201360 breaths per minute. Infants (1 month to 1 year) have a heart rate of 100\u2013160 beats per minute and respirations of 25\u201350 breaths per minute. Toddlers (1 to 3 years) have a heart rate of 90\u2013150 beats per minute and respirations of 20\u201330 breaths per minute. Preschool-aged children (3 to 6 years) have a heart rate of 80\u2013140 beats per minute and respirations of 20\u201325 breaths per minute. School-aged children (6 to 12 years) have a heart rate of 70\u2013120 beats per minute and respirations of 15\u201320 breaths per minute. Adolescents (12 to 18 years) have a heart rate of 60\u2013100 beats per minute and respirations of 12\u201320 breaths per minute.",
        "High Body Temperature": "Flushed, red skin, sweating, and restlessness often accompany high temperatures in children. You can often feel a high temperature just by touching the child\u2019s chest and head. A child\u2019s heart rate increases with each degree of temperature rise.",
        "Respiratory Care": "Neither adults nor children can tolerate a lack of oxygen for more than a few minutes before permanent brain damage occurs.\n\nIt is important for you to open and maintain the airway and to ventilate adequately any child with a respiratory condition. Otherwise, the child may go into respiratory arrest, followed by cardiac arrest because of the lack of oxygen to the heart. This is a different situation than adults, who usually experience cardiopulmonary arrest as a result of a heart attack.\n\nSome of the specific causes of cardiopulmonary arrest in children include suffocation caused by the aspiration of a foreign body, infections of the airway such as croup and acute epiglottitis, sudden infant death syndrome (SIDS), accidental poisonings, and injuries around the head and neck. This chapter covers each condition in detail.",
        "Treating Respiratory Emergencies in Infants and Children": "You need four types of skills to treat respiratory emergencies in children: opening the airway, basic life support, suctioning, and the use of airway adjuncts. Each of these skills is described below.",
        "Treatment": "Essential skills in treating pediatric respiratory emergencies include the following:\n1. Opening the airway\n2.Basic life support\n3.Suctioning\n4.Using airway adjuncts",
        "Opening the Airway": "When opening the airway of a child or an infant, use the same general techniques that you use for an adult patient. The head tilt\u2013chin lift maneuver can be used for children who have not sustained an injury to the neck or head. When using the head tilt\u2013chin lift maneuver on a child, be sure that you do not hyperextend the neck when you tilt the head back. Hyperextending a child\u2019s neck can occlude the airway. Use a neutral or slight sniffing position. You can place a folded towel under the child\u2019s shoulders to help maintain this position. If the possibility of injury to the head or neck exists, try the jaw-thrust maneuver to open the airway. If the jaw-thrust maneuver does not open the airway, use the head tilt\u2013chin lift maneuver because opening the airway is a top priority for an unresponsive patient.",
        "Basic Life Support": "Because children are smaller than adults, you must use specific techniques when you perform cardiopulmonary resuscitation (CPR) on children. There are special procedures for hand placement, compression pressure, and airway positioning. CPR for children (1 year of age to the onset of puberty) is different from adult CPR in the following three ways: \n1. If you are alone, without help, and no one has called EMS Perform five cycles or 2 minutes of CPR before activating the EMS system. \n2. Use the heel of one hand or two hands to perform chest compressions, depending on the size of the child \n3.Compress the sternum at least one-third the depth of the chest (about 2 inches [5 cm])\n\nCPR for infants (younger than 1 year) has the following five differences from adult CPR: Check for responsiveness by tapping the infant\u2019s foot or gently shaking the shoulder. Check the pulse by using the brachial pulse as shown. Use your middle and ring fingers to compress the sternum just below the nipple line. Compress the sternum to a depth of at least one-third the depth of the chest (about 1.5 inches [4 cm]). Give gentle rescue breaths, using mouth-to-mouth-and-nose ventilations.",
        "Treatment_0": "To review techniques for CPR for infants and children, see Chapter 7, Airway Management, and Chapter 8, Professional Rescuer CPR. These chapters describe the techniques in detail.",
        "Suctioning": "To clear secretions, vomitus, or blood from a patient\u2019s airway, turn the patient on his or her side and use your gloved fingers to scoop out as much of the substance as possible. You can use suctioning (aspirating or sucking out fluid by mechanical means) to remove the foreign substances that cannot be removed with your gloved fingers. Suctioning to open a blocked airway can be a lifesaving procedure.\n\nThe procedure used for suctioning infants and children is generally the same as for adults, with the following exceptions:\n1. Use a tonsil tip or rigid tip to suction the mouth. Do not insert the tip any farther than you can see.\n2. Use a flexible catheter to suction the nose of a child; set the suction on low or medium power.\n3. Use a bulb syringe to suction the nose of an infant. Remember that an infant can breathe only through the nose.\n4. Never suction for more than 5 seconds at one time.\n5. Try to ventilate and re-oxygenate the patient before repeating the suctioning.\n\nFor a complete description of how to use suctioning, review the material presented in Chapter 7, Airway Management, and Chapter 16, Childbirth.",
        "Airway Adjuncts": "An oral airway can maintain an open airway after you have opened the patient\u2019s airway by manual means. Use the steps in Skill Drill 17-1 to insert an oral airway in a child or an infant.\n\n1. Select the proper size oral airway by measuring from the patient\u2019s ear lobe to the corner of the mouth Step 1.\n2. Position the patient\u2019s airway. If the emergency is medical, use the head tilt\u2013chin lift maneuver, avoiding hyperextension. If the patient has a traumatic injury, use the jaw-thrust maneuver Step 2.\n3. Depress the patient\u2019s tongue with two or three stacked tongue blades. Press the tongue forward and away from the roof of the mouth Step 3.\n4. Follow the anatomic curve of the roof of the patient\u2019s mouth to slide the airway into place.\n5. Be gentle. The mouths of children and infants are fragile.\n\nEMRs usually do not use nasal airways for children. If you have questions about using nasal airways in pediatric patients, check with your medical director.",
        "Treatment_1": "In pediatric patients, you must be careful not to overextend the neck. In infants and some small children, the overextension may actually obstruct the airway because of the flexibility of the child\u2019s neck. Smaller children may breathe easier if the neck is held in a neutral position rather than overextended. To maintain the neutral position, you can use a towel to support the patient\u2019s shoulders.",
        "Skill Drill 17-1: Inserting an Oral Airway in a Child": "\nStep 1: Select the proper size oral airway by measuring from the patient\u2019s ear lobe to the corner of the mouth.\nStep 2: Position the pediatric patient\u2019s airway with the appropriate method.\nStep 3: Depress the patient\u2019s tongue and press the tongue forward and away from the roof of the mouth. Follow the anatomic curve of the roof of the patient\u2019s mouth to slide the airway into place.",
        "Mild (Partial) Airway Obstruction": "You can usually relieve a mild (partial) airway obstruction by placing the child on his or her back (supine), tilting the head, and lifting the chin in the head tilt\u2013chin lift maneuver.\n\nAn airway blocked by an aspirated foreign object (eg, small toy, piece of candy, balloon) is a common occurrence in young children, particularly in children who are crawling. If the foreign object is only partially blocking the airway, the child will probably be able to pass some air around the object. You can remove the object if it is clearly visible in the mouth and you can remove it easily. However, if you cannot see the object or if you do not think you can remove it easily, do not attempt to remove it as long as the child can still breathe air around the object. Sometimes trying to remove an object that is partially blocking the airway can result in a severe airway blockage, which is an extremely serious situation. \n\nChildren with a partial (mild) airway obstruction should be transported to the emergency department. During treatment and transport, talk constantly to a child with a partially obstructed airway about what you are doing. Carrying on a conversation with the child oftentimes comforts the child and reduces the terror of having something stuck in the throat.\n\nThe presence of a parent during transport can provide emotional support to both the parent and the child. The parent\u2019s presence can often reassure and calm the child. Judge each situation carefully. Not all parents are able to remain calm during such a serious situation. However, most of the time, parents are able to realize the seriousness of the situation, redirect their emotions, and work with you to reassure and calm the child.\n\nIf you have oxygen available and are trained in its use, administer it by carefully placing the oxygen mask over the child\u2019s mouth and nose. Do not try to get an airtight seal on the mask; hold it 1 or 2 inches (3 to 5 cm) away from the child\u2019s face. If you tell the child what you are doing with the oxygen and how it will make breathing easier, you may be able to calm and relax the child. Carefully monitor this critical situation to ensure that the mild obstruction does not become a severe obstruction.",
        "Severe (Complete) Airway Obstruction in Children": "A severe (complete) airway obstruction is a serious emergency. A severe airway obstruction exists when the child has poor air exchange, increased breathing difficulty, a silent cough, the inability to speak, or no air movement because of an obstruction. You have only a few minutes to act before permanent brain damage occurs. Use the Heimlich maneuver (abdominal thrusts) because it provides enough energy to expel most foreign objects that could completely block a child\u2019s airway\n\nThe steps for relieving an airway obstruction in a conscious child (1 year to the onset of puberty) are the same as for an adult patient. However, the anatomic differences between adults and children require that you make some adjustments in your technique. When opening the airway of a child or infant, tilt the head back just past the neutral position. Tilting the head too far back (hyperextending the neck) can actually obstruct the airway of a child or infant. If you are by yourself and a child with an airway obstruction becomes unresponsive, perform CPR for five cycles (about 2 minutes) before activating the EMS system.",
        "A skill performance sheet titled Child: Foreign Body Airway Obstruction": "**Figure 17-8: Skill Performance Sheet \u2013 Child: Foreign Body Airway Obstruction**\n1. Ask, \u201cAre you choking?\u201d  \n2. Give abdominal thrusts.  \n3. Repeat thrusts until the foreign body is dislodged or until the patient becomes unresponsive.  \n\n**If the patient becomes unresponsive:**  \n4. If a second rescuer is available, have him or her activate the EMS system.  \n5. Begin CPR:  \u2022 Open the airway using the head tilt\u2013chin lift maneuver.  \u2022 Look into the mouth for any foreign object. Use finger sweeps only if you can see a foreign object.  \u2022 Attempt to give one ventilation. If air does not go in, reposition the head and attempt another breath.  \u2022 If air still does not go in, begin chest compressions. (See Chapter 8, *Professional Rescuer CPR*, for detailed coverage of this step.)  \n6. Continue CPR for five cycles (about 2 minutes), then activate the EMS system if you are by yourself.  \n7. Continue CPR until more advanced EMS personnel arrive.",
        "Complete or Severe Airway Obstruction in Infants": "An infant (younger than 1 year) is very fragile. Infants\u2019 airway structures are very small and they are more easily injured than those of an adult. If you suspect an airway obstruction, first assess the infant to determine whether there is any air exchange. If the infant is crying, the airway is not completely obstructed. If no air is moving in or out of the infant\u2019s mouth and nose, suspect an obstructed airway. Find out what was happening when the episode of breathing difficulties began. Someone may have seen the infant put a foreign body into his or her mouth. To relieve an airway obstruction in a conscious infant, use a combination of back slaps and the chest-thrust maneuver. Be sure you are holding the infant securely as you alternate the back slaps and chest thrusts.\n\nIf there is no movement of air from the infant\u2019s mouth and nose, a sudden onset of severe breathing difficulty, a silent cough, or a silent cry, suspect a severe airway obstruction. To relieve a severe airway obstruction in an infant, use a combination of back slaps and chest thrusts. Review the following sequence until you can carry it out proficiently and automatically. To assist a conscious infant with a severe airway obstruction, perform the following steps:\n1. Assess the infant\u2019s airway and breathing status. Determine that there is no air exchange. \n2. Place the infant in a facedown position over your forearm and support your forearm with your thigh. Support the infant\u2019s head and neck with one hand and place the infant\u2019s head lower than the trunk. Use the heel of your hand and deliver five back slaps forcefully between the infant\u2019s shoulder blades.\n3. Next, continuing to support the head, turn the infant faceup by sandwiching the infant between your hands and arms. Rest the infant on his or her back with the head lower than the trunk.\n4. Deliver five chest thrusts in the middle of the sternum. Use two fingers and deliver the thrusts firmly.\n5. Repeat the series of back slaps and chest thrusts until the infant expels the foreign object or becomes unresponsive.\n6. If the infant becomes unresponsive, continue with the following steps.\n7. Ensure that EMS has been activated.\n8. Begin CPR: Open the airway by using the head tilt\u2013chin lift maneuver. Look into the mouth for any foreign object. Use finger sweeps only if you can see a foreign object. Attempt to give one ventilation. If air does not go in, reposition the head and attempt another breath. If air still does not go in, begin chest compressions. (See Chapter 8, Professional Rescuer CPR, for coverage of this part of the CPR sequence.)\n9. Continue these CPR steps until more advanced EMS personnel arrive.Note: If you are alone, administer CPR for five cycles (about 2 minutes) andthen activate EMS.\n\nRecent studies have shown that administering chest compressions to an unresponsive patient increases the pressure in the chest similar to administering chest thrusts and may relieve an airway obstruction. Therefore, performing CPR on an infant who has become unresponsive has the same effect as administering chest thrusts on a conscious patient",
        "**Infant: Foreign Body Airway Obstruction \u2013 Skill Performance Sheet**": "1. Confirm severe airway obstruction. Check for sudden onset of serious breathing difficulty, ineffective cough, silent cough, or silent cry.  \n2. Give up to five back slaps and up to five chest thrusts.  \n3. Repeat Step 2 until the foreign body is dislodged or until the infant becomes unresponsive.  \n\n**If the infant becomes unresponsive:**  \n4. If a second rescuer is available, have him or her activate the EMS system.  \n5. Begin CPR:  \u2022 Open the airway using the head tilt\u2013chin lift maneuver.  \u2022 Look into the mouth for any foreign object. Use finger sweeps only if you can see a foreign object.  \u2022 Attempt to give one ventilation. If air does not go in, reposition the head and attempt another breath.  \u2022 If air still does not go in, begin chest compressions. (See Chapter 8, *Professional Rescuer CPR*, for full CPR sequence.)  \n6. Continue CPR for five cycles (about 2 minutes), then activate the EMS system if you are by yourself.  \n7. Continue CPR until more advanced EMS personnel arrive.",
        "Swallowed Objects": "Children often swallow small, round objects like marbles, beads, buttons, and coins. If these objects do not become airway obstructions, they usually pass uneventfully through the child and are eliminated in a bowel movement. However, sharp or straight objects such as open safety pins, bobby pins, and bones are dangerous if swallowed. Arrange for prompt transport to an appropriate medical facility is necessary because special instruments and techniques are required to locate and remove the object from the stomach and intestinal tract.",
        "Respiratory Distress": "Respiratory distress indicates that a child has a serious condition that requires immediate medical attention. Often respiratory distress quickly leads to respiratory failure. You must be able to recognize the following signs of respiratory distress:\n1. A breathing rate of more than 60 breaths per minute in infants\n2. A breathing rate of more than 30 to 40 breaths per minute in children\n3. Nasal flaring on each breath\n4. Retraction of the skin between the ribs and around the neck muscles\n5. Stridor (a high-pitched sound on inspiration)\n6. Cyanosis of the skin\n7. Altered mental status\n8. Combativeness or restlessness\nIf you see that any of the listed signs are present, try to determine the cause. Support the child\u2019s respirations by placing the child in a comfortable position, usually sitting. Keep the child as calm as possible by letting a parent hold the child if practical. Prepare to administer oxygen if it is available and you are trained in its use. Monitor the child\u2019s vital signs and arrange for prompt transport to an appropriate medical facility.",
        "Respiratory Failure/Arrest": "Respiratory failure often results as respiratory distress proceeds. Many of the same factors that cause respiratory distress can cause respiratory failure. Characteristics of respiratory failure include the following conditions:\n1. A breathing rate of fewer than 20 breaths per minute in an infant\n2. A breathing rate of fewer than 10 breaths per minute in a child\n3. Limp muscle tone\n4. Unresponsiveness\n5. Decreased or absent heart rate\n6. Weak or absent distal pulses\nA child in respiratory failure is on the verge of experiencing respiratory and cardiac arrest. Immediately assess the child and take whatever steps are appropriate to support the patient. Support respirations by performing mouth-to-mask ventilations. Administer oxygen if it is available and you have been trained to use it. Begin chest compressions if the heart rate is absent or less than 60 beats per minute. Arrange for prompt transport to an appropriate medical facility. Continue to monitor the patient\u2019s vital signs and support the airway, breathing, and circulation functions as well as you can.",
        "Circulatory Failure": "The most common cause of circulatory failure in children is respiratory failure. Uncorrected respiratory failure in children can lead to circulatory failure, and uncorrected circulatory failure can lead to cardiac arrest. That is why it is so important for you to correct respiratory failure before it progresses to circulatory failure. However, this is not always possible, so you should learn the signs of circulatory failure and its treatment. An increased heart rate, pale or blue skin, and changes in mental status indicate circulatory failure. If the child or infant\u2019s heart rate is more than 60 beats per minute, your treatment should consist of completing the patient assessment sequence, supporting ventilations, administering oxygen if available, and observing vital signs for any changes. If the heart rate of a child or infant is less than 60 beats per minute and there are signs of poor circulation, such as cyanosis, you should begin chest compressions and rescue breathing.",
        "Sudden Illness and Medical Emergencies": "Not many illnesses occur suddenly in young children, but most of the medical calls for children will involve sudden illnesses. It is important that you be able to recognize and treat these key pediatric illnesses.",
        "Altered Mental Status": "Altered mental status in children can be caused by a variety of conditions, including low blood glucose level, poisoning, postseizure state, infection, head trauma, and decreased oxygen levels. Sometimes you will be able to determine the cause of the altered mental status and take steps to correct the condition. For example, if the parent tells you that the child has diabetes and is experiencing insulin shock, you can administer glucose to increase the patient\u2019s blood glucose level. However, in many situations, you will not be able to determine the cause of the altered mental status and will have to treat the patient\u2019s symptoms. Complete your patient assessment, paying particular attention to any clues at the scene. Question any bystanders or family about the situation and try to get as much of the medical history as possible. Pay particular attention to the patient\u2019s initial vital signs. Recheck vital signs regularly to monitor any changes. Calm the patient and the patient\u2019s family. Be prepared to support the patient\u2019s airway, breathing, and circulation if needed. Place an unconscious patient in the recovery position to help keep an open airway and to aid in drainage of any secretions.",
        "Special Populations_2": "Key pediatric medical concerns include altered mental status and respiratory emergencies such as asthma, croup, and epiglottitis. Other serious conditions are drowning, heat-related illness, high fever, seizures, vomiting and diarrhea, abdominal pain, poisoning, and sudden infant death syndrome (SIDS).",
        "Respiratory Illnesses": "A respiratory condition in an infant or child can range from a minor cold to complete blockage of the airway. Because infants breathe primarily through their noses, even a minor cold can cause breathing difficulties. The excessive mucus in the nose resulting from a cold makes it more difficult for an infant to breathe than for an older child who can breathe through both the nose and mouth. Although colds cause most common respiratory conditions in children, you should also be able to recognize and treat the three more serious conditions: asthma, croup, and epiglottitis.",
        "Asthma": "A child who has asthma is usually already being treated for the condition by a physician and is taking a prescribed medication. In most situations, the child\u2019s parents call for assistance or transport only if the child is experiencing unusual breathing difficulties.\n\nAsthma can occur in children older than 1 year; it rarely occurs during the first year of life. It is caused by a spasm or constriction (narrowing) and inflammation of the smaller airways in the lungs and usually produces a characteristic wheezing sound. Asthma attacks can range from mild to severe and can be triggered by many factors, including feathers, animal fur, tobacco smoke, pollen, respiratory infections, exercise, and even emotional situations. \n\nA child who is experiencing an asthma attack is in obvious respiratory distress. During a severe attack, you can often hear the characteristic wheezing on exhalation\u2014even without a stethoscope. The child can inhale air without difficulty but must labor to exhale the air. The effort to exhale is both frightening and tiring for the child\n\nYour primary treatment consists of calming and reassuring both the parents and the child. Tell them everything possible is being done and encourage them to relax.\n\nPlace the child in a sitting position to make breathing more comfortable. Ask the child to purse his or her lips, as if blowing up a balloon. Tell the child to blow out with force while doing this. Breathing through pursed lips helps in two ways: Both parents and the child feel that something is being done and this type of breathing relieves some of the internal lung pressures that cause the asthma attack.\n\nIf a child has asthma medication but it has not been administered, help the parent administer the medication. The parents should contact the child\u2019s physician for further advice. If the child\u2019s physician is not available, arrange for prompt transport to the emergency department.",
        "Signs and Symptoms of croup": "Signs and symptoms of croup include the following:\nNoisy, whooping inhalations\nSeal-like, barking cough\nHistory of a recent or current cold\nLack of fright or anxiety\nWillingness to lie down",
        "Croup": "Croup is an infection of the upper airway that occurs mainly in children who are between 6 months to 6 years. The lower throat swells and Croup occurs often in colder climates (during fall and winter) and is frequently accompanied by a cold. The child usually has a moderate fever and a croupy noise that has developed over time. The worst episodes of croup usually occur in the middle of the night. A lack of fright or anxiety in the child and his or her willingness to lie down are important signs for you to note because they can help you distinguish croup from epiglottitis. Epiglottitis is a more serious condition that is discussed in the next section.\n\nAlthough the signs and symptoms of croup are frightening for parents, it may not frighten the child. In many childhood emergencies, you must respond to the emotional needs and concerns of the parents as well as the medical needs of the child. Do not assume that croup is the cause of noisy breathing. Look to see if the child is choking on a toy, food, or foreign object lodged in the airway. If the EMS unit is delayed, ask the parents to turn on the hot water in the shower and close the bathroom door. After the bathroom steams up, ask the parents to wait in there with the child until the EMS unit arrives. The moist, warm air relaxes the vocal cords and lessens the croupy noise. This effectively treats the child and reassures the parents. Have the parents contact the child\u2019s physician for further instructions or arrange for transport to an appropriate medical facility.",
        "Epiglottitis": "The third and most severe major respiratory condition is epiglottitis. Epiglottitis is a severe inflammation of the epiglottis, the small flap that covers the trachea during swallowing. In this condition, the flap is so inflamed and swollen that air movement into the trachea is completely blocked. Epiglottitis usually occurs in children between ages 3 to 6 years. Because of the widespread vaccination of infants against the bacteria (Haemophilus influenzae type b) that causes epiglottitis, the incidence of this disease is much less common now than in the past. This condition also occurs in adult patients who have not received the vaccination for Haemophilus influenzae.\n\nWhile you conduct your initial examination, you may think the child has croup. However, because epiglottitis poses an immediate threat to life, you must be able to recognize the differences between croup and epiglottitis and know the signs and symptoms of epiglottitis; this is a very serious respiratory emergency. There is little that you can provide in the way of treatment except to make the child comfortable with as little handling as possible, keep everyone calm, administer oxygen (if you have it available and have been trained to use it), and arrange for prompt transport to an appropriate medical facility. You may consider letting a parent hold the child during transport if the emotional attitudes of the child and parent are appropriate.",
        "Safety": "Do not examine a child\u2019s throat if you suspect epiglottitis! An examination can cause more swelling of the epiglottis, resulting in a complete airway blockage.",
        "Signs and Symptoms of epiglottitis": "The signs and symptoms of epiglottitis include the following:\n\nThe child is usually sitting upright (he or she does not want to lie down).\n\nThe child cannot swallow.\n\nThe child is not coughing.\n\nThe child is drooling.\n\nThe child is anxious and frightened (he or she knows that something is seriously wrong).\n\nThe child\u2019s chin is thrust forward.",
        "Treatment_7": "The child with epiglottitis must have medical attention to ensure an open airway.",
        "Drowning": "Drowning is caused by submersion in water and initially causes respiratory arrest. It is the second most common cause of accidental death among children 5 years of age or younger in the United States. Although swimming pools, lakes, streams, and oceans present significant risks of drowning, ordinary water sources around the home increase the risk of drowning for young children. Children left unattended in washbowls or bathtubs\u2014for even a few minutes\u2014can drown. Buckets of water and toilet bowls also pose threats to young children who put their heads down to look into the water, lose their balance, fall in, and are unable to get out. \n\nThe many sources of water around a home increase the chance that you may encounter a drowning situation when responding to a medical emergency involving a child. If you respond to a drowning situation, make sure that you do not put yourself in danger as you attempt a rescue.\n\nAfter the child is removed from the water, begin assessment and treatment. Signs and symptoms of drowning include lack of breathing and no pulse. Begin by assessing the airway, breathing, and circulation. Make sure the airway is clear of water. Turn the child to one side and allow the water to drain out of the mouth. Use suction if it is available, start rescue breathing if necessary, and administer supplemental oxygen if it is available. If no pulse is present, start chest compressions. Because there is a chance that the patient has a cervical spine injury, stabilize the neck. To reduce the risk of hypothermia, dry the child with towels and cover the child with dry blankets or jackets.\n\n Arrange for prompt transport of the patient to an appropriate medical facility. A physician needs to evaluate all patients who have experienced submersion, because serious respiratory conditions may develop several hours after submersion.",
        "Heat-Related Illnesses": "Heat-related illnesses may range from relatively minor muscle cramps to vomiting, heat exhaustion, and heatstroke. The most dangerous heat-related illness in children is heatstroke. Any child who is in a closed, parked car on a hot day or in a poorly ventilated room and who has hot, dry skin may be experiencing heatstroke. This is a serious and potentially fatal condition that requires you to provide rapid treatment to cool the child and reduce his or her body temperature. Remove the child\u2019s clothing, sponge water over the child, and fan him or her to help lower the body temperature quickly. You may wrap the child in wet sheets (if they are available) to speed up the evaporation and cooling process, but do not let the child become chilled. Finally, be sure that you have arranged for rapid transport to an appropriate medical facility.",
        "High Fever": "Fevers occur quite commonly in children and can be caused by many different infections, especially ear and gastrointestinal infections. Because the temperature-regulating mechanism in young children has not fully developed, a very high temperature (104\u00b0F to 106\u00b0F [40\u00b0C to 41\u00b0C]) can occur quickly even with a relatively minor infection. Most children can tolerate temperatures as high as 104\u00b0F (40\u00b0C), but a high fever may require that the child be hospitalized so that the underlying cause can be discovered and treated. Your first step in treating a child with a high fever is to uncover the child so that body heat can escape. Layers of clothing or blankets retain body heat and can increase the patient\u2019s body temperature high enough to cause convulsions. About 10% of children between 1 and 6 years of age are susceptible to seizures brought on by high fevers. Remember that in attempting to reduce a high fever, you are treating only the symptom and not the source. A physician must see the child as soon as possible to determine the cause of the fever. If you encounter a child with a temperature above 104\u00b0F (40\u00b0C), take these steps to treat the fever symptoms: 1. Make certain the child is not wrapped in too much clothing or too many blankets. 2. Attempt to reduce the high temperature by undressing the child. 3. Fan the child to cool him or her down. 4. Protect the child during any seizure (do not restrain the child\u2019s motion), and make certain that normal breathing resumes after each seizure.",
        "Seizures": "Seizures (convulsions) can result from a high fever or from disorders such as epilepsy. Seizures can vary in intensity from simple, momentary staring spells (without body movements) to generalized seizures in which the entire body stiffens and shakes severely. Although seizures can be frightening to parents, bystanders, and rescuers, they are not usually dangerous. During a seizure, a child becomes unconscious, the eyes roll back, the teeth become clenched, and the body shakes with severe jerking movements. Often, the child\u2019s skin becomes pale or turns blue. Sometimes the child has a loss of bladder and bowel control and soils his or her clothing. Seizures caused by a high fever usually last about 20 seconds.\n\nIf a seizure occurs, place the child on a soft surface (sofa, bed, or rug) to protect the child from injury during the seizure. Reassure the child\u2019s parents who may be frightened by the seizure. If they become too emotional, ask them to leave the room. Carefully monitor the child\u2019s airway during and after the seizure.\n\nAs an EMR, you can provide the following treatment for seizures:\n1. Place the patient on the floor or a bed to prevent injury.\n2. Maintain an adequate airway after the seizure ends.\n3. Provide supplemental oxygen after the seizure if it is available and you are trained to use it.\n4. Arrange for prompt transport to an appropriate medical facility.\n5. Continue to monitor the patient\u2019s vital signs and support the ABCs if necessary.\n6. After the seizure is over, cool the patient if the patient has a high fever.",
        "Voices of Experience": "Suddenly, he made a loud noise, spit out his pacifier, and began full-body convulsions. During my EMS training, my instructor always told me I needed to learn my skills until I could do them without thinking. When we moved to the pediatrics section of the curriculum, my instructors increased their prompting to engrain the basics in our minds. They kept teaching, I kept learning, but I never realized why I needed to focus so much on the repetition of skills. Then I became an instructor and I continued to tell my students much the same. We need to engrain the basics into you so that you can accomplish the needs of the scene without having to think about the basics. Why do we teach that? I recently was presented with a situation that would test my knowledge without me knowing. During a normal day, enjoying a nice lunch with family and friends, my son began to develop a fever. He was playing, having fun, and enjoying the company of close friends. However, by the time we finished lunch and made it home to place him down to take his afternoon nap, his fever had increased. My wife and I determined that he was probably developing another ear infection because he had been treated for three within the past 2 months. We decided to take him to the pediatrician\u2019s office during their daily sick call. We arrived at the office, signed him in, and then sat down awaiting his turn with the physician. Our son, who is normally a very active child, wanted simply to sit in our laps and watch the television. He was calm, but his temperature continued to increase. Suddenly, he made a loud noise, spit out his pacifier, and began full-body convulsions. Without hesitation, I moved from the parental mode to that of an emergency medical provider. I carefully moved him from a sitting position to a carry and informed the receptionist at the window. we needed to go to the examination area immediately. At that point we passed our physician, and I explained that my son was experiencing an active febrile seizure. The nursing staff and physicians quickly responded and together we were able to open and maintain his airway, assess his breathing rate and quality, and increase his oxygen levels through the administration of blow-by oxygen. The team ensured adequate circulation during the episode and continued a watch of the oxygen levels perfusing my son\u2019s body. We used multiple avenues of temperature control, active cooling procedures such as strategic placement of ice packs, passive cooling procedures (including removal of clothing), and medications, thereby preventing further seizure activity. During the coming minutes, he continued to experience a postseizure state, which required a constant watch over his airway, breathing, and circulatory status. The amount of time that I have spent and continue to spend dedicated to the basics of emergency medical care resulted in my body\u2019s ability to take that information and translate it to immediate action without a conscious thought on my part. As emergency medical providers, we are not faced with pediatric patients requiring assistance as often as adult patients. Because we do not see them as often, and because pediatric patients decline quickly and drastically, emergency medical responders such as yourself should prepare for the worst and train to achieve the best outcome.",
        "Vomiting and Diarrhea": "Children are very susceptible to vomiting and diarrhea, which are usually caused by gastrointestinal infections. Prolonged vomiting and diarrhea may produce severe dehydration. The dehydrated child is lethargic and has very dry skin, which can be especially noticeable around the mouth and nose. Hospitalization may be required to replace fluids through the veins. If you suspect that a child may be dehydrated, arrange for transport to an appropriate medical facility.",
        "Abdominal Pain": "One of the most serious causes of abdominal pain in children is appendicitis. Although it can occur at any age, appendicitis is often seen in people who are between 10 and 25 years. A cramping pain usually starts in the belly button area of the abdomen. Within a few hours, the pain moves to the right lower quadrant of the abdomen, becoming steady and more severe. Usually the child is nauseated, has no appetite, and occasionally will vomit Because there are several potential causes of abdominal pain, including appendicitis, do not try to make a diagnosis in the field. Even physicians may find it difficult to diagnose the cause of abdominal pain. A good rule for you to follow is to treat every child with a sore or tender abdomen as an emergency and arrange for transport to an appropriate medical facility for an appropriate diagnosis.",
        "Poisoning": "Young children are curious and often like to sample the contents of brightly colored bottles or cans looking for something good to eat or drink. However, many common household items contain poisonous substances. The two most common types of poisonings in children are caused by ingestion and absorption.",
        "Ingestion": "An ingested poison is taken by mouth. A child who has ingested a poison may have chemical burns, odors, or stains around the mouth and be experiencing nausea, vomiting, abdominal pain, or diarrhea. Later symptoms may include abnormal or decreased respirations, unconsciousness, or seizures. If you believe a child has ingested a poisonous substance, do the following: 1. Try to identify what the child has swallowed, attempt to estimate the amount ingested, and send the bottle or container along with the child to the emergency department. 2. Gather any spilled tablets if the child swallowed tablets from a medicine bottle and replace them in the bottle so they can be counted. The emergency physician may then be able to determine how many tablets the child has taken. 3. Contact your local poison control center if transportation to an appropriate medical facility is delayed. The poison control center will need to know the following information: Age of the patient Identification of the poison Weight of the patient Estimated quantity of the poison taken 4. Follow the directions provided by the poison control center. You may need to perform the following actions: Dilute the poison by giving the child large amounts of water. Administer activated charcoal if it is available and you have been trained in its use (the usual dose for pediatric patients is 12.5 to 25 grams). 5. Monitor the child\u2019s breathing and pulse closely. This is a critical step, and you must be prepared to provide emergency care, including rescue Breathing and CPR 6. Arrange for prompt transport to an appropriate medical facility for examination by a physician.",
        "Treatment_11": "Do not attempt to give liquids or induce vomiting in an unconscious or partially conscious child because of the danger of aspiration of the vomitus.",
        "Safety_12": "Be careful not to get any chemical on your skin. ",
        "Absorption": "Poisoning by absorption occurs when a poisonous substance enters the body through the skin. A child who has absorbed a poison may have localized symptoms, such as skin irritation or burning, or may have systemic signs and symptoms of the poisoning, such as nausea, vomiting, dizziness, and shock.\n\nIf you believe a child has absorbed a poisonous substance, perform the following actions:\n1. Ensure that the child is no longer in contact with the poisonous substance.\n2. Protect yourself from exposure to the poison. Call for specially trained personnel if indicated.\n3. Remove the child\u2019s clothing if you think it is contaminated.\n4. Brush off any dry chemical. After you have removed all dry chemical, wash the child with water for at least 20 minutes.\n5. Wash off any liquid poisons by flushing with water for at least 20 minutes.\n6. Try to identify the poison and send any containers with the child to the emergency department.\n7. Monitor the child for any changes in respiration and pulse. Be prepared to administer rescue breathing or CPR if needed.\n8. If the child has vomited, save a sample in a clean container and send it with the patient to the hospital if you can perform this action without detracting from the care of the patient.\n9. Arrange transport to an appropriate medical facility for examination by a physician.",
        "Treatment_12": "Chemical burns to the eyes cause extreme pain and injury. Gently flush the affected eye or eyes with water for at least 20 minutes. Hold the eye open to allow water to flow over its entire surface. Direct the water from the inner corner of the eye to the outward edge of the eye to avoid contaminating the other eye. After flushing the eyes for 20 minutes, loosely cover both eyes with gauze bandages and arrange for prompt transport to an appropriate medical facility.",
        "Sudden Infant Death Syndrome": "A condition that is frequently mistaken for child abuse is sudden infant death syndrome (SIDS), also called crib death or sudden unexpected infant death (SUID). It is the sudden and unexpected death of an apparently healthy infant. SIDS usually occurs in infants between the ages of 3 weeks and 7 months. The infants are usually found dead in their cribs. Currently, no adequate scientific explanation exists for SIDS. These deaths are not the result of smothering, choking, or strangulation. SIDS deaths often remain unexplained, even after a complete and thorough autopsy. You can imagine the shock and grief felt by parents who find their apparently healthy infant dead in bed. Your actions and words can help relieve their feelings of remorse and guilt. If the infant is still warm, begin CPR and continue until help arrives (infant CPR is described in Chapter 7, Airway Management, and Chapter 8, Professional Rescuer CPR). In many cases, the infant has been dead several hours and the body is cold and lifeless. Do not mistake the large, bruise-like blotches on the infant\u2019s body for signs of child abuse. The blotches are caused by the pooling of the infant\u2019s blood after death. Sometimes you may find a small amount of bloody foam on the infant\u2019s lips. If the child is obviously dead, follow the protocol in your community for the management of deceased patients. Know your local guidelines for the management of SIDS. Remember that the parents could do nothing to prevent the death. Be compassionate and supportive during this tragic situation.",
        "Pediatric Trauma": "Trauma remains the number one killer of children. Each year, many young lives are lost because of accidental injury, particularly motor vehicle crashes. Treat an injured child as you would treat an injured adult, but remember the following differences: \n1. A child cannot communicate symptoms as well as an adult. \n2.A child may be shy and overwhelmed by adult rescuers (especially those in uniform), so it is important to develop a good relationship quickly to reduce the child\u2019s fear and anxiety. \n3. You may have to adapt materials and equipment to the child\u2019s size. \n4.A child does not show signs of shock as early as an adult but can progress into severe shock quickly.",
        "Patterns of Injury": "The type of trauma a child experiences, the type of activity causing the injury, and the child\u2019s anatomy affect the pattern of injuries sustained by the child. Motor vehicle crashes produce different patterns of injuries depending on whether the patient was using a seat belt, whether the patient was strapped into a car seat, and whether an air bag inflated in the crash. Unrestrained patients tend to have more head and neck injuries. Restrained passengers often sustain head injuries, spinal injuries, and abdominal injuries. Children struck while riding a bicycle often have head, spinal, abdominal, and extremity injuries. The use of bicycle helmets greatly reduces the number and severity of head injuries. Pedestrians who are struck by a vehicle often sustain chest and abdominal injuries with internal bleeding, injuries to the thighs, and head injuries. Falls from a height or diving accidents tend to cause head and spinal injuries and extremity injuries. Burns are a major cause of injuries to children. Sports activities cause a wide variety of injuries depending on the type of sports activity. By learning some of the basic patterns of injury, you can anticipate the injuries you may find when carefully examining pediatric patients.\n\nIf the child has been struck by a motor vehicle, look for the common types of injuries shown in Figure 17-12. Major trauma in children usually results in multiple system injuries. No matter what the cause of injury, your first priority is always to check the patient\u2019s ABCs. Stop severe bleeding, treat the patient for shock, and proceed with the full-body assessment described in Chapter 9, Patient Assessment, to determine the extent of any other injuries Figure 17-13. The full-body assessment is a hands-on procedure. A complete examination is especially important because a child cannot always communicate symptoms. Involve the child in the physical examination as much as possible. Ask the child simple questions. Complete the full-body assessment even if the patient is too young to understand what is happening. Then stabilize all injuries you find. Splint suspected fractures, bandage wounds, and immobilize suspected spinal injuries\n\nIf your patient has head lacerations, remember that the generous blood supply to the scalp can result in severe bleeding. Treat these wounds with direct pressure and appropriate bandaging techniques. See Chapter 14, Bleeding, Shock, and Soft-Tissue Injuries, for a review of effective bandaging techniques.",
        "Traumatic Shock in Children": "Children show shock symptoms much more slowly than adults, but they progress through the stages of shock quickly. An injured child displaying obvious shock symptoms such as cool, clammy skin; a rapid, weak pulse; or rapid or shallow respirations is already experiencing severe shock. It is vital that you learn to recognize and treat shock quickly. Review the signs and symptoms of shock in Chapter 14, Bleeding, Shock, and Soft-Tissue Injuries. Immediate treatment of an injured child experiencing shock includes controlling external bleeding, keeping the child warm, and administering oxygen if it is available. Children who show signs of shock should be transported as soon as possible to an emergency department. Seizures are relatively common in children who have sustained a serious head injury. Be prepared to manage this condition by maintaining the airway and protecting the child from further injury.\n\nThe greatest dangers to any patient who has sustained trauma are airway obstruction and hemorrhage. When caring for an injured child, the most important actions you should perform are as follows: Open and maintain the airway. Control bleeding. Arrange for prompt transport to an appropriate medical facility.",
        "Car Seats and Children": "The impact of mandatory child restraint laws means that EMRs are finding more children still strapped into car seats after motor vehicle crashes. You should become familiar with child restraint seats and understand how to gain access to children restrained in them. If you find a child properly restrained in a car seat, leave the child in the car seat until the ambulance arrives. In many situations, a child can be secured in the seat, the seat removed from the vehicle, and both the seat and the child transported together to the hospital.",
        "Treatment_13": "Children younger than 9 years who are not in a booster seat but are wearing a seat belt are at risk for sliding out of the lap belt during a crash. Rapid, jackknife bending of the child\u2019s body increases the chances of intra-abdominal, spinal cord, and brain injuries.",
        "Child Abuse": "Child abuse is not limited to any ethnic, social, or economic group or to families with any particular level of education. Suspect child abuse if the child\u2019s injuries do not match the story you are told about how the injuries occurred. Child abuse is often masked as an accident. The abused or battered child may have many visible injuries\u2014all at different stages of healing. The child may appear to be withdrawn, fearful, or even hostile. Be concerned if the child refuses to discuss how an injury occurred. Occasionally, the child\u2019s parents or caretaker will reveal a history of several \u201caccidents\u201d in the past. Treat the child\u2019s injuries and, if you are suspicious that this may be a case of child abuse, ensure the safety of the child.\n\nMake sure that the child receives transport to an appropriate medical facility. If the parents object to having the child examined by a physician, summon law enforcement personnel and explain your concerns to them. The safety of the child is your foremost concern in these situations.\n\nNeglect is also a form of child abuse. Children who are neglected are often dirty or too thin or appear developmentally delayed because of a lack of stimulation. You may observe such children when you are making calls for unrelated problems. The parents of an abused child need help, and the child may need protection from the parents\u2019 future actions. Handle each situation in a nonjudgmental manner. Know whom you need to contact (usually the emergency department staff or law enforcement personnel), and report any instances of suspected child abuse.",
        "Signs and Symptoms of neglect": "Signs and symptoms of neglect include the following:\nLack of adult supervision\nMalnourished-appearing child\nUnsafe living environment\nUntreated chronic illness",
        "Sexual Assault of Children": "Sexual abuse occurs in children as well as adults. It may occur in both male and female infants, young children, and adolescents. In addition to sexual assault, the child may have been beaten and may have other serious injuries. If you suspect sexual assault has occurred, obtain as much information as possible from the child and any witnesses. Realize that the child may be hysterical or unwilling to talk, especially if the abuser is a brother or sister, parent, or family friend. Providing a caring approach to these children is extremely important, and take appropriate action to shield them from onlookers.\nAll victims of sexual assault should receive transport to an appropriate medical facility. Sexual assault is a crime; cooperate with law enforcement officials during their investigation.",
        "Signs and Symptoms_15": "Signs and symptoms of child abuse include the following:\nMultiple fractures\nBruises in various stages of healing (especially those clustered on the torso and buttocks)\nHuman bites\nBurns (particularly cigarette burns and scalds from hot water)\nReports of bizarre accidents that do not seem to have a logical explanation",
        "Emergency Medical Responder Debriefing": "As an EMR, you will respond to many calls that involve children. These calls tend to produce strong emotional reactions. At times, you may experience a feeling of helplessness when an innocent child is seriously injured or gravely ill. An ill or injured child may remind you of your own children. You may feel especially angry or helpless when you suspect the neglect or abuse of a child.\n\nAfter you have completed your treatment of the patient and transferred the responsibility for care to other EMS personnel, you may need to talk about your frustrations with a counselor or with another member of your department. After a major incident or an especially emotional incident involving children, it may be helpful for you to set up a critical incident stress debriefing session. Although you cannot change the types of traumatic events you will see, you can use your department\u2019s resources to work through your feelings about these events. By attending a debriefing session, you can express your feelings, learn some coping strategies, and maintain a healthy approach to future calls",
        "Prep Kit-Ready for Review": "Sudden illnesses and medical emergencies are common in children and infants. Because the anatomy of children and infants differs from that of adults, emergency medical responders need special knowledge and skills to assess and treat pediatric patients.\nManaging a pediatric emergency can be a stressful situation for emergency medical responders. Because both the child and the parents may be frightened and anxious, you must behave in a calm, controlled, and professional manner.\nA child\u2019s airway is smaller in relation to the rest of the body; therefore, secretions and swelling from illnesses or trauma can more easily block the child\u2019s airway. Because the tongue is relatively larger than the tongue of an adult, a child\u2019s tongue can more easily block the airway. Hyperextension of a child\u2019s neck can occlude the airway.\nThe pediatric assessment triangle is designed to give you a quick general impression of the child using only your senses of sight and hearing. The three components of the pediatric assessment triangle are overall appearance, work of breathing, and circulation to the skin.\nCarefully evaluate the child who is unresponsive, lackluster, and appears ill, because the lack of activity and interest signal serious illness or injury.\nAfter you conduct your primary assessment, carry out the routine patient examination, paying special attention to mental awareness, activity level, respiration, pulse rate, body temperature, and color of the skin.\nIt is important for you to open and maintain the patient\u2019s airway and to ventilate adequately any child with a respiratory condition. Otherwise, the child may experience respiratory arrest, followed by cardiac arrest.\nCardiopulmonary resuscitation for children and infants differs from adult cardiopulmonary resuscitation in several important ways. Be certain that you understand these differences and are able to perform the appropriate steps confidently in the field.\nSuctioning removes foreign substances that you cannot remove with your gloved fingers from the airway of a child. An oral airway can be used to maintain an open airway after you have opened the child\u2019s airway by manual means.\nYoung children often obstruct their upper and lower airway with foreign objects, such as small toys or candy. If the object is only partially blocking the airway, the child should be able to pass some air around it. Attempt to remove the object only if it is clearly visible and you can remove it easily.\nIn complete or severe airway obstruction in a conscious child, perform the Heimlich maneuver (abdominal thrusts). If the child becomes unresponsive, begin cardiopulmonary resuscitation.\nTo relieve an airway obstruction in an infant, use a combination of back slaps and chest thrusts.\nChildren in respiratory distress require immediate medical attention. Signs of respiratory distress include a rapid or slow breathing rate, nasal flaring, retraction of the skin between the ribs and around the neck muscles, stridor, cyanosis, altered mental status, and combativeness. Respiratory distress can lead to respiratory failure, which in turn can lead to circulatory failure.\nThree serious respiratory conditions in pediatric patients are asthma, croup, and epiglottitis. A child who has asthma is usually already being treated for the condition by a physician; your primary treatment consists of calming and reassuring the parents and the child. Croup is an upper airway infection that results in a barking cough. Although epiglottitis resembles croup, it is a serious respiratory emergency and you must arrange for prompt transport.\nOther pediatric medical emergencies include drowning, heat-related illnesses such as heatstroke, high fevers, seizures, vomiting and diarrhea, and abdominal pain.\nChildren\u2019s natural curiosity may lead them to sample medications or household items that contain poisonous substances. The two most common types of poisonings in children are caused by ingestion (taken by mouth) and absorption (entering through the skin).\nSudden infant death syndrome, also called crib death, is the unexpected death of an apparently healthy infant. Know your local guidelines for the management of sudden infant death syndrome. Remember that the parents could do nothing to prevent the death.\nWhen caring for pediatric trauma patients, remember that you may have to adapt materials and equipment to the child\u2019s size. Also remember that children do not show signs of shock as early as adults, although they can progress into severe shock quickly.\nMajor trauma in children usually results in multiple system injuries. Your first priority is always to check the ABCs and then stop severe bleeding, treat for shock, and proceed with the physical examination. If you suspect child abuse or sexual assault, arrange for transport to an appropriate medical facility.",
        "Vital Vocabulary": "asthma: A disease in which the airway becomes narrowed and inflamed, resulting in episodes of shortness of breath because of air being trapped in the small air sacs of the lungs., chest-thrust maneuver: A series of manual thrusts to the chest to relieve upper airway obstruction; used in the treatment of infants, pregnant women, or extremely obese people., croup: Inflammation and narrowing of the air passages in young children, causing a barking cough, hoarseness, and a harsh, high-pitched breathing sound., drowning: Submersion in water or other fluids that results in suffocation or respiratory impairment., epiglottitis: Severe inflammation and swelling of the epiglottis; a life-threatening situation., epilepsy: A disease manifested by seizures, caused by an abnormal focus of electrical activity in the brain., mottling: Patchy skin discoloration caused by too little or too much circulation., pediatric assessment triangle (PAT): An assessment tool that measures the severity of a child\u2019s illness or injury by evaluating the child\u2019s appearance, work of breathing, and circulation to the skin., stridor: A high-pitched sound heard during inspiration. It is a sign of a narrowing or partial obstruction., suctioning: Aspirating (sucking out) fluid in the mouth or airway by mechanical means."
    },
    {
        "Special Patient Populations": "Applies a fundamental knowledge of the growth, development, and aging and assessment findings to provide basic emergency care and transportation for a patient with special needs.",
        "Patients With Special Challenges": "Recognizing and reporting abuse and neglect",
        "Health care implications of": "Abuse \nNeglect",
        "Pediatrics": "Age-related assessment findings, and age-related assessment and treatment modifications for pediatric-specific major diseases and/or emergencies\nUpper airway obstruction\nLower airway reactive disease\nRespiratory distress/failure/arrest",
        "Age-related assessment findings, and age-related assessment and treatment modifications for pediatric-specific major diseases and/or emergencies (cont\u2019d)": "Shock\nSeizures\nSudden infant death syndrome",
        "Age-related assessment findings, and developmental stage-related assessment and treatment modifications for pediatric-specific major diseases and/or emergencies": "Upper airway obstruction\nLower airway reactive disease\nRespiratory distress/failure/arrest\nShock",
        "Age-related assessment findings, and developmental stage-related assessment and treatment modifications for pediatric-specific major diseases and/or emergencies (cont\u2019d)": "Seizures\nSudden infant death syndrome\nGastrointestinal disease",
        "Trauma": "Applies fundamental knowledge to provide basic emergency care and transportation on assessment findings for an acutely injured patient.",
        "Special Considerations in Trauma": "Recognition and management of trauma in\nPediatric patient",
        "National EMS Education Standard Competencies": "Pathophysiology, assessment, and management of trauma in the\nPediatric patient",
        "Introduction": "Children differ anatomically, physically, and emotionally from adults. \nIllnesses and injuries that children sustain, and their responses to them, vary based on age or developmental level.\nImportant to remember that children are not small adults\nFear of EMS providers and pain can make the child difficult to assess. Once you learn how to approach children of different ages and what to expect while caring for them, you will find that treating children also offers some very special rewards.",
        "Communication With the Patient and the Family When caring for a pediatric patient, you must care for parents or caregivers as well.": "A calm parent usually results in a calm child.\nRemain calm, efficient, professional, and sensitive.",
        "Growth and Development Many physical and emotional changes occur during childhood (birth to age 18).": "Stages of thoughts and behaviors:\nInfancy: first year of life\nToddler: 1 to 3 years\nPreschool-age: 3 to 6 years\nSchool-age: 6 to 12 years\nAdolescent: 12 to 18 years",
        "The Infant": "Infancy is defined as first year of life.\nFirst month after birth is neonatal or newborn period.\n0 to 2 months\nSpend most time sleeping and eating\nRespond mainly to physical stimuli\nCannot tell the difference between parents and strangers\nCrying is one of the main modes of expression. 0 to 2 months (cont\u2019d)\nAn inconsolable infant could be a sign of significant illness.\nPredisposed to hypothermia 2 to 6 months\nMore active at this stage\nMay follow objects with eyes\nPersistent crying, irritability, or lack of eye contact can be an indicator of serious illness, depressed mental status, or a delay in development. 6 to 12 months\nBecome mobile, which predisposes them to physical danger\nPlace things in their mouth leading to choking or poisoning\nMay cry if separated from their parents or caregivers\nPersistent crying or irritability can be a symptom of serious illness. Assessment\nObserve infant from a distance.\nCaregiver should hold baby during physical assessment.\nProvide sensory comfort.\nWarm hands and end of stethoscope.\nDo painful procedures at end of assessment.",
        "The Toddler": "After infancy until 3 years of age\nExperience rapid changes in growth and development\n12 to 18 months\nExplorers by nature and not afraid\nThey lack molars and may not be able to chew food fully increasing the risk of choking. Assessment\nMay have stranger anxiety\nMay resist separation from caregiver\nMay have a hard time describing pain\nCan be distracted\nBegin your assessment at the feet.\nPersistent crying can be a symptom of serious illness or injury.\nPrevious medical experiences may lead to hesitation toward you.",
        "The Preschool-Age Child": "Ages 3 to 6 years\nHave a rich imagination and can be fearful about pain\nMay believe injury is a result of earlier bad behavior \nForeign body aspiration airway obstruction continues to be a high risk. Assessment\nCan understand directions and be specific in describing painful areas\nMuch history must still be obtained from caregivers.\nCommunicate simply and directly.\nAppealing to child\u2019s imagination may facilitate examination. Assessment (cont\u2019d)\nNever lie to the patient.\nPatient may be easily distracted.\nBegin assessment at feet, moving to head.\nUse adhesive bandages to cover the site of an injection or other small wound.\nModesty is developing; keep child covered as much as possible.",
        "School-Age Years": "6 to 12 years\nBeginning to act more like adults\nCan think in concrete terms\nCan respond sensibly to questions\nCan help take care of themselves\nSchool is important. \nChildren begin to understand death. Assessment\nAssessment begins to be more like adults.\nTo help gain trust, talk to the child, not just the caregiver.\nStart with head and move to the feet.\nIf possible, give the child choices. \nAsk only the type of questions that let you control the answer. \nDo not bargain or debate with the patient. Assessment (cont\u2019d)\nAllow the child to listen to his or her heartbeat through the stethoscope.\nCan understand the difference between physical and emotional pain\nProvide simple explanations about what is causing their pain and what will be done.\nAsk the parent\u2019s or caregiver\u2019s advice about which distraction will work best.",
        "Adolescents": "13 to 18 years\nPhysically similar to adults\nPuberty begins.\nConcerned about body image and appearance\nStrong feelings about privacy \nTime of experimentation and risk-taking\nOften feel \u201cindestructible\u201d\nStruggle with independence, loss of control, body image, sexuality, and peer pressure Assessment\nCan often understand complex concepts and treatment options\nAllow them to be involved in their own care.\nProvide choices, while lending guidance.\nEMT of same gender should do physical examination, if possible. Assessment (cont\u2019d)\nAllow them to speak openly and ask questions.\nRisk-taking behaviors are common.\nCan ultimately facilitate development and judgment, and shape identity\nCan also result in trauma, dangerous sexual practices, and teen pregnancy Assessment (cont\u2019d)\nFemale patients may be pregnant.\nAdolescent may not want parents to know this information.\nTry to interview without the caregiver/parent present.\nHave clear understanding of pain\nGet them talking to distract them.",
        "Anatomy and Physiology Body is growing and changing very rapidly during childhood.": "You must understand the physical differences between children and adults and alter your patient care accordingly.",
        "The Respiratory System": "Anatomy of airway differs from adult\u2019s.\nPediatric airway is smaller in diameter and shorter in length.\nLungs are smaller.\nHeart is higher in child\u2019s chest. FIGURE 35-9 The anatomy of a child\u2019s airway differs from\nthat of an adult in several ways. The back of the head is\nlarger in a child. The tongue is proportionately larger and is\nlocated more anterior in the mouth. The trachea is smaller\nin diameter and more flexible. The airway itself is lower\nand narrower (funnel-shaped). \u00a9 Jones & Bartlett Learning. Anatomy of airway differs from adult\u2019s. (cont\u2019d)\nGlottic opening is higher and positioned more anteriorly, and neck appears to be nonexistent.\nAs child develops, the neck becomes proportionally longer as the vocal cords and epiglottis achieve anatomically correct adult position. Anatomy of airway differs from adult\u2019s. (cont\u2019d)\nLarger, rounder occiput\nProportionally larger tongue\nLong, floppy, U-shaped epiglottis\nLess-developed rings of cartilage in the trachea\nNarrowing, funnel-shaped upper airway Anatomy of airway differs from adult\u2019s. (cont\u2019d)\nDiameter of trachea in infants is about the same as a drinking straw.\nAirway is easily obstructed by secretions, blood, or swelling.\nInfants are nose breathers and may require suctioning and airway maintenance.\nRespiratory rate of 20 to 60 breaths/min is normal for a newborn. Anatomy of airway differs from adult\u2019s. (cont\u2019d)\nChildren have an oxygen demand twice that of an adult.\nIncreases risk for hypoxia Anatomy of airway differs from adult\u2019s. (cont\u2019d)\nMuscles of diaphragm dictate the amount of air a child inspires.\nPressure on child\u2019s abdomen can cause respiratory compromise.\nUse caution when applying the straps of a spinal immobilization device. Anatomy of airway differs from adult\u2019s. (cont\u2019d)\nGastric distention can interfere with movement of the diaphragm and lead to hypoventilation.\nBreath sounds are more easily heard in children because of their thinner chest walls.\nDetection of poor air movement or complete absence of breath sounds may be more difficult.",
        "The Circulatory System": "Important to know normal pulse ranges\n Infants heart can beat 160 beats/min or more.\nChildren are able to compensate for decreased perfusion by constricting the vessels in the skin.\nSigns of vasoconstriction include pallor (early sign), weak distal pulses in the extremities, delayed capillary refill, and cool hands or feet.",
        "The Nervous System": "Pediatric nervous system is immature, underdeveloped, and not well protected.\nHead-to-body ratio is larger.\nOccipital region of head is larger.\nSubarachnoid space is relatively smaller, leaving less cushioning for brain.\nBrain tissue and cerebral vasculature are fragile and prone to bleeding from shearing forces. Pediatric brain requires higher cerebral blood flow, oxygen, and glucose.\nAt risk for secondary brain damage from hypotension and hypoxic events\nSpinal cord injuries are less common.\nIf injured, it is more likely to be an injury to the ligaments because of a fall.\nFor suspected neck injury, perform manual in-line stabilization or follow local protocols.",
        "The Gastrointestinal System Abdominal muscles are less developed.": "Less protection from trauma\nLiver, spleen, and kidneys are proportionally larger and situated more anteriorly and close to one another.\nProne to bleeding and injury\nThere is a higher risk for multiple organ injury.",
        "The Musculoskeletal System": "Open growth plates allow bones to grow.\nAs a result of growth plates, children\u2019s bones are softer and more flexible, making them prone to stress fracture.\nBone length discrepancies can occur if injury to growth plate occurs.\nImmobilize all strains and sprains. Bones of an infant\u2019s head are flexible and soft.\nSoft spots are located at front and back of head.\nReferred to as fontanelles\nWill close at particular stages of development\nFontanelles of an infant can be a useful assessment tool. Thoracic cage is highly elastic and pliable.\nComposed of cartilaginous connective tissue\nRibs and vital organs are less protected.",
        "The Integumentary System Pediatric system differs in a few ways:": "Thinner skin and less subcutaneous fat\nComposition of skin is thinner and tends to burn more deeply and easily with less exposure. \nHigher ratio of body surface area to body mass leads to larger fluid and heat losses.",
        "Scene Size-up": "Assessment begins at time of dispatch.\nPrepare mentally for approaching and treating an infant or child.\nPlan for pediatric size-up, equipment, and age-appropriate physical assessment.\nCollect age and gender of child, location of scene, NOI or MOI and chief complaint from dispatch. Scene safety\nEnsure proper safety precautions and standard precautions.\nNote position in which patient is found.\nLook for possible safety threats.\nPatient may be safety threat if he or she has infectious disease.\nDo an environmental assessment.",
        "Form a general impression.": "Use pediatric assessment triangle (PAT).\nDoes not require you to touch the patient \nCan be performed in less than 30 seconds FIGURE 35-10 The three components of the pediatric\nassessment triangle (PAT) include appearance, work of\nbreathing, and circulation to the skin. Used with permission of American Academy of Pediatrics, Pediatric Education for Prehospital Professionals, \u00a9 American Academy of Pediatrics, 2000. PAT\nDoes not require equipment\nThree elements\nAppearance\nWork of breathing\nCirculation Appearance\nNote LOC, interactiveness, and muscle tone.\nUse the AVPU scale, modified as necessary for the pediatric patient\u2019s age. \nNormal level of consciousness: act appropriately for age, exhibit good muscle tone, and maintain good eye contact\nTICLS mnemonic helps determine if patient is sick or not sick: Tone, Interactiveness, Consolability, Look or gaze, Speech or cry Work of breathing\nIncreases as the body attempts to compensate for abnormalities in oxygenation and ventilation \nMay manifest as abnormal airway noise, accessory muscle use, retractions, head bobbing, nasal flaring, tachypnea, and tripod position. Circulation to the skin\nWhen cardiac output fails, the body shunts blood from areas of lesser need to areas of greater need.\nPallor of skin and mucous membranes may be seen in compensated shock. \nMottling is sign of poor perfusion. \nCyanosis reflects decreased level of oxygen. From PAT findings, you will decide if the patient is stable or requires urgent care.\nIf unstable, assess XABCs, treat life threats, and transport immediately.\nIf stable, continue with the remainder of the assessment process. Hands-on XABCs\nAssess and treat any life threats as you identify them by following the XABCDE format\nExsanguination\nAirway\nBreathing\nCirculation\nDisability\nExposure Airway\nIf airway is open and will remain open, assess respiratory adequacy.\nIf patient is unresponsive or has difficulty keeping airway open, ensure it is properly positioned and clear of mucus, vomitus, blood, and foreign bodies. Airway (cont\u2019d)\nAlways position airway in neutral sniffing position.\nKeeps trachea from kinking\nMaintains proper alignment\nEstablish whether patient can maintain his or her own airway. Breathing\nUse the look, listen, feel technique.\nPlace both hands on patient\u2019s chest to feel for rise and fall of chest wall.\nBelly breathing in infants is considered adequate.\nBradypnea is an ominous sign and indicates impending respiratory arrest. Circulation\nDetermine if patient has a pulse, is bleeding, or is in shock.\nIn infants, palpate brachial or femoral pulse.\nIn children older than 1 year, palpate carotid pulse.\nStrong central pulses usually indicate that the child is not hypotensive. Circulation (cont\u2019d)\nWeak or absent peripheral pulses indicate decreased perfusion.\nTachycardia may be early sign of hypoxia.\nInterpret pulse within the context of overall history, the PAT, and primary assessment. \nEvaluate trend of increasing or decreasing pulse rate.\nFeel skin for temperature and moisture.\nEstimate the capillary refill time. Disability\nUse AVPU scale or pediatric GCS.\nCheck pupil response.\nLook for symmetric movement of extremities.\nPain is present with most types of injuries.\nAssessment of pain must consider developmental age of patient. Exposure\nHands-on ABCs require that the caregiver remove some of patient\u2019s clothing for observation.\nAvoid heat loss by covering the patient as soon as possible.\nMore prone to hypothermic events \nShould be kept warm during transport Transport decision\nDetermine whether rapid transport to the hospital is indicated. \nRapid transport indicated if:\nSignificant MOI\nHistory compatible with serious illness\nPhysical abnormality noted\nPotentially serious anatomic abnormality\nSignificant pain\nAbnormal level of consciousness Transport decision (cont\u2019d)\nAlso consider:\nType of clinical problem\nBenefits or ALS treatment in field\nLocal EMS protocol\nYour comfort level \nTransport time to hospital\nIf patient\u2019s condition is urgent, initiate immediate transport to the closest appropriate facility. Transport decision (cont\u2019d)\nLess than 40 lb, transport in car seat.\nMount a car seat to a stretcher.\nFollow manufacturer\u2019s instructions to secure car seat in captain\u2019s chair.\nPatients who require spinal immobilization: immobilize on long backboard or other suitable spinal immobilization device. Transport decision (cont\u2019d)\nPatients in cardiopulmonary arrest: use a device that can be secured to the stretcher.\nDo not use the pediatric patient\u2019s own car seat.\nThe goal is to secure and protect the pediatric patient for transport in the ambulance.",
        "History Taking": "Approach to history depends on age of patient.\nHistory information for an infant, toddler, or preschool-age child will be obtained from caregiver.\nAdolescent information is obtained from patient.\nQuestioning the parents or child about the immediate illness or injury should be based on the child\u2019s chief complaint. Questions to ask based on chief complaint\nNOI or MOI\nLength of sickness or injury\nKey events leading up to injury or illness\nPresence of fever\nEffects of illness or injury on behavior\nPatient\u2019s activity level\nRecent eating, drinking, and urine output Questions to ask (cont\u2019d)\nChanges in bowel or bladder habits\nPresence of vomiting, diarrhea, abdominal pain\nPresence of rashes\nObtain name and phone number of caregiver if they are not able to come to the hospital with you. SAMPLE history\nSame as adult\u2019s\nQuestions based on age and developmental stage\nObtaining OPQRST\nSame for children and adults\nQuestions based on age and developmental stage",
        "Physical examinations": "Secondary assessment of the entire body should be used when patient is unresponsive or has significant MOI.\nFocused assessments should be performed on patients without life threats. Physical examinations (cont\u2019d)\nInfants, toddlers, and preschool-age children should be assessed started at the feet and ending at the head.\nSchool-aged children and adolescents should be assessed using the head-to-toe approach. Physical examinations (cont\u2019d)\nHead\nLook for bruising, swelling, and hematomas.\nAssess fontanelles in infants.\nNose\nNasal congestion and mucus can cause respiratory distress.\nGentle bulb or catheter suction may bring relief. Physical examinations (cont\u2019d)\nEars\nDrainage from ears may indicate skull fracture.\nBattle sign may indicate skull fracture.\nPresence of pus may indicate infection.\nMouth\nLook for active bleeding and loose teeth.\nNote the smell of the breath. Physical examinations (cont\u2019d)\nNeck\nExamine tracheal area for swelling or bruising.\nNote if patient cannot move neck and has high fever.\nChest\nExamine for penetrating trauma, lacerations, bruises, or rashes.\nFeel clavicles and every rib for tenderness and/or deformity. Physical examinations (cont\u2019d)\nBack\nInspect back for lacerations, penetrating injuries, bruises, or rashes.\nAbdomen\nInspect for distention.\nGently palpate and watch for guarding or tensing of muscles.\nNote tenderness or masses.\nLook for seat belt abrasions or bruising. Physical examinations (cont\u2019d)\nExtremities\nAssess for symmetry.\nCompare both sides for color, warmth, size of joints, swelling, and tenderness.\nPut each joint through a full range of motion while watching the patient\u2019s eyes for signs of pain. Vital signs\nSome guidelines/equipment used to assess adult circulatory status have limitations in pediatric patients.\nNormal heart rates vary with age in pediatric patients.\nBlood pressure is usually not assessed in patients younger than 3 years. Vital signs (cont\u2019d)\nAssessment of skin is a better indication of pediatric patient\u2019s circulatory status.\nUse appropriately sized equipment. \nUse a cuff that covers two thirds of the pediatric patient\u2019s upper arm. Vital signs (cont\u2019d)\nFormula to determine blood pressure for children ages 1\u201310 years: \n70 + (2 \u00d7 child\u2019s age in years) = systolic blood pressure\nCount respirations for at least 30 seconds and double that number.\nIn infants and those younger than 3 years, evaluate respirations by assessing the rise and fall of the abdomen. Vital signs (cont\u2019d)\nAssess pulse rate by counting at least 1 minute, noting quality and regularity.\nNormal pediatric vital signs vary with age.\nEvaluate pupils using a small pen light.\nPulse oximeter is a valuable tool for patients with respiratory issues.",
        "Reassessment": "Reassess the pediatric patient\u2019s condition as necessary.\nObtain vitals every 15 minutes if stable.\nObtain vitals every 5 minutes if unstable.\nContinually monitor respiratory effort, skin color and condition, and level of consciousness or interactiveness. Interventions\nParents or caregivers may be able to assist you by calming and reassuring the child.\nCommunication and documentation\nCommunicate and document all relevant information to ED personnel.",
        "Respiratory Emergencies and Management": "Respiratory problems are the leading cause of cardiopulmonary arrest in the pediatric population.\nIn the early stages, you may note changes in behavior, such as combativeness, restlessness, and anxiety. Signs and symptoms of increased work of breathing:\nNasal flaring\nAbnormal breath sounds\nAccessory muscle use\nTripod position As the pediatric patient progresses to possible respiratory failure:\nEfforts to breathe decrease.\nChest rises less with inspiration.\nBody has used up all available energy stores and cannot continue to support extra work of breathing. As the patient progresses to possible respiratory failure: (cont\u2019d)\nChanges in behavior and eventually, altered level of consciousness\nPatient may experience periods of apnea.\nHeart muscle becomes hypoxic, and the heart rate slows. As the patient progresses to possible respiratory failure: (cont\u2019d)\nRespiratory failure does not always indicate airway obstruction.\nCondition can progress from respiratory distress to failure at any time; reassess frequently.\nA child or infant needs supplemental oxygen.\nAssist ventilation with a bag-mask device and 100% oxygen.\nAllow patient to remain in a comfortable position.",
        "Children can obstruct airway with any object they can fit into their mouth.": "In cases of trauma, teeth may have been dislodged into the airway. FIGURE 35-22 Any number of objects can obstruct a\nchild\u2019s airway, including batteries, coins, toys, buttons, and  candy. \u00a9 Jones & Bartlett Learning. Photographed by Kimberly Potvin. Blood, vomitus, or other secretions can cause severe airway obstruction.\nInfections can cause obstruction.\nInfection should be considered if patient has congestion, fever, drooling, and cold symptoms.\nCroup is an infection in the airway below the level of the vocal cords.\nEpiglottitis is an infection of the soft tissue above the level of the vocal cords. FIGURE 35-23 Epiglottitis is an infection that can cause airway obstruction in pediatric patients. \u00a9 Jones & Bartlett Learning. Obstruction by foreign object may involve upper or lower airway.\nMay be partial or complete\nSigns and symptoms associated with partial upper airway obstruction include decreased breath sounds and stridor.\nSigns and symptoms of lower airway obstruction include wheezing and/or crackles. Best way to auscultate breath sounds in pediatric patient is to listen to both sides of the chest at armpit level. Immediately begin treatment of airway obstruction.\nEncourage coughing to clear airway when patient is conscious and forcibly coughing.\nIf this does not remove the object, do not intervene except to provide oxygen.\nAllow patient to remain in whatever position is most comfortable. If you see signs of a severe airway obstruction, attempt to clear the airway immediately.\nIneffective cough (no sound)\nInability to speak or cry \nIncreasing respiratory difficulty, with stridor\nCyanosis\nLoss of consciousness If an infant is conscious with a complete airway obstruction, perform up to five back blows followed by chest thrusts.\nIf a child is conscious with a complete airway obstruction, perform abdominal thrusts (Heimlich maneuver). Use head tilt\u2013chin lift and finger sweep to remove a visible foreign body in an unconscious pediatric patient.\nUse chest compressions to relieve a severe airway obstruction in an unconscious pediatric patient.",
        "A condition in which the bronchioles become inflamed, swell, and produce excessive mucus, leading to difficulty breathing": "A true emergency if not promptly identified and treated \nCommon causes for asthma attack include upper respiratory infection, exercise, exposure to cold air or smoke, and emotional stress. Signs and symptoms\nWheezing as patient exhales\nIn some cases, airway is completely blocked, and no air movement is heard.\nCyanosis and respiratory arrest may quickly develop.\nTripod position allows for easier breathing. Treatment\nAllow patient to assume a position of comfort. \nAdminister supplemental oxygen.\nBronchodilator via metered-dose inhaler with a spacer mask device (if protocol allows)\nIf assisting ventilations, use slow, gentle breaths.\nContact ALS.",
        "Leading cause of death in children": "Pneumonia is a general term that refers to an infection to the lungs.\nOften a secondary infection\nCan also occur from chemical ingestion\nDiseases causing immunodeficiency in children increase risk.\nIncidence is greatest during fall and winter months. Presentation in pediatric patient\nUnusual rapid breathing\nSometimes with grunting or wheezing sounds\nNasal flaring\nTachypnea\nHypothermia or fever\nUnilateral diminished breath sounds or crackles over the infected lung segments Pediatric patient treatment\nPrimary treatment will be supportive.\nMonitor airway and breathing status.\nAdminister supplemental oxygen if required.\nIf the child is wheezing, administer a bronchodilator, if permitted.\nDiagnosis of pneumonia must be confirmed in the hospital.",
        "An infection of the airway below the level of the vocal cords, usually caused by a virus": "Typically seen in children between ages 6 months and 3 years\nEasily passed between children\nStarts with a cold, cough, and a low-grade fever that develops over 2 days\nHallmark signs are stridor and a seal-bark cough. Treatment\nCroup often responds well to the administration of humidified oxygen.\nBronchodilators are not indicated for croup and can make the child worse.",
        "Epiglottitis Bacterial infection of the soft tissue in the area above the vocal cords": "Incidence decreased since development of vaccine.\nEpiglottis can swell to two to three times normal size.\nChildren look ill, report a very sore throat, and have a high fever.\nTripod position and drooling",
        "Bronchiolitis": "Specific viral illness of newborns and toddlers, often caused by RSV\nCauses inflammation of the bronchioles\nRSV is highly contagious and spread through coughing or sneezing.\nVirus can survive on surfaces.\nVirus tends to spread rapidly through schools and in childcare centers. More common in premature infants and results in copious secretion\nOccurs during first 2 years of life; more common in males\nMost widespread in winter and early spring\nBronchioles become inflamed, swell, and fill with mucus. \nAirways can easily become blocked. \nLook for signs of dehydration, shortness of breath, and fever. Treatment\nUse calm demeanor when approaching.\nAllow patient to remain in position of comfort.\nTreat airway and breathing problems.\nHumidified oxygen is helpful.\nConsider ALS backup.",
        "Caused by a bacterium spread via respiratory droplets": "Less common in the United States\nSigns and symptoms: coughing, sneezing, and a runny nose\nCoughing becomes more severe with distinctive whoop sound during inspiration.\nInfants may develop pneumonia or respiratory failure. To treat pediatric patients, keep the airway patent (open) and transport.\nPertussis is contagious, so follow standard precautions, including wearing a mask and eye protection.",
        "Devices that help to maintain the airway or assist in providing artificial ventilation, including:": "Oropharyngeal and nasopharyngeal airways\nBite blocks\nBag-mask devices",
        "Oropharyngeal airway": "Keeps tongue from blocking airway and makes suctioning easier\nShould be used for pediatric patients who are unconscious and in respiratory failure\nShould not be used in conscious patients or those who have a gag reflex or who may have ingested a caustic or petroleum-based product",
        "Nasopharyngeal airway": "Usually well tolerated\nUsed for responsive pediatric patients\nUsed in association with possible respiratory failure\nRarely used in infants younger than 1 year\nShould not be used if there is nasal obstruction or head trauma",
        "Airway Adjuncts": "Nasopharyngeal airway potential problems\nMay become obstructed by mucus, blood, vomitus, or the soft tissues of the pharynx\nMay stimulate the vagus nerve and slow the heart rate, or enter the esophagus, causing gastric distention\nMay cause a spasm of the larynx and result in vomiting if inserted into responsive patient\nShould not be used when pediatric patients have facial trauma because the airway may tear soft tissues and cause bleeding into the airway.",
        "Oxygen Delivery Devices": "Several options for pediatric patient\nBlow-by technique at 6 L/min provides more than 21% oxygen concentration.\nNasal cannula at 1 to 6 L/min provides 24% to 44% oxygen concentration.\nNonrebreathing mask at 10 to 15 L/min provides up to 95% oxygen concentration.\nBag-mask device at 10 to 15 L/min provides nearly 100% oxygen concentration. Nonrebreathing mask, nasal cannula, or simple face mask is indicated for pediatric patients who have adequate respirations and/or tidal volumes.\nBag-mask device is used for those with respirations less than 12 breaths/min or more than 60 breaths/min, an altered LOC, or inadequate tidal volume. Blow-by method\nLess effective than face mask or nasal cannula for oxygen delivery\nDoes not provide high oxygen concentration\nAdministration\nPlace tubing through hole in bottom of cup.\nConnect tube to oxygen source at 6 L/min.\nHold cup 1 to 2 inches away from nose and mouth. Nasal cannula\nSome patients prefer the nasal cannula; some find it uncomfortable.\nApplying a nasal cannula\nChoose appropriately sized nasal cannula.\nConnect tubing to an oxygen source at 1 to 6 L/min. FIGURE 35-28 The blow-by technique may be less frightening to a child than an oxygen mask. Make a small hole in an 8-oz (237-mL) cup, or use a funnel inserted into the end of the oxygen tubing. Connect tubing to an oxygen source, and hold the cup approximately 1 to 2 inches (2 to 5 cm) from the child\u2019s face. \u00a9 Jones & Bartlett Learning. FIGURE 35-29 The prongs of a pediatric nasal cannula should not fill the nares entirely. \u00a9 Jones & Bartlett Learning. Nonrebreathing mask\nDelivers up to 90% oxygen\nAllows patient to exhale all carbon dioxide without rebreathing it\nApplying a nonrebreathing mask\nSelect appropriately sized mask.\nConnect tubing to oxygen source at 10 to 15 L/min.\nAdjust oxygen flow as needed. Bag-mask device\nIndicated in patients with too fast or too slow respirations, who are unresponsive, or who do not respond to painful stimuli\nAssisting ventilations with bag-mask device\nSelect appropriately sized equipment.\nMaintain a good seal with the mask on the face.\nVentilate at the appropriate rate and volume, using a slow, gentle squeeze. FIGURE 35-30 A pediatric nonrebreathing mask delivers up to 95% oxygen and allows the patient to exhale carbon dioxide without rebreathing it. \u00a9 Jones & Bartlett Learning. FIGURE 35-31 Proper mask size for bag-mask ventilation is critical. The mask should extend from the bridge of the nose to the cleft of the chin, avoiding compression of the eyes. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Two-person bag-mask ventilation\nSimilar to one-person bag-mask ventilation except one rescuer holds the mask to the face and maintains the head position\nUsually more effective in maintaining a tight seal",
        "Cardiopulmonary Arrest Cardiac arrest in pediatric patients is associated with respiratory failure and arrest.": "Children are affected differently by decreasing oxygen concentration.\nChildren become hypoxic and their hearts slow down, becoming more bradycardic.",
        "Develops when the circulatory system is unable to deliver a sufficient amount of blood to the organs": "Results in organ failure and eventually cardiopulmonary arrest\nCompensated shock is the early stage of shock.\nDecompensated shock is the later stage of shock. Common causes include:\nTrauma injury with blood loss\nDehydration from diarrhea or vomiting\nSevere infection\nNeurologic injury Common causes include: (cont\u2019d)\nSevere allergic reaction/anaphylaxis to an allergen \nDiseases of the heart\nTension pneumothorax\nBlood or fluid around the heart \nCardiac tamponade \nPericarditis Pediatric patients respond differently than adults to fluid loss.\nMay respond by increasing heart rate, increasing respirations, and showing signs of pale or blue skin Signs of shock in children\nTachycardia\nPoor capillary refill time (> 2 seconds)\nMental status changes\nTreat shock by assessing XABCs.\nThe order becomes CAB if there is obvious life-threatening external hemorrhage or if cardiac arrest is suspected.\nBlood pressure does not fall until shock is severe. Treatment \nLimit your management to simple interventions.\nDo not waste time performing field procedures.\nEnsure airway is open; prepare for artificial ventilation.\nControl bleeding. Treatment (cont\u2019d)\nGive supplemental oxygen by mask or blow-by. \nContinue to monitor airway and breathing.\nPosition the patient in a position of comfort.\nKeep warm with blankets and heat.\nProvide immediate transport.\nContact ALS backup as needed. Anaphylaxis\nA life-threatening allergic reaction that involves generalized, multisystem response\nCharacterized by airway swelling and dilation of blood vessels\nCommon causes are insect sting, medications, or food allergy. Anaphylaxis (cont\u2019d)\nSigns and symptoms\nHypoperfusion\nStridor and/or wheezing\nIncreased work of breathing\nRestlessness, agitation, and sometimes a sense of impending doom\nHives Anaphylaxis (cont\u2019d)\nTreatment\nMaintain airway and administer oxygen.\nAllow caregiver to assist in positioning the patient, oxygen delivery, and maintaining calm.\nAssist with epinephrine auto-injector based on protocol.\nProvide rapid transport.",
        "Bleeding Disorders Hemophilia is a congenital condition in which patients lack normal clotting factors.": "Most forms are hereditary and severe.\nPredominantly found in male population\nBleeding may occur spontaneously.\nAll injuries become serious because blood does not clot.",
        "Altered Mental Status": "Abnormal neurologic state\nUnderstanding developmental changes and listening to caregiver\u2019s opinion are key.\nAEIOU-TIPPS reflects major causes of AMS. Signs and symptoms vary from simple confusion to coma.\nManagement focuses on ABCs and transport.",
        "Result of disorganized electrical activity in the brain": "Manifests in a variety of ways\nSubtle in infants, with an abnormal gaze, sucking, and/or \u201cbicycling\u201d motions\nMore obvious in older children with repetitive muscle contractions and unresponsiveness Once seizure stops and muscles relax, it is referred to as postical state.\nThe longer and more intense the seizures are, the longer it will take for this imbalance to correct itself.\nPostictal state is over once normal level of consciousness is regained. Status epilepticus \nSeizures that continue every few minutes without regaining consciousness in between or last longer than 30 minutes\nRecurring or prolonged seizures should be considered life threatening.\nIf patient does not regain consciousness or continues to seize, protect him or her from harming self and call for ALS backup. Management\nSecuring and protecting airway are priority.\nPosition head to open airway.\nClear mouth with suction.\nUse recovery position if patient is vomiting.\nProvide 100% oxygen by nonrebreathing mask or blow-by method.\nBegin bag-mask ventilations if no signs of improvement. Management (cont\u2019d)\nSome caregivers will have given the child a rectal dose of diazepam (Diastat) prior to your arrival; monitor breathing and level of consciousness carefully.\nTransport to the appropriate facility.",
        "Inflammation of tissue that covers the spinal cord and brain": "Caused by infection by bacteria, viruses, fungi, or parasites\nLeft untreated, can lead to brain damage or death\nBeing able to recognize a pediatric patient with meningitis is important. Individuals at greater risk\nMales\nNewborn infants\nCompromised immune system by AIDS or cancer\nHistory of brain, spinal cord, back surgery\nChildren who have had head trauma\nChildren with shunts, pins, or other foreign bodies in their brain or spinal cord Signs and symptoms vary with age.\nFever and altered level of consciousness\nChild may experience seizure.\nInfants younger than 2 to 3 months can have apnea, cyanosis, fever, distinct high-pitched cry, or hypothermia. Signs and symptoms (cont\u2019d)\n\u201cMeningeal irritation\u201d or \u201cmeningeal signs\u201d are terms to describe pain that accompanies movement.\nOften results in characteristic stiff neck\nIn an infant, increasing irritability and a bulging fontanelle without crying Neisseria meningitidis is a bacterium that causes rapid onset of meningitis symptoms.\nOften leads to shock and death\nChildren present with small, pinpoint, cherry-red spots or a larger purple/black rash. FIGURE 35-33 Children infected with Neisseria\nmeningitidis typically have small, pinpoint, cherry-red spots or a larger purple or black rash. \u00a9 Mediscan/Alamy Stock Photo. Patients with suspected meningitis should be considered contagious.\nUse standard precautions.\nFollow up to learn the patient\u2019s diagnosis. \nTreatment\nProvide supplemental oxygen and assist with ventilations, if needed.\nReassess vital signs frequently.",
        "Gastrointestinal Emergencies and Management": "Never take a complaint of abdominal pain lightly.\nComplaints of gastrointestinal origin are common in pediatric patients.\nIngestion of certain foods or unknown substance\nIn most cases, patient will be experiencing abdominal discomfort with nausea, vomiting, and diarrhea. Appendicitis is also common.\nIf untreated, can lead to peritonitis or shock\nWill typically present with fever and pain upon palpation of right lower quadrant\nRebound tenderness is a common sign.\nIf you suspect appendicitis, promptly transport to the hospital for evaluation. Obtain a thorough history from the primary caregiver.\nHow many wet diapers today?\nIs the child tolerating liquids and keeping them down?\nHow many times has the child had diarrhea and for how long?\nAre tears present during crying?",
        "Poisoning Emergencies and Management": "Common among children\nCan occur by ingesting, inhaling, injecting, or absorbing toxic substances\nCommon sources\nAlcohol\nAspirin and acetaminophen\nCosmetics\nHousehold cleaning products \nHouseplants Common sources (cont\u2019d)\nIron\nPrescription medications of family members\nIllicit (street) drugs\nVitamins\nSigns and symptoms vary, depending on substance, age, and weight. Be alert for signs of abuse.\nAfter primary assessment, ask caregiver the following:\nWhat is the substance involved?\nApproximately how much was ingested?\nWhat time did the incident occur?\nAny changes in behavior or level of consciousness?\nAny choking or coughing after the exposure? Contact Poison Control for assistance.\nTreatment\nPerform external decontamination.\nAssess and maintain ABCs and monitor breathing.\nIf shock is present, treat and transport. \nGive activated charcoal according to medical control or local protocol.",
        "Dehydration Emergencies and Management": "Occurs when fluid loss is greater than fluid intake\nVomiting and diarrhea are common causes.\nInfants and children are at greater risk.\nCan be mild, moderate, or severe Mild dehydration signs\nDry lips and gums, decreased saliva and wet diapers\nModerate dehydration signs\nSunken eyes, sleepiness, irritability, loose skin, sunken fontanelles\nSevere dehydration signs\nMottled, cool, clammy skin; delayed CRT; increased respiration Treatment\nAssess ABCs and obtain baseline vital signs.\nIf severe, ALS backup may be necessary for IV access.\nTransport to ED. FIGURE 35-35 An infant with dehydration may exhibit \u201ctenting\u201d or poor skin turgor. Courtesy of Ronald Dieckmann, MD.",
        "Fever Emergencies and Management": "An increase in body temperature\n100.4\u00b0F (38\u00b0C) or higher is abnormal.\nRarely life threatening\nCauses \nInfection\nStatus epilepticus\nCancer\nDrug ingestion (aspirin) Causes (cont\u2019d)\nArthritis\nSystemic lupus erythematosus (rash on nose)\nHigh environmental temperature\nResult of internal body mechanism in which heat generation is increased and heat loss is decreased Accurate body temperature is important for pediatric patients.\nRectal temperature is most accurate for infants and toddlers.\nUnder tongue or arm will work for older children. Patient may present with signs of respiratory distress, shock, a stiff neck, a rash, hot skin, flushed cheeks, and, in infants, bulging fontanelles.\nTransport and manage ABCs.",
        "Common between 6 months and 6 years": "Caused by fever alone\nTypically occur on first day of febrile illness\nCharacterized by tonic-clonic activity\nLast less than 15 minutes with little or no postictal state\nMay be sign of more serious problem Assess ABCs, provide cooling measures with tepid water, and provide prompt transport.\nAll patients with febrile seizures need to be seen in the hospital setting.",
        "Drowning Emergencies and Management": "Second-most-common cause of unintentional death among children\nPrincipal condition is lack of oxygen.\nHypothermia from submersion in icy water\nDiving increases risk of neck and spinal cord injuries. Signs and symptoms\nCoughing and choking\nAirway obstruction and difficulty breathing\nAMS and seizure activity\nUnresponsiveness\nFast, slow, or no pulse\nPale, cyanotic skin\nAbdominal distention Management\nAssess and manage ABCs.\nContact ALS crew to intervene if needed.\nAdminister 100% oxygen.\nApply cervical collar if trauma is suspected.\nPerform CPR in unresponsive patient in cardiopulmonary arrest.",
        "Pediatric Trauma Emergencies and Management Number one killer of children in the US": "Quality of care can impact recovery.\nThe muscles and bones of children continue to grow well into adolescence. \nFracture of the femur is rare.\nOlder children and adolescents are prone to long bone fractures.",
        "Physical Differences Children are smaller than adults.": "Locations of injuries may be different.\nChildren\u2019s bones and soft tissues are less well developed than an adult\u2019s.\nForce of injury affects structures differently.",
        "Psychological Differences Psychological differences": "Often injured because of underdeveloped judgment and lack of experience\nAlways assume the child has serious head and neck injuries.",
        "Vehicle collisions": "Exact area struck depends on the child\u2019s height and the final position of the bumper at impact.\nTypically sustain high-energy injuries to the head, spine, abdomen, pelvis, or legs.",
        "Sport injuries": "Children are often injured in organized sports activities.\nHead and neck injuries can occur in contact sports.\nRemember to immobilize cervical spine.",
        "Injuries to Specific Body Systems": "Head injuries\nCommon in children because the size of the head in relation to the body\nInfant has softer, thinner skull.\nMay result in brain injury\nScalp and facial vessels may cause great deal of blood loss if not controlled. Head injuries (cont\u2019d)\nNausea and vomiting are common signs and symptoms of a head injury in children.\nEasy to mistake for abdominal injury or illness\nSuspect a serious head injury in any child who experiences nausea and vomiting after a traumatic event. Immobilization \nNecessary for all children with possible head or spinal injuries after a traumatic event\nCan be difficult because of the child\u2019s body proportions\nYounger children require padding under the torso to maintain a neutral position.\nMay be necessary to immobilize child in a car seat Chest injuries\nUsually the result of blunt trauma \nChest wall flexibility in children can produce a flail chest.\nMay be injuries within the chest even though there may be no sign of external injury\nPediatric patients are managed in the same way as adults. Abdominal injuries\nCommon in children\nChildren can compensate for blood loss better than adults.\nChildren can have a serious injury without early external evidence of a problem.\nMonitor all children for signs of shock.\nIf signs of shock are evident, prevent hypothermia with blankets. FIGURE 35-37 All children with abdominal injuries should be monitored closely for signs of shock. Although children may compensate for significant blood loss better than adults, shock develops in children after proportionally smaller blood losses. \u00a9 Jones & Bartlett Learning. Burns\nConsidered more serious than burns to adults\nHave more surface area to relative total body mass, which means greater fluid and heat loss\nDo not tolerate burns as well as adults\nMore likely to go into shock, develop hypothermia, and experience airway problems Burns (cont\u2019d)\nCommon ways that children are burned\nExposure to hot substances\nHot items on a stove\nExposure to caustic substances\nInfection is a common problem.\nBurned skin cannot resist infection as effectively.\nSterile techniques should be used when handling skin. Burns (cont\u2019d)\nConsider child abuse in any burn situation.\nReport any information about suspicions.\nSeverity\nMinor\nModerate\nCritical Burns (cont\u2019d)\nPediatric patients are managed in the same manner as adults.\nPrevent hypothermia if shock is suspected.\nIf patient shows bradycardia, ventilate.\nMonitor the patient during transport. Injuries to the extremities\nChildren have immature bones with active growth centers.\nGrowth of long bones occurs from the ends at specialized growth plates.\nPotential weak spots\nIncomplete or greenstick fractures can occur. Injuries to the extremities (cont\u2019d)\nGenerally, extremity injuries in children are managed in the same manner as adults.\nPainful deformed limbs with evidence of broken bones should be splinted. Pain management\nLook for visual clues and use the Wong-Baker FACES pain scale.\nInterventions are limited to positioning, ice packs, and extremity elevation.\nALS interventions may be needed.\nAnother important tool is kindness and providing emotional support.",
        "JumpSTART triage system": "Intended for patients younger than age 8 years and weighing less than 100 lb\nFour triage categories\nGreen\nYellow\nRed\nBlack",
        "JumpSTART triage system (cont\u2019d)": "Green: minor; not in need of immediate treatment\nAble to walk (except in infants)\nYellow: delayed treatment\nPresence of spontaneous breathing, with peripheral pulse, responsive to painful stimuli JumpSTART triage system (cont\u2019d)\nRed: immediate response\nApnea responsive to positioning or rescue breathing; respiratory failure; breathing but without a pulse; or inappropriate painful response \nBlack: deceased or expectant deceased\nApneic without pulse, or apneic and unresponsive to rescue breathing",
        "Disaster Management": "FIGURE 35-39 The JumpSTART triage system \u00a9 Lou Romig, MD, 2002.",
        "Child Abuse and Neglect Any improper or excessive action that injures or otherwise harms a child": "Includes physical abuse, sexual abuse, neglect, and emotional abuse\nOver half a million children are victims of child abuse annually.\nMany children suffer life-threatening injuries.",
        "Signs of Abuse": "Child abuse occurs in every socioeconomic status.\nBe aware of patient\u2019s surroundings.\nDocument findings objectively. Ask yourself the following:\nInjury typical for age of child?\nMOI reported consistent with the injury?\nCaregiver behaving appropriately?\nEvidence of drinking or drug use at scene?\nDelay in seeking care for the child?\nGood relationship between child and caregiver or parent? Ask yourself the following: (cont\u2019d)\nAre there multiple injuries at different stages of healing?\nAny unusual marks or bruises that may have been caused by cigarettes, heating grates, or branding injuries?\nAre there several types of injuries?\nAny burns on hands or feet that involve a glove distribution? Ask yourself the following: (cont\u2019d)\nIs there unexplained decreased level of consciousness?\nIs the child clean and an appropriate weight for his or her age?\nIs there any rectal or vaginal bleeding?\nWhat does the home look like? Clean or dirty? Warm or cold? Is there food? CHILD ABUSE mnemonic may help. Bruises\nObserve color and location. \nNew bruises are pink or red.\nOver time turn blue, then green, then yellow-brown and faded\nBruises to the back, buttocks, or face are suspicious and are usually inflicted by a person. Burns\nBurns to the penis, testicles, vagina, or buttocks are usually inflicted by someone else.\nBurns that look like a glove are usually inflicted by someone else.\nSuspect child abuse if the child has cigarettes burns or grid pattern burns. Fractures\nFractures of the humerus or femur do not normally occur without major trauma.\nFalls from bed are not usually associated with fractures.\nMaintain an index of suspicion if an infant or young child sustains a femur fracture or a complete fracture of any bone. Shaken baby syndrome\nInfants may sustain life-threatening head trauma by being shaken or struck.\nBleeding within the head and damage to the cervical spine\nInfant will be found unconscious, often without evidence of external trauma. Neglect\nRefusal or failure to provide life necessities\nExamples are water, clothing, shelter, personal hygiene, medicine, comfort, personal safety",
        "Symptoms and Other Indicators of Abuse": "Abused children may appear withdrawn, fearful, or hostile.\nBe concerned if child does not want to discuss how an injury occurred.\nParent may reveal a history of \u201caccidents.\u201d\nBe alert for conflicting stories or lack of concern.\nAbuser may be a parent, caregiver, relative, or friend of the family. EMTs in all states must report suspected abuse.\nMost states have special forms to do so.\nSupervisors are generally forbidden to interfere with the reporting.\nLaw enforcement and child protection services will determine whether there is abuse.",
        "Children of any age and gender can be victims of sexual abuse.": "Maintain an index of suspicion.\nOften long-standing abuse by relatives \nAssessment\nLimited to determining type of dressing required\nTreat bruises and fractures as well.\nDo not examine genitalia unless there is evidence of bleeding or other injury. Assessment (cont\u2019d)\nDo not allow child to wash, urinate, or defecate until a physician completes examination.\nEnsure an EMT or police officer of the same gender remains with the child.\nMaintain professional composure.\nAssume a caring, concerned approach.\nShield the child from onlookers. Assessment (cont\u2019d)\nObtain as much information as possible from the child and any witnesses.\nTransport all children who are victims of sexual assault.\nSexual abuse is a crime. \nCooperate with law enforcement officials in their investigations.",
        "Sudden Unexpected Infant Death": "Sudden unexplained death (SUID) refers to a sudden unexpected death where the cause is not known until and investigation is conducted.\nOne of the causes of SUID is sudden infant death syndrome (SIDS), which results in death that cannot be explained by any other means.",
        "Sudden Unexpected Infant Death Syndrome": "About 3,500 infants die of SIDS annually. \nBaby should be placed on his or her back on a firm mattress, in a crib free of bumpers, blankets, and toys. \nBaby should sleep in the same room, but not the same bed, chair, or sofa as an adult.\nBreastfeeding and use of a pacifier may lower the risk.",
        "Sudden Infant Death Syndrome": "Risk factors\nMother younger than age 20 years\nMother smoked during pregnancy\nMother used alcohol or illicit drugs during pregnancy or after birth\nLow birth weight\nCan occur at any time of day You are faced with three tasks\nAssessment of the scene\nAssessment and management of patient\nCommunication and support of the family",
        "Patient Assessment and Management": "Victim of SIDS will be pale or blue, not breathing, and unresponsive.\nOther causes include:\nOverwhelming infection\nChild abuse\nAirway obstruction\nMeningitis Other causes include: (cont\u2019d)\nAccidental or intentional poisoning\nHypoglycemia\nCongenital metabolic defects\nBegin with XABC assessment.\nProvide necessary interventions. Depending on how much time has passed, the child may show postmortem changes.\nIf you see these signs, call medical control.\nIf no signs of postmortem changes, begin CPR immediately. Pay special attention to any marks or bruises on the child before performing any procedures.\nNote any interventions that were performed before your arrival.",
        "Scene Assessment Carefully inspect environment, noting condition of scene and where infant was found.": "Assessment should concentrate on:\nSigns of illness\nGeneral condition of the house\nSigns of poor hygiene\nFamily interaction\nSite where the infant was discovered",
        "Communication and Support of the Family Sudden death of an infant is devastating for a family.": "Tends to evoke strong emotional responses among health care providers\nAllow the family to express their grief.",
        "Provide the family with empathy and understanding.": "The family may want you to initiate resuscitation efforts, which may or may not conflict with your EMS protocols.\nIntroduce yourself to the child\u2019s parents or caregivers and ask about the child\u2019s date of birth and medical history. Do not speculate on the cause of the child\u2019s death.\nThe family should be asked whether they want to hold the child and say good-bye.\nThe following interventions are helpful.\nUse the child\u2019s name.\nSpeak to family members at eye level.\nUse \u201cdied\u201d and \u201cdead\u201d instead of \u201cpassed away\u201d or \u201cgone.\u201d Helpful interventions (cont\u2019d):\nAcknowledge family\u2019s feelings, but never say, \u201cI know how you feel.\u201d\nOffer to call other family members or clergy.\nKeep any instructions short, simple, and basic.\nAsk family members if they want to hold the child.\nWrap the child in a blanket and stay with the family while they hold the child.\nDo not to remove equipment that was used in attempted resuscitation. Everyone expresses grief in a different way.\nSome will require intervention.\nMany caregivers feel directly responsible for the death of a child.\nSome EMS systems arrange for home visits after a child\u2019s death for closure.\nYou need training for these visits. Child\u2019s death can be very stressful.\nTake time before going back to the job.\nTalk with other EMS colleagues.\nBe alert for signs of posttraumatic stress in yourself and others.\nConsider the need for help if signs occur.",
        "Infants who are not breathing, cyanotic, and unresponsive sometimes resume breathing and color with stimulation.": "Apparent life-threatening event (ALTE)\nClassic ALTE is characterized by:\nDistinct change in muscle tone\nChoking or gagging After ALTE, child may appear healthy and show no signs of illness or distress.\nComplete careful assessment and provide rapid transport to the ED.\nPay strict attention to airway management.\nAssess infant\u2019s history and environment.\nAllow caregivers to ride in the back of the ambulance.",
        "Brief Unresolved Unexplained Event Signs and symptoms": "Brief changes in color such as pale skin or cyanosis\nChoking\nAbsent, slow, or irregular breathing\nDecreased level of consciousness\nNo abnormality found on assessment\nTransport required for evaluation"
    },
    {
        "neonate": "a baby that is less than 1 month old.",
        "ductus arteriosa": "a duct from the pulmonary arteries to the aorta that bypasses the non-function pulmonary system of a fetus.",
        "apgar score": "appearance. pulse. grimace. activity. respirations.",
        "normal apgar score": "a score between 7-10 is normal for neonates.",
        "apgar score of 4-6": "mild distress. stimulation and oxygenation indicated.",
        "apgar score < 4": "severe distress. immediate resuscitation required: ppv and/or chest compressions. do not delay resuscitative efforts to acquire apgar in the event of apnea or other obvious sign of distress.",
        "at a heart rate of 60 bpm, what intervention is indicated for a neonate?": "chest compressions and positive pressure ventilations.",
        "at a heart rate of 100 bpm, what intervention is indicated for a neonate?": "positive pressure ventilations",
        "unless resuscitation is require, at what time are apgar scores indicated?": "at 1 min and then at 5 min after birth. continue updating scores at 5-10 min intervals.",
        "how many veins are in the umbilical cord and what color are they?": "there are 1 vein and it is red.",
        "how many arteries are in the umbilical cord and what color are they?": "there is two arteries in the umbilical cord and it is blue.",
        "premature neonate": "a neonate born prior to 37 weeks gestation.",
        "what is the most common cause of respiratory distress and cyanosis in a newborn/neonate?": "prematurity of the neonate. (underdeveloped respiratory system)"
    },
    {
        "pediatric assessment triangle": "appearance. work of breathing. circulation of skin.",
        "appearance section (peds. assessment triangle)  and ticls": "tone. interactiveness. consolability. look/gaze. speech/cry. \nthese categories help assess a pediatric level of alertness and their verbal response to stimuli.",
        "work of breathing section (peds. assessment triangle)": "abnormal sounds, abnormal position (i.e. sniffing position or tripod position), abnormal effort (i.e. accessory muscle use, see-saw breathing)",
        "circulation to skin (peds. assessment triangle)": "pallor, mottling, cyanosis. skin temperature, check pulse, capillary refill (< 5 years old).",
        "respiratory rates for a neonate-infant (< 1 y/o).": "30-60 breaths/min.",
        "respiratory rate for toddler (1-3 y/o)": "24-40 breaths/min",
        "respiratory rate for preschooler (3-5 y/o)": "24-40 breaths/min",
        "respiratory rate school age (6-10 y/o)": "18-30 breaths/min",
        "respiratory rate early adolescence (11-14 y/o)": "12-26 breaths/min",
        "retraction (respiration)": "skin and soft tissues of the chest visibly depress around ribs and above the collar bone. sign of respiratory distress or increased work of breathing.",
        "nasal flaring": "the stretching of the nostrils, increasing diameter. normally seen on respiration. sign of respiratory distress or increased work of breathing.",
        "head bobbing": "the lifting and tilting of the head backwards during inspiration and forward on inspiration. normally seen in young children in respiratory distress with increased work of breathing.",
        "grunting (respiration)": "a sound made by infants in respiratory distress who are attempting to maintain his/her alveoli by creating back pressure.",
        "pulse rate newborn (< 1 month)": "100-180 bpm",
        "pulse rate infant (1-12 months)": "100-160 bpm",
        "pulse rate toddler (1-3 y/o)": "80-110 bpm",
        "pulse rate preschooler (3-5 y/o)": "70-110 bpm",
        "pulse rate school age (6-10 y/o)": "65-110 bpm",
        "pulse rate early adolescence (11-14 y/o)": "60-90 bpm",
        "equations for pediatric systolic blood pressure (higher limit and lower limit)": "higher limit: 90 + (2 x age)\nlower limit: 70 + (2 x age)"
    },
    {
        "what about the anatomy of infants and small children increase the incidence of anatomical airway obstruction?": "pediatrics have a relatively larger tongue that can more easily obstruct the upper airway. pediatrics heads are larger resulting in flexion of the neck in the supine position which can cause obstruction of their (more flexible) upper airway.",
        "what effect does the anatomy of infants and small children have on direct visualization of the vocal cords?": "it makes it more difficult to create a visual plane from the mouth to the pharynx.",
        "what type of laryngoscope blade is recommended for small children and infants?": "a strait blade is preferred to displace the tongue and improve visualization in the small oropharynx.",
        "what is the narrowest portion of a pediatric airway?": "the cricoid ring.",
        "equation for calculating pediatric endotracheal tube size": "(age in years + 16) / 4",
        "what about a pediatric vagal nerve makes intubation attempts more risky?": "pediatrics have increased vagal tone and are more susceptible to vagal stimulation during intubation.",
        "effects of vagal stimulation": "dramatically decreased heart rate, reduction in cardiac output and blood pressure.",
        "what are some advanced intervention options during a foreign body airway obstruction? (bls interventions unsuccessful)": "direct visualization and removal with magill forceps. endotracheal intubation. needle cricothyrotomy.",
        "positive pressure ventilation should be given at the minimal force and volume to achieve...": "chest rise",
        "when manually opening a pediatric airway with a head-tilt/chin lift, you want to avoid...": "hyperextension of the neck. this can cause injury and possible airway obstruction."
    },
    {
        "document title": "Pediatric Cardiovascular Emergencies",
        "protocol title": "Medical - Newborn/Neonatal Resuscitation",
        "overview": "The majority of newborns will require only warmth, stimulation, and occasionally some oxygen after birth. That treatment is recommended before attempting the more aggressive interventions of positive-pressure ventilation (PPV) and chest compressions.Remember that a newborn\u2019s cardiac output is rate dependent. Bradycardia usually is the result of hypoxia. Once the hypoxia is corrected, the heart rate may spontaneously correct itself. A \u201cnewborn\u201d is defined as within one month of age post delivery.",
        "procedure": "1. If obvious obstruction to spontaneous breathing or requires positive pressure ventilation, gently suction the newborn\u2019s mouth, then nostrils, with a bulb syringe for 3 to 5 seconds. Don\u2019t routinely suction an active baby. \n2. If meconium staining is present: - a. If the newborn is vigorous (strong respiratory effort, good muscle tone, and a heart rate greater than 100 bpm), no routine suctioning is required. - b. If the newborn is NOT vigorous (poor or absent respiratory effort, flaccid, lethargic), consider immediate MECONIUM ASPIRATION via endotracheal suctioning. Suctioning of meconium should not distract from the need for emergent oxygenation and ventilation of the newly born. In the patient with meconium aspiration and respiratory failure or apnea, quickly suction meconium and then begin BVM ventilations. \n3. If meconium staining is not present, rub the newborn\u2019s back vigorously. Simultaneously begin drying and warming measures. \n4. KEEP THE NEWBORN WARM AND DRY. \n5. Evaluate respirations, heart rate (apical pulse or pulse at the base of the umbilical cord), and state of oxygenation. Obtain 1 minute APGAR. \n6. If respirations are inadequate, HR > 100 bpm: - a. Initiate positive -pressure ventilation with a BVM NOT attached to oxygen. Deliver 40 to 60 breaths per minute. Use only enough volume to make the newborn\u2019s chest rise. \n7. If respirations are inadequate and HR less than 100 bpm:  - a. Initiate positive -pressure ventilation with a BVM on room air. If no increase in HR after 90 seconds, administer 100% oxygen. - b. If HR is below 60 bpm, begin compressions.",
        "apgar score \u2013 1st and 5th minute post birth": "| **Sign** | **0 Points** | **1 Point** | **2 Points** |\n|---|---|---|---|\n| **Activity (Muscle Tone)** | Flaccid | Some Flexion | Active Motion |\n| **Pulse** | Absent | < 100 | > 100 |\n| **Grimace (Reflex Irritability)** | No Response | Some | Vigorous |\n| **Appearance (Skin Color)** | Blue, Pale | Blue Extremities | Fully Pink |\n| **Respirations** | Absent | Slow, Irregular | Strong Cry |",
        "supportive care": "- Maintain airway. Suction as needed with bulb syringe. \n- Obtain blood glucose sample. If BGL is < 40 mg/dL, administer Dextrose 10% 2cc / kg (0.5 g / kg) slow IV / IO push. Repeat as necessary.\n- Maintain warmth via blankets and Porta -Warm mattress or skin -to-skin.",
        "procedure for making dextrose 10%": "In 50 ml syringe, mix 10 ml of Dextrose 50% with 40 ml Normal Saline. Mixture will yield 50 ml of Dextrose 10%\n| **Age** | **Pre-Term** | **Term** |\n------- | -------- | -------- |\n| **Weight (lb / kg)** | 3.3 lbs<br>1.5 kg | 6.6 lbs<br>3.0 kg |\n| **Epinephrine 1:10,000**<br>(1 mg / 10 ml) | 0.01 mg / kg | 0.015 mg | 0.03 mg |\n| **Dextrose 10%** | 2.0 ml / kg | 3.0 ml | 6.0 ml |",
        "pearls": "1. The primary measure of adequate initial ventilation is prompt improvement in heart rate.\n2. In the presence of thick meconium and an infant who is limp, aggressive suctioning is required.\n3. A 3:1 ratio of compressions to ventilations with 90 compressions and 30 breaths should be used to achieve approximately 120 events per minute to maximize ventilation at an achievable rate. Each event should be allotted approximately \u00bd second, with exhalation occurring during the first compression following, each ventilation.\n4. Arterial saturations of a term infant at birth can be as low as 60% and can require more than 10 minutes to reach saturations of > 90%. Hyperoxia can be toxic, particularly to the preterm baby."
    },
    {
        "document title": "Pediatric Cardiovascular Emergencies",
        "protocol title": "General \u2013 Cardiac Arrest",
        "overview": "During cardiac arrest, there is no effective pumping activity, pulse, or blood pressure.\n\nMost commonly, the rhythms that cause pulseless arrest are: ventricular fibrillation, ventricular tachycardia, pulseless electrical activity, or asystole. The ECG of ventricular fibrillation shows a fine to coarse zigzag pattern without discernible P waves or QRS complexes. Ventricular fibrillation / ventricular tachycardia is most commonly seen in patients with severe ischemic heart disease and is the most frequently encountered rhythm in sudden cardiac death in adults. Defibrillation is required to stop VF / VT. It constitutes the most important aspect of therapy for VF / VT. The sooner the shocks are given, the more likely they are to be successful.",
        "hpi": "* Estimated down time\n* Past medical history\n* Medications\n* Events leading to arrest",
        "signs and symptoms": "* Unresponsive, apneic, pulseless\n* Ventricular fibrillation or pulseless ventricular tachycardia on ECG\n* Asystole",
        "considerations": "* Renal failure / dialysis\n* DNR or living will\n* Artifact / Device failure\n* Cardiac\n* Endocrine / metabolic\n* Drugs\n* Respiratory Arrest",
        "possible causes of pulseless arrest": "**A** Alcohol, Abuse, Acidosis\n**T** Toxidromes, Trauma, Temperature, Tumor\n**E** Endocrine, Electrolytes, Encephalopathy\n**I** Infection, Intussusception\n**I** Insulin\n**P** Psychogenic, Porphyria, Pharmacological\n**O** Oxygenation, Overdose, Opiates\n**S** Space occupying lesion, Sepsis, Seizure, Shock\n**U** Uremia",
        "infant dosing chart": "Age     Term     6 months  \nWeight (lb/kg)     6.6 lb  3 kg     17.6 lb  \n8 kg  \nDefibrillation     2 joules / kg     6 joules     16 joules  \nDefibrillation     4 joules / kg     12 joules    32 joules  \nEpinephrine     1:10,000     (1 mg / 10 ml)     0.01 mg / kg     0.03 mg    0.08mg  \nAmiodarone     5 mg / kg     15 mg     40 mg  \nMagnesium     Sulfate     25 - 50 mg / kg     75 mg    200 mg",
        "pediatric dosing chart": "Age     1  \nyears     3  \nyears     6  \nyears     8  \nyears     10  \nyears     12  \nyears     14  \nyears  \nWeight (lb / kg)     22 lb 10  \nkg     30.8 lb     14 kg     44 lb 20  \nkg     55 lb 25  \nkg     75 lb 34  \nkg     88 lb 40  \nkg     110 lb  \n50 kg  \nDefibrillation     2 joules / kg 20  \njoules     28     \njoules     40     \njoules     50     \njoules     68     \njoules     80     \njoules     100  \njoules  \nDefibrillation     4 joules / kg 40  \njoules     56     \njoules     80     \njoules     100    \njoules     136     \njoules     160     \njoules     200  \njoules  \nEpinephrine     1:10,000     (1 mg / 10 ml)     0.01 mg / kg     0.1 mg 0.14  \nmg 0.2     \nmg 0.25     \nmg 0.34     \nmg 0.4     \nmg 0.5     \nmg  \nAmiodarone     5 mg / kg     50  \nmg     70     \nmg     100     \nmg     125     \nmg     170     \nmg     200     \nmg     250  \nmg  \nMagnesium     Sulfate     25 - 50 mg / kg     250  \nmg     350     \nmg     500     \nmg     625      \nmg     850     \nmg     1      \ngm     1.25    \ngm",
        "monitor operation note": "Ensure you are operating according to the specifications of the manufacturer of your particular monitor.",
        "pearls": "1. If airway maintainable initially with BVM, delay advanced airway insertion until after initial medication administration. The best airway is an effective airway with the least potential complications.\n2. Do not stop CPR to give ventilations once advanced airway has been secured.\n3. CPR should not be stopped for any reason, if at all avoidable, other than to check for rhythm change. Any stop of compressions should kept as short as possible, preferably a maximum of 10 seconds. IV / IO access and advanced airway placement should be performed while compressions are being performed.\n4. Pay close attention to rate of manual ventilation. Hyperventilation produces decrease in preload, cardiac output, coronary perfusion, and cerebral blood flow."
    },
    {
        "document title": "Pediatric Cardiovascular Emergencies",
        "protocol title": "Cardiac Arrest \u2013 Unknown Rhythm (i.e. BLS)",
        "possible causes of pulseless arrest": "* A Alcohol, Abuse, Acidosis\n* T Toxidromes, Trauma, Temperature, Tumor\n* E Endocrine, Electrolytes, Encephalopathy\n* I Infection, Intussusception\n* I Insulin\n* P Psychogenic, Porphyria, Pharmacological\n* O Oxygenation, Overdose, Opiates\n* S Space occupying lesion, Sepsis, Seizure, Shock\n* U Uremia",
        "pearls": "1. If airway is maintainable initially with a BVM, delay rescue airway insertion until after initial defibrillation. The best airway is an effective airway with the least potential complications.\n2. Continue CPR while AED is charging.\n3. CPR should not be stopped for any reason, if at all avoidable, other than to check rhythm immediately prior to defibrillation. Any stop of compressions should kept as short as possible, preferably a maximum of 10 seconds. Alternate airway placement should be performed during compressions.\n4. Pay close attention to rate of manual ventilation. Hyperventilation produces decrease in preload, cardiac output, coronary perfusion, and cerebral blood flow.\n5. AED\u2019s may be used for patients all ages. For children less than 8 years of age, use an AED equipped with a pediatric attenuator. If an AED with pediatric attenuator is not available, use a standard AED."
    },
    {
        "document title": "Pediatric Cardiovascular Emergencies",
        "protocol title": "Medical \u2013 Supraventricular Tachycardia (including atrial fibrillation) Medical \u2013 Tachycardia Medical \u2013 Ventricular Tachycardia with a Pulse",
        "overview": "Tachycardia is an abnormally fast rhythm of the heart. It is most commonly caused by a reentry mechanism that involves an accessory pathway or the AV conduction system.\nSVT is the most common tachyarrhythmia producing cardiovascular compromise during infancy.",
        "hpi": "* Past medical history\n* Medications, toxin ingestion (aminophylline, diet pills, thyroid supplements, decongestants, digoxin)\n* Drugs (nicotine, cocaine)\n* Congenital heart disease",
        "signs and symptoms": "* Respiratory distress\n* Syncope, near syncope\n* Heart rate:\n    * Child > 180 / min\n    * Infant > 220 / min\n* QRS < 0.08 seconds\n* Pale or cyanosis\n* Diaphoresis\n* Tachypnea\n* Vomiting\n* Hypotension\n* Altered mental status\n* Pulmonary congestion\n* Syncope",
        "considerations": "* Heart disease (congenital)\n* Hypo / hyperthermia\n* Hypovolemia\n* Anemia\n* Electrolyte imbalance\n* Anxiety, pain, emotional stress\n* Fever, infection, sepsis\n* Hypoxia\n* Hypoglycemia\n* Medication, toxin, drugs\n* Pulmonary embolus\n* Trauma",
        "infant dosing chart": "Infant Dosing Chart:\n| Age | Term | 6 months |\n|---|---|---|\n| Weight (lb / kg) | 6.6 lb / 3 kg | 17.6 lb / 8 kg |\n| Defibrillation | 2 joules / kg | 6 joules | 16 joules |\n| Defibrillation | 4 joules / kg | 12 joules | 32 joules |\n| Epinephrine 1:10,000 (1 mg / 10 ml) | 0.01 mg / kg | 0.03 mg | 0.08mg |\n| Amiodarone | 5 mg / kg | 15 mg | 40 mg |\n| Magnesium Sulfate | 25 - 50 mg / kg | 75 mg | 200 mg |\n\n| Age | 1 years | 3 years | 6 years | 8 years | 10 years | 12 years | 14 years |\n|---|---|---|---|---|---|---|---|\n| Weight (lb / kg) | 22 lb / 10 kg | 30.8 lb / 14 kg | 44 lb / 20 kg | 55 lb / 25 kg | 75 lb / 34 kg | 88 lb / 40 kg | 110 lb / 50 kg |\n| Defibrillation | 2 joules / kg | 20 joules | 28 joules | 40 joules | 50 joules | 68 joules | 80 joules | 100 joules |\n| Defibrillation | 4 joules / kg | 40 joules | 56 joules | 80 joules | 100 joules | 136 joules | 160 joules | 200 joules |\n| Epinephrine 1:10,000 (1 mg / 10 ml) | 0.01 mg / kg | 0.1 mg | 0.14 mg | 0.2 mg | 0.25 mg | 0.34 mg | 0.4 mg | 0.5 mg |\n| Amiodarone | 5 mg / kg | 50 mg | 70 mg | 100 mg | 125 mg | 170 mg | 200 mg | 250 mg |\n| Magnesium Sulfate | 25 - 50 mg / kg | 250 mg | 350 mg | 500 mg | 625 mg | 850 mg | 1 gm | 1.25 gm |",
        "pearls": "1. SVT is often diagnosed in infants because of symptoms of congestive heart failure. SVT usually presents differently in older children. Common signs and symptoms of SVT in infants include: poor feeding, rapid breathing, irritability, unusual sleepiness, pale or blue skin color, and vomiting. SVT is initially well tolerated in most infants and older children. It can, however, lead to heart failure and clinical evidence of shock, particularly if baseline myocardial function is impaired by congenital heart disease or cardiomyopathy. It can ultimately cause cardiovascular collapse.\n2. Approved vagal maneuvers include coughing, bearing down as if attempting a bowel movement. Carotid sinus massage and / or ocular massage is not approved.",
        "amiodarone drip": "(5 mg / kg over 40 minutes)\nDilute calculated volume of Amiodarone in 50 ml D 5W\nUsing a 60 gtts / mL administration set, flow infusion at 60 gtts. (1 mL / min, 1 gtt / sec)"
    },
    {
        "document title": "Pediatric Cardiovascular Emergencies",
        "protocol title": "Medical - Bradycardia",
        "overview": "Bradycardia is the most common dysrhythmia in the pediatric population. Bradycardia, in pediatric patients, typically is the result of some form of respiratory depression and initial treatment should be directed to ensuring that the patient is breathing adequately and providing supplemental oxygenation and ventilation as needed. Since the etiology of bradycardia is usually hypoxemia, initial management is ventilation and oxygenation while perfusion is maintained with chest compressions in children with a heart rate of less than 60 beats per minute. Symptomatic bradycardia is defined in pediatrics as hypotension or other signs and/or symptoms of poor perfusion, with a (relative to age) bradycardia. Most bradycardia is hypoxia related, and will usually respond to oxygenation.",
        "hpi": "* Past medical history\n* Foreign body exposure\n* Respiratory distress or arrest\n* Apnea\n* Possible toxic or poison Environmental exposure\n* Congenital disease\n* Medication (maternal or infant)",
        "signs and symptoms": "* Heart rate < 60 bpm\n  * Delayed capillary refill or cyanosis\n  * Mottled, cool skin\n  * Hypotension or arrest\n  * Altered mental status",
        "considerations": "* Respiratory effort\n* Respiratory obstruction\n* Foreign body, secretions\n* Croup, epiglottitis\n* Hypovolemia\n* Hypothermia\n* Infection, sepsis\n* Medication, toxin\n* Hypoglycemia\n* Trauma",
        "pearls": "1. Pharmacological treatment of bradycardia is based upon the presence or absence of significant signs and symptoms (symptomatic vs. asymptomatic).\n2. Although noninvasive pacing may be attempted, typically bradycardias of hypoxic etiology do not respond. First line therapy is prompt airway support, ventilation and oxygenation.\n3. Capture thresholds in children are similar to those in adults. Studies indicate no relationship between body surface area, weight, and capture thresholds and although many children will achieve capture between 50 - 100 mA, higher current requirements are possible. The pacing rate must be set high enough to perfuse the patient.\n4. Electrical capture during transcutaneous pacing is defined as an electrical stimulus marker followed by a wide QRS complex, with no underlying intrinsic rhythm, followed by a T-wave. This should occur for each electrical complex.\n5. Mechanical capture is confirmed when the patient\u2019s pulse matches the displayed pace rate.  Because pacing stimuli generally causes muscular contractions that can be mistaken for a pulse, you should never take a pulse on the left side of the body to confirm mechanical capture. Pectoral muscle contractions due to pacing also do not indicate mechanical capture. To avoid mistaking muscular response to pacing stimuli for arterial pulsations, use ONLY the (1) Femoral artery or (2) Right brachial or radial artery for confirming mechanical capture."
    },
    {
        "document title": "Pediatric Trauma Patient Care",
        "protocol title": "Pediatric Traumatic Arrest",
        "overview": "Survival from traumatic cardiac arrest is poor. Ideally, patients in traumatic arrests are managed in the field until ROSC or termination of efforts.",
        "transport decisions": "Distance from the level 1 or 2 trauma center may influence transport decisions. Transport times greater than 15 minutes to the trauma center should be managed in the field unless extenuating circumstances exist.",
        "pearls": "* Consider anterior mid-axillary placement for larger adults when using 14-gauge IV catheters.\n* Penetrating traumatic cardiac arrest generally has better outcomes than blunt traumatic arrest.\n* ACLS drugs may impair tissue perfusion in hemorrhagic shock and should be limited to a single early dose if used.\n* Focus on managing external hemorrhaging, airway, needle decompression, chest compressions, and defibrillation as appropriate.\n* Priority of transport destination:\n    * Level 1 Trauma Center\n    * Level 2 Trauma Center\n    * Level 3 Trauma Center\n    * Closest Appropriate Facility\n* Consider scene safety and security when making transport decisions."
    },
    {
        "document title": "Pediatric Trauma Emergencies",
        "protocol title": "Injury \u2013 Burns \u2013 Thermal",
        "overview": "Burns are a devastating form of trauma associated with high mortality rates, lengthy rehabilitation, cosmetic disfigurement, and permanent physical disabilities. Thermal, chemical, electrical, (nuclear) radiation or solar sources may cause burns. Burns can affect more than just the skin. Burns are classified by degree, 1 \uf0b0 (superficial) some reddening to skin, 2 \uf0b0 (partial thickness) has blistering and deep reddening to the skin, and 3\uf0b0 (full thickness) causes damage to all skin layers and is either charred / black or white / leathery with little or no pain at the site. The patient\u2019s palm equals 1% of body surface area when determining the area affected. Scald injuries are more common in younger children while flame injuries are more common in older children and account for the most fatalities. Smoke inhalation is the most common cause of death in the first hour after a burn injury. Children who have burn injuries are at a greater risk than adults for shock and hypothermia because of their proportionately large body surface.",
        "hpi": "* Type of exposure (heat, gas, chemical)\n* Time of injury\n* Past medical history\n* Medications\n* Other trauma",
        "signs and symptoms": "* Inhalation injury\n* Burns, pain, swelling\n* Dizziness\n* Loss of consciousness\n* Hypotension/ shock\n* Airway compromise, distress\n* Singed facial or nasal hair\n* Hoarseness, wheezing\n* Superficial (1 \uf0b0), red and painful\n* Partial thickness (2 \uf0b0), blistering\n* Full thickness (3 \uf0b0), painless and charred leathery skin",
        "considerations": "* Chemical, Thermal, Radiation",
        "procedure": "1. Stop the burning process:\n   a. Thermal burns: Lavage the burned area with sterile water or saline to cool skin. Do not attempt to wipe off semisolids (grease, tar, wax, etc.) Do not apply ice. Dry the body when the burn area is greater than or equal to 10% TBSA to prevent hypothermia.\n   b. Dry chemical burns: Brush off dry powder, then lavage with copious amounts of tepid water (sterile, if possible) for 20 minutes. Continue en route to the hospital.\n   c. Liquid chemical burns: Lavage the burned area with copious amounts of tepid water (sterile, if possible) for 20 minutes. Continue en route to the hospital.\n2. Support life-threatening problems.\n3. Perform general patient management.\n4. Administer oxygen, via non-rebreather mask, at 10 - 15 L / min. as necessary. Use humidified oxygen if suspected inhalation injury and when available.\n5. If the patient is in critical respiratory distress, consider early placement of an advanced airway.\n   *Endotracheal Intubation / cricothyrotomy are reserved as Paramedic only.*\n6. Remove clothing from around burned area, but do not remove/peel off skin or tissue. Remove and secure all jewelry and tight fitting clothing.\n7. Assess the extent of the burn using the rule of nines and the degree of burn severity.\n8. Cover the burned area with a clean, dry dressing. Wet dressing may be used if the burned TBSA is less than 10%.\n9. If a partial or full thickness burn involves more than 20% TBSA, establish an IV of NS or LR (if available). Infuse the fluid amounts listed as below. If the patient develops signs and symptoms of fluid overload respiratory distress (dyspnea, crackles, rhonchi, decreasing SpO2), slow the IV to KVO.\n   a. For patients 5 years and younger, start at 125mL/hr.\n   b. For patients 6 -13 years, start at 250mL/hr.\n   c. For patients 14 years and older, start rate at 500 mL/hr.\n10. For pain control, refer to the Pediatric Pain Management protocol.\n11. Perform ongoing assessment as indicated and transport major burns to Level 1 Burn Center. Transport minor burns to appropriate facility.",
        "management notes": "Excessive fluid resuscitation can lead to compartment syndromes.\n**Normal Saline or Lactated Ringers are fluids of choice in burn patients**",
        "pearls": "1. Remove patient\u2019s clothing as appropriate. Remove rings, bracelets and other constricting items in areas of burn, if possible.\n2. Critical burns: burns over > 25% TBSA, 2\uf0b0 burns > 10% TBSA, 2\uf0b0 and 3\uf0b0 burns to the face, eyes, hands, or feet, electrical burns, respiratory burns, deep chemical burns, burns with extremes of age or chronic disease, and burns with associated major traumatic injury. These patients should be transported directly to a VCU Pediatric Emergency department, if possible.\n3. Have a high index of suspicion and a low intubation threshold when treating burn patients with possible airway involvement. Early intubation is recommended in significant inhalation injuries.\n4. Circumferential burns to extremities are dangerous due to potential vascular compromise secondary to soft tissue swelling.\n5. Burn patients are prone to hypothermia \u2013 never cool burns that involve > 15% TBSA.\n6. Never overlook the possibility of multi-system trauma.\n7. Burns are extremely painful. Strongly consider pain management medications as needed.\n8. Assess for potential child abuse and follow appropriate reporting mechanism as needed.\n9. Keep the child warm and protect from hypothermia. Be cautious with cool dressings."
    },
    {
        "document title": "Pediatric Trauma Patient Care",
        "protocol title": "General \u2013 Neglect or Abuse Suspected",
        "overview": "Child r abuse, which includes sexual abuse, physical abuse, and neglect, is often overlooked and under-reported. It is the ethical and legal responsibility to notify the receiving hospital of suspicions of child abuse as it may prevent serious injury and death. Proof of abuse is not needed to make the report to hospital, CPS, or social services. Patterns of abuse can reflect any form of physical and/or mental trauma, but are usually characterized by unexplained or poorly explained injuries of different ages and delay in seeking medical care. There may be sometimes be no external signs of injuries. Observation, transport, and reporting are the key responsibilities of the prehospital provider.",
        "hpi": "Time of injury \nMechanism: blunt vs penetrating\nLoss of consciousness\nBleeding\nPast medical history\nMedications\nEvidence of multisystem trauma",
        "signs and symptoms": "Pain, swelling, bleeding\nAltered mental status, unconsciousness\nRespiratory distress, failure\nDehydration\nFractures\nDecubitus\nMajor traumatic mechanism of injury",
        "considerations": "Skull fracture\nBrain injury(concussion, contusion, hemorrhage, or laceration\nEpidural hematoma\nSubdural hematoma\nSubarachnoid hemorrhage\nSpinal injury",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems; C-spine precautions.\n3. Administer oxygen, to maintain SPO2 94 - 99%. Support respirations as necessary with a BVM.\n4. Observe and record objectively the surroundings and conditions of the scene and patient.\n5. Refer to the appropriate Medical or Trauma Patient Care protocol for obvious injuries / illnesses.\n6. UNDER VIRGINIA LAW, EMS PROVIDERS ARE MANDATORY REPORTERS OF SUSPECTED CHILD ABUSE. (VA code 63.2-1509) Report suspicions to the receiving facility emergency department attending physician on arrival, or report suspicions immediately to Child Protective Services. CPS Hotline: 800-552-7096.\n7. Transport as soon as possible."
    },
    {
        "document title": "Pediatric Trauma Emergencies",
        "protocol title": "Injury \u2013 Abdomen (Abdominal Trauma)",
        "overview": "Blunt and penetrating trauma are major causes of morbidity and mortality in the United States. Pediatric abdominal anatomy differs from adults in several unique ways. There is significantly less protection due to thinner muscle walls and less fat. Ribs protecting the thoracic abdomen have increased flexibility more easily allowing the ribs to injure the abdominal organs. Solid organs within the pediatric abdomen have a larger surface area thus a greater area is exposed for potential injury. The organ attachments are also more elastic, increasing the chances of tearing and shearing injuries. Lastly, the bladder extends to the umbilicus in the pediatric patient, increasing its chance for injury. When performing a focused abdominal assessment, be organized, efficient, and thorough. Initial abdominal examinations only identify injury about 65% of the time; secondary exams are needed when there is a high index of suspicion for abdominal trauma. A proper abdominal examination involves exposing the entire abdomen from the nipple line to the groin and using a standard examination sequence of inspection, auscultation, percussion, and palpation.",
        "hpi": "* Time of injury\n* Mechanism: blunt vs penetrating\n* Loss of consciousness\n* Damage to structure, vehicle\n* Location in structure or vehicle\n* Speed, details of MVC\n* Restraints, protective devices\n* Medical history\n* Medications\n* Evidence of multi-system trauma",
        "signs and symptoms": "* Pain, swelling, bleeding\n* Deformity, lesions\n* Altered mental status, unconsciousness\n* Respiratory distress, failure\n* Hypotension, shock\n* Arrest\n* Significant mechanism of injury",
        "procedure": "1. Maintain scene and provider safety.\n2. Perform general patient management.\n3. Administer supplemental oxygen to maintain SpO2 94-99%. If need to assist ventilations with BVM, maintain C-spine precautions.\n4. Identify mechanism of injury.\n5. Establish large bore IV\u2019s of normal saline. Titrate to an appropriate systolic blood pressure:\n    a. Birth to 1 month - 60 mmHg\n    b. 1 month to 1 year -  > 70 mmHg\n    c. Greater than 1 year - 70 + [2 x Age (years)]\n6. Treat pain if indicated. Refer to Pediatric Pain Management protocol.\n7. Consider ONDANSETRON (ZOFRAN)  0.1mg / kg slow IVP over 2 \u2013 5 minutes, max 4.0 mg per dose as needed per Pediatric Nausea and vomiting protocol.\n8. Transport to the appropriate hospital per Trauma Triage Scheme and reassess as indicated.",
        "considerations": "Impaled Objects:\nStabilize impaled objects in place with bulky dressings.\n\nSevere Hemorrhage from Open Penetrating Injury:\nControl bleeding with well-aimed direct pressure directly on the bleeding source.  Once controlled apply dry, sterile dressing.\n\nEvisceration with Protruding Abdominal Contents:\nLoosely wrap any protruding abdominal contents with a sterile dressing moistened with Normal Saline and cover in entirety with an occlusive dressing over top.",
        "pearls": "1. The amount of external bleeding is not an indicator of the potential severity of internal bleeding associated with an underlying trauma.\n2. Abdominal eviscerations are a surgical emergency. The protruding organ requires careful cleaning and evaluation prior to reinsertion. Do not attempt to reinsert the organs in  the pre-hospital setting.\n3. Impaled objects in the abdomen often tamponade internal hemorrhage, and removing them may trigger significant internal bleeding. Remember that any bump against the object moves the distal end in the organ and worsens damage."
    },
    {
        "document title": "Pediatric Trauma Patient Care",
        "protocol title": "PROTOCOL TITLE: General \u2013 Pediatric SMR",
        "overview": "Mechanism of injury alone has not been shown to be a predictor for spinal injury. An appropriate patient assessment can be used to determine the need for spinal motion restriction. The below are cervical spinal motion restriction selection guidelines taken from National Model Guidelines V2 and NEXUS (National Emergency X-Radiography Utilization Study).\nThere is limited data studying spinal motion in patients with applied cervical collars. Patients exiting a car under their own power, with cervical collar in place, may result in the least amount of motion of the cervical spine. Cervical spinal motion restriction devices include, but are not limited to, soft and hard collars.\nLong backboards have not been shown to reduce spinal injury complications. Long backboards are associated with increased pain, decubitus development, and possibly decreased functional residual capacity of the lungs. Long backboards and scoop stretchers may be used for the safe movement/transfer of patients. However, if used in this way, patients should be removed from the device as soon as possible.",
        "hpi considerations": "* Time of injury\n* Mechanism of injury (blunt vs. penetrating)\n* Restraints/protective devices\n* Prior cervical spine surgery\n* Known vertebral disease\n* Medical history\n* Medications\n* Evidence of multi-system trauma",
        "signs and symptoms": "* Spine pain\n* Limited neck mobility\n* Neurological deficit\n* Unstable/abnormal vital signs\n* Spinal cord injury\n* Fracture of vertebrae\n* Head injury\n* Neurogenic shock\n* Distracting injury",
        "procedure": "1. Maintain scene and provider safety.\n2. Perform general patient management.\n3. Support life-threatening problems.\n4. Spinal motion restriction is not recommended in patients with penetrating trauma.\n5. Cervical spinal motion restriction should be used in patients meeting the below criteria.\n    a. Patients 14 years of age and younger with a traumatic mechanism and any one of the following criteria:\n        - Torticollis\n        - Substantial Injury\n        - High-risk MVC\n        - Diving Incidents\n        - Neurological Deficits\n        - Altered Mental Status\n        - Intoxication\n    c. Any patient where provider judgment indicates the use of SMR (backboard, strapped to stretcher, Reeves, etc.)\n6. Backboards may be used for movement or extrication of the patient. Patients should be removed from the backboard as soon as possible.\n7. Transport to an appropriate facility as indicated by the Regional Field Triage Scheme if applicable, and perform ongoing assessment as indicated."
    },
    {
        "document title": "Pediatric Trauma Emergencies",
        "protocol title": "Injury \u2013 Electrical Injuries",
        "overview": "The vast majority of electrical injuries are caused by generated electricity, such as that encountered in power lines and household outlets. Relative to the external damage caused by electrical injuries, internal damage is often more severe, and can include damage to muscles, blood vessels, organs, and nerves. Damaged muscle releases myoglobin and potassium, which can precipitate in the kidneys and cause acute renal failure. Electrical current as low as 20 mA can cause respiratory arrest and as little as 50 mA can cause ventricular fibrillation. Although long-bone fractures and spinal injuries can occur due to falls after electrocution, they can additionally occur due to severe tetanic muscle spasms with high amplitude electrocutions. Before treating any patient with an electrical injury, ensure your personal safety. Do not touch the patient, if the patient is still in contact with the electrical source.",
        "hpi": "* Lightning or electrical exposure\n* Single or multiple victims\n* Trauma secondary to fall from high wire or MVC into line\n* Duration of exposure\n* Voltage and current (AC / DC)",
        "signs and symptoms": "* Burns\n* Pain\n* Entry and exit wounds\n* Hypotension and shock\n* Cardiac and / or respiratory arrest",
        "considerations": "Cardiac arrest\nRespiratory arrest\nSeizure\nBurns\nMultisystem trauma",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems.\n3. Administer oxygen to maintain SPO2 94 - 99%. Consider supporting respirations with a BVM.\n4. Determine extent of any burn injuries. Refer to the Pediatric Burns protocol. Avoid initiating IVs in areas of burn unless absolutely necessary.\n5. Place patient on cardiac monitor; obtain / interpret 12 Lead ECG. Refer to the appropriate Pediatric Cardiac Care protocol for dysrhythmias.\n6. Establish an IV of normal saline to titrate an appropriate BP:\n   a. Birth to 1 month -> 60 mmHg\n   b. 1 month to 1 year -> 70 mmHg\n   c. Greater than 1 year - 70 + [2 x Age (years)]\n7. Consider administration of pain management per Pediatric Pain Management protocol.\n8. Transport to an appropriate facility and perform ongoing assessment as indicated.",
        "pearls": "1. Ventricular fibrillation and asystole are the common presenting dysrhythmias associated with electrical injuries.\n2. Injuries are often hidden. The most severe injuries will occur internally in the muscles, vessels, organs, and nerves.\n3. Do not overlook other trauma (i.e ., falls).\n4. Lightning is a massive DC shock most often leading to asystole as a dysrhythmia.\n5. In lightning injuries, most of the current will travel over the body surface producing flash burns over the body that appears as freckles."
    },
    {
        "document title": "Pediatric Trauma Emergencies",
        "protocol title": "Injury \u2013 Head Injury",
        "overview": "Brain injury and its accompanying pathologic processes continue to be the leading cause of mortality associated with trauma. Whether the injury is due to a blunt or penetrating mechanism, bleeding or swelling of the brain and surrounding tissue may lead to an increase in pressure within the cranial cavity, otherwise known as intracranial pressure, (ICP). If pressure within the skull is not controlled, neurologic changes may produce signs and symptoms ranging from headache to coma with loss of protective reflexes. Blunt force trauma may result in scalp injury, skull fracture, and meningeal and brain tissue injury. Penetrating trauma may produce focal or diffuse injury, depending on the velocity of the penetrating object. Although the pre-hospital provider cannot reverse the brain tissue damage from the initial/primary brain injury that has already occurred, they can play a major role in preventing or limiting the processes that exacerbate and lead to a secondary brain injury. The pre-hospital provider\u2019s goal is to focus on reversing any hypoxia, hypotension, hypercarbia, acidosis, or increasing intracranial pressure.",
        "hpi signs and symptoms": "- Time of injury\n- Mechanism: blunt vs penetrating\n- Loss of consciousness\n- Bleeding\n- Past medical history\n- Medications\n- Evidence of multi-system trauma\n- Pain, swelling, bleeding\n- Altered mental status, unconsciousness\n- Respiratory distress, failure\n- Vomiting\n- Seizure",
        "considerations": "- Major traumatic mechanism of injury\n- Skull fracture\n- Brain injury (concussion, contusion, hemorrhage, or laceration)\n- Epidural hematoma\n- Subdural hematoma\n- Subarachnoid hemorrhage\n- Spinal injury\n- Abuse",
        "procedure": "1. Perform general patient management and baseline GCS.\n2. Support life-threatening problems associated with airway, breathing, and circulation. Obtain mechanism or injury.\n3. Administer oxygen to maintain SpO2 94 - 99%. Consider supporting respirations with a BVM. If signs of hypoventilation are present, ventilate with BVM at an age appropriate rate.\n4. Monitor capnography if BVM or intubated/alternative airway. Attempt to maintain between 35 - 45 mm Hg.\n5. Consider spinal precautions based on MOI. Avoid excessive compression around the neck by cervical collar. Assess and document PMS in all extremities before and after movement.\n6. Place patient on cardiac monitor.\n7. Establish an IV of normal saline, if indicated, to maintain an appropriate systolic BP:\n   a. Birth to 1 month \u2013 60 mmHg\n   b. 1 month to 1 year \u2013 > 70 mmHg\n   c. Greater than 1 year - 70 + [2 x Age (years)]\n8. Obtain a blood glucose sample.\n9. If patient is exhibiting signs of shock, refer to Pediatric Shock protocol.\n10. Transport per Trauma Triage Scheme and perform ongoing assessment as indicated.",
        "pearls": "1. Hyperventilation is not recommended with head-injury patients.\n2. One of the most important indicators of worsening head injury is a change in LOC and/or GCS.\n3. Increased ICP may cause hypertension and bradycardia (Cushing\u2019s response).\n4. Hypotension usually indicates injury or shock unrelated to the head injury and should be treated aggressively.\n5. A decrease of two (2) or more in the patient\u2019s GCS should be considered due to a severe head injury until proven otherwise.\n6. Recognize that \u201cnormal\u201d blood pressure is not as important as \u201cnormal for the patient\u201d when assessing maintenance of adequate cerebral blood flow and adequate cerebral perfusion.",
        "glasgow coma scale modified for pediatric patients": "Eye Opening Response (<1 year)\nSpontaneous: 4\nTo shout: 3\nTo pain: 2\nNone: 1\n\nVerbal Response (0 to 2 years)\nBabbles, coos appropriately: 5\nCries but inconsolably: 4\nPersistent crying or screaming in pain: 3\nGrunts or moans to pain: 2\nNone: 1\n\nMotor Response (<1 year)\nSpontaneous: 6\nLocalizes pain: 5\nWithdraws to pain: 4\nAbnormal flexion to pain (decerebrate): 3\nAbnormal extension to pain (decordicate): 2\nNone: 1"
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Overdose/Poisoning/Toxic Ingestion",
        "overview": "Ingestion and overdose are among the most common pediatric \u201caccidents.\u201d The substance usually is a medication prescribed for family members or for the child. Other commonly ingested poisons include cleaning chemicals, plants, and anything that fits in a child\u2019s mouth. Primary manifestations may be a depressed mental status and/or respiratory and cardiovascular compromise. Contact Medical Control for patient care orders. Contact Poison Control (804-828-1222 or 800-222-1222) for advice. Do not confuse Poison Control with Medical Control.",
        "hpi": "- Use or suspected use of\n  - a potentially toxic\n    substance\n- Substance ingested,\n  - route, and quantity used\n- Time of use\n- Reason (suicidal,\n  - accidental, criminal)\n- Available medications in\n  - home",
        "signs and symptoms": "- Mental status changes\n- Hypotension /\n  - hypertension\n- Hypothermia /\n  - hyperthermia\n- Decreased respiratory\n  - rate\n- Tachycardia, other\n  - dysrhythmias\n- Seizures",
        "considerations": "- Acetaminophen\n  - (Tylenol)\n- Depressants\n- Stimulants\n- Anticholinergic\n- Cardiac medications\n- Solvents, alcohols\n- Cleaning agents\n- Insecticides",
        "procedure": "1. Perform general patient management. *****\n2. Support life-threatening problems associated with airway, breathing, and circulation. *****\n3. Administer oxygen to maintain SpO2 94 - 99%. *****\n4. Establish an IV of normal saline per patient assessment. **\n5. If child is over 20kg and respiratory effort remains diminished and opiate administration is suspected, give NARCAN INTRANASAL 2mg (one vial). May repeat one time. ***\n6. a. If respiratory effort remains diminished and opiate administration is suspected, give NARCAN 0.1mg/kg slow IVP/IM max 2mg (ALS only). ***\n7. Place patient on cardiac monitor and monitor pulse oximetry. **\n8. Transport and perform ongoing assessment as indicated. *****",
        "narcan dosage guide": "Age Pre-Term Term 3 mos. 6 mos. 1 year 3 years 6 years 8 years\n\nWeight (lb / kg) 3.3 lb\n1.5 kg 6.6 lb\n3 kg 13.2 lb\n6 kg 17.6 lb\n8 kg 22 lb\n10 kg 30.8 lb\n14 kg 44 lb\n20 kg 55 lb 25 kg\n\nNarcan IV 0.1 mg / kg 0.15 mg 0.3 mg 0.6 mg 0.8 mg 1.0 mg 1.4 mg 2.0 mg 2.0 mg"
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Diabetic \u2013 Hypoglycemia",
        "overview": "Symptomatic hypoglycemia is defined as a blood glucose level < 60 mg / dL with signs of altered mental status and / or unconsciousness. The many signs and symptoms that are associated with hypoglycemia can be divided into two broad categories: adrenergic and neurologic. The adrenergic stimulation is due to the increased epinephrine levels and the neurologic due to central nervous system dysfunction from the decreased glucose levels.",
        "hpi": "* History of diabetes\n* Onset of symptoms\n* Medications\n* Fever or recent infection\n* Alcohol consumption\n* Last meal",
        "signs and symptoms": "* Anxiety, agitation, and / or confusion\n* Cool, clammy skin\n* Diaphoresis\n* Seizure\n* Decreased visual acuity, blindness\n* Abnormal/ hostile behavior\n* Tachycardia\n* Hypertension\n* Dizziness, headache, weakness",
        "considerations": "* Hypoxia\n* Seizure\n* Stroke\n* Brain trauma\n* Alcohol intoxication\n* Toxin/ substance abuse\n* Medication effect / overdose",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation.\n3. Assess for signs of trauma. Provide spinal immobilization as necessary.\n4. Administer oxygen to maintain SPO2 94 - 99%.\n5. For altered mental status, perform rapid glucose determination.\n6. If glucose < 60 mg / dL or clinical signs and symptoms indicate hypoglycemia:\n    a. If the patient can protect airway, give Oral Glucose 15 grams. Repeat in 15 minutes if necessary.\n7. If glucose < 60 mg / dL or clinical signs and symptoms indicate hypoglycemia and oral glucose is contraindicated: Establish an IV of normal saline at KVO.\n    a. If > 30 days, administer DEXTROSE 10% (5 mL / kg, max dose 100mL ) via IV or IO.\n    b. If < 30 days, administer DEXTROSE 10% (2 mL / kg) via IV or IO.\n    c. If DEXTROSE 10% bag unavailable:\n        * If patient is < 30 days old, administer Dextrose 10% (2cc/kg) IV or IO, mixed as below.\n        * If patient is > 30 days old but < 8 years old, administer Dextrose 25% (2cc/kg) IV or IO, mixed as below.\n        * If patient is > 8 years old, administer Dextrose 50% (0.5mg/kg, max 25gm) IV or IO.\n    d. If unable to establish an IV, alternatively administer GLUCAGON:\n        * Under 20 kg: 0.5 mg IM/IN (ALS only)\n        * >20 kg: 1.0 mg IM/IN (EMT and above) (over 20kg only)\n8. For signs and symptoms of hypovolemic shock or dehydration, follow the Pediatric Shock protocol.\n9. Place on cardiac monitor per patient assessment.\n10. Transport and perform ongoing assessment as indicated.",
        "procedure for making dextrose 25 and 10 percent": "Dextrose 25%: In 50 ml syringe, mix 25 ml of Dextrose 50% with 25 ml Normal Saline. Mixture will yield 50 ml of Dextrose 25%.\nDextrose 10%: In 50 ml syringe, mix 10 ml of Dextrose 50% with 40 ml Normal Saline. Mixture will yield 50 ml of Dextrose 10%.",
        "dosage guide by age and weight": "For preterm infants (weight not specified), glucagon is not indicated; dextrose 10% (bag or diluted at 2 mL/kg) is given as 4.0 mL, while dextrose 10% at 5 mL/kg and dextrose 25% at 2 mL/kg are not applicable. For term infants (6.6 lb/3 kg), give glucagon 0.5 mg, dextrose 10% (bag or diluted at 2 mL/kg) as 6.0 mL, and no dose of dextrose 10% at 5 mL/kg or dextrose 25% at 2 mL/kg. At 3 months (13.2 lb/6 kg), administer glucagon 0.5 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 30.0 mL; dextrose 25% at 2 mL/kg is 12.0 mL (3 g). At 6 months (17.6 lb/8 kg), administer glucagon 0.5 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 40.0 mL; dextrose 25% at 2 mL/kg is 16.0 mL (4 g). At 1 year (22 lb/10 kg), administer glucagon 0.5 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 50.0 mL; dextrose 25% at 2 mL/kg is 20.0 mL (5 g). At 3 years (30.8 lb/14 kg), administer glucagon 0.5 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 70.0 mL; dextrose 25% at 2 mL/kg is 28.0 mL (7 g). At 6 years (44 lb/20 kg), administer glucagon 1.0 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 100 mL; dextrose 25% at 2 mL/kg is 40.0 mL (10 g). Finally, at 8 years (55 lb/25 kg), administer glucagon 1.0 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 100 mL; dextrose 25% at 2 mL/kg is 50.0 mL (12.5 g).",
        "pearls": "1. Hypoglycemia is the most common metabolic problem in neonates.\n2. Use aseptic techniques to draw blood from finger. Allow alcohol to dry completely prior to puncturing finger for blood glucose level. Alcohol may cause inaccurate readings. Do not blow on or fan site to dry faster.\n3. Blood glucose levels should be taken from extremity opposite IV and medication administration for most accurate reading.\n4. After puncturing finger, use only moderate pressure to obtain blood. Excessive pressure may cause rupture of cells causing inaccurate results.\n5. Know your specific agency\u2019s glucometer parameters for a \u201cHI\u201d and \u201cLO\u201d reading.\n6. When administering IV fluids, a minimum amount should be delivered as large amounts may lower blood glucose level and impede original goal of administering Dextrose.\n7. Patients who are consuming aspirin, acetaminophen, anti-psychotic drugs, beta-blockers, oral diabetic medications, or antibiotics such as sulfa-based, tetracycline, and amoxicillin that experience a hypoglycemic episode are at a greater risk for relapse. These patients should be strongly encouraged to accept transport.\n8. An inadequate amount of glucose for heat production, combined with profound diaphoresis, may place a hypoglycemic patient at greater risk for hypothermia. Keep patient warm as needed.\n9. Glucagon causes a breakdown of stored glycogen to glucose. Glucagon may not work if glycogen stores are previously depleted due to liver dysfunction, alcoholism, or malnutrition. Effects of Glucagon may take up to 30 minutes.\n10. Any patient that has had a hypoglycemic episode without a clear reason should be transported for further evaluation."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Hypotension/Shock (Non-trauma)",
        "overview": "Shock is defined as a state of inadequate tissue perfusion. This may result in acidosis, derangements of cellular metabolism, potential end-organ damage, and death. Early in the shock process, patients are able to compensate for decreased perfusion by increased stimulation of the sympathetic nervous system, leading to tachycardia and tachypnea. Later, compensatory mechanisms fail, causing a decreased mental status, hypotension, and death. Early cellular injury may be reversible if definitive therapy is delivered promptly.",
        "hpi": "- Blood loss (vaginal or gastrointestinal)\n- Fluid loss (vomiting, diarrhea)\n- Fever\n- Infection\n- Medications\n- Allergic Reaction\n- Pregnancy, ectopic\n- Trauma\n- Coffee -ground emesis\n- Tarry stools",
        "signs and symptoms": "- Restlessness, confusion\n- Weakness, dizziness\n- Weak, rapid pulse\n- Pale, cool, clammy skin\n- Delayed capillary refill\n- Hypotension",
        "considerations": "- Hypovolemic\n- Cardiogenic\n- Septic\n- Neurogenic\n- Anaphylactic\n- Ectopic pregnancy\n- Dysrhythmia\n- Pulmonary embolus\n- Tension pneumothorax\n- Medication effect / overdose\n- Vaso -vagal\n- Trauma",
        "procedure": "1. Perform general patient management.\n2. Support life -threatening problems associated with airway, breathing, and circulation.\n3. Assess for signs of shock including, but not limited to: Restlessness, altered mental status, hypoperfusion (cool, pale, moist skin), tachypnea (rapid breathing), rapid, weak pulse, orthostatic hypotension (blood pressure suddenly drops on standing up), nausea and thirst.\n4. Administer oxygen to maintain SpO2 94 - 99%. Support respirations as necessary with a BVM.\n5. Transport as soon as possible.\n6. Control external bleeding with direct pressure, then tourniquet if direct pressure is inadequate.\n7. Establish a large bore IV or IO of Normal Saline. If time permits, establish second access. Do not delay transport to establish vascular access\n8. Maintain systolic BP appropriate for patient:\n    - Birth to 1 month - 60 mmHg\n    - 1 month to 1 year - > 70 mmHg\n    - Greater than 1 year - 70 + [2 x Age (years)]\n9. Give a 20 mL / kg bolus. If no improvement after first 20 mL / kg bolus, may repeat once. While administering a fluid bolus, frequently reassess perfusion for improvement. If perfusion improves, slow the IV to KVO and monitor closely. If patient develops fluid overload respiratory distress (dyspnea, crackles, rhonchi, decreasing SpO2), slow the IV to KVO.\n10. Place the patient on the cardiac monitor.\n11. Transport and perform ongoing assessment as indicated.",
        "classes of shock": "Hypovolemic: Caused by hemorrhage, burns, or dehydration.\nDistributive: Maldistribution of blood, caused by poor vasomotor tone in neurogenic shock, sepsis, anaphylaxis, severe hypoxia, or metabolic shock.\nCardiogenic: Caused by necrosis of the myocardial tissue, or by arrhythmias.\nObstructive: Caused by impairment of cardiac filling, found in pulmonary embolism, tension pneumothorax, or cardiac Tamponade.",
        "pearls": "1. GI bleeding may be a less obvious cause of hypovolemic shock if it has been gradual. Ask patient about possible melena, hematemesis, and hematochezia.\n2. Ectopic pregnancy may be a less obvious cause of hypovolemic shock. Consider this diagnosis in all female patients of child-bearing age if there is a complaint of abdominal or pelvic pain."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Altered Mental Status",
        "overview": "Although each of these presentations has unique considerations, prehospital treatment is similar. The unconscious patient is one of the most difficult patient-management problems in pre-hospital care. Causes range from benign problems to potentially life-threatening cardiopulmonary or central nervous system disorders. In the usual clinical approach to a patient, the provider first obtains a history, performs a physical examination, and then administers treatment. However, this sequence must be altered for patients that are unconscious or with an altered level of consciousness. Simple syncope may be the result of a wide variety of medical problems, although the major cause of syncope is a lack of oxygenated blood to the brain. In this situation, it is quickly remedied when the patient collapses, improving circulation to the brain. Altered LOC is such a major variance from normal neurological function that immediate supportive efforts may be required. Efforts should be made to obtain as much of an HPI as possible from family members or bystanders.",
        "hpi signs symptoms considerations": "Cardiac history, stroke, seizures Occult blood loss (GI, ectopic)\nFemales (LMP, vaginal bleeding) Fluid loss (nausea, vomiting, diarrhea)\nPast medical history Recent trauma\nComplaint prior to event Loss of consciousness with recovery\nLightheadedness, dizziness Palpitations, slow or rapid pulse\nPulse irregularity Decreased blood pressure\nVaso-vagal Orthostatic hypotension\nCardiac syncope / dysrhythmia Micturation\nPsychiatric Hypoglycemia\nSeizure Shock\nGI Bleed Ectopic Pregnancy\nToxicological (ETOH) Medication effect (hypertension)",
        "procedure": "1. Perform general patient management.\n2. Maintain patient in a supine position and assess for C -spine precautions.\n3. Administer oxygen to maintain SPO2 94 - 99% \uf0b7\n4. Assess blood glucose level.  Refer to Pediatric Hypoglycemia Protocol.\n5. If child is over 20kg and respiratory effort remains diminished and opiate administration is suspected, give NARCAN INTRANASAL 2mg (one vial). May repeat one time. \n6. Establish IV of Normal Saline. Keep at KVO rate unless hypotensive. If hypotensive, refer to Pediatric Shock protocol.  \n7. Transport and reassess as needed.",
        "narcan dosage guide": "Age Pre-Term Term 3 6 1 3 6 8\nWeight (lb / kg) 3.3 lb1.5 kg 6.6 lb3 kg 13.2 lb6 kg 17.6 lb8 kg 22 lb10 kg 30.8 lb14 kg 44 lb20 kg 55 lb25 kg\nNarcan IV 0.1 mg/kg 0.15 ml 0.3 ml 0.6 ml 0.8 ml 1.0 ml 1.4 ml 2.0 ml 2.0 ml",
        "pearls": "1. Assess for signs and symptoms of trauma if questionable or suspected fall with syncope.\n2. Consider dysrhythmias, GI bleed, ectopic pregnancy, and seizure as possible causes of syncope."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Seizure",
        "overview": "A seizure is a period of altered neurologic function caused by abnormal neuronal electrical discharges. Generalized seizures begin with an abrupt loss of consciousness. If motor activity is present, it symmetrically involves all four extremities. Episodes that develop over minutes to hours are less likely to be seizures; most seizures only last 1 - 2 minutes. Patients with seizure disorders tend to have stereotype, or similar, seizures with each episode and are less likely to have inconsistent or highly variable attacks. True seizures are usually not provoked by emotional stress. Most seizures are followed by a postictal state of lethargy and confusion.",
        "hpi signs symptoms": "Reported, witnessed seizure activity description\n Previous seizure history information\n Medic alert tag\n Seizure medications\n History of trauma\n History of diabetes mellitus\n History of pregnancy\n Decreased mental status\n Sleepiness\n Incontinence\n Observed seizure activity\n Evidence of trauma",
        "considerations": "CNS (head) trauma\n Tumor\n Metabolic, hepatic, renal failure\n Diabetic\n Hypoxia\n Electrolyte abnormality\n Drugs, medications, non-compliance\n Infection, fever, meningitis\n Alcohol withdrawal\n Hyperthermia",
        "procedure": "1.Perform general patient management.\n2.Support life-threatening problems associated with airway, breathing, and circulation.\n2a.Suction the oro - and nasopharynx as necessary.\n2b.Place a nasopharyngeal airway as necessary (avoid in head trauma).\n3.Administer oxygen to maintain SpO2 94 - 99%. Support respirations as necessary with a BVM.\n4.Do not restrain the patient. Let the seizure take its course but protect patient from injury.\n5.If the seizure persists give MIDAZOLAM 0.2 mg / kg INTRANASAL (max single dose 10 mg) \u2013OR- give MIDAZOLAM 0.1 mg / kg IV / IM (max single dose 10 mg)\n5a.Repeat dose in 5 minutes if seizure persists.\n5b.If Midazolam is unavailable, administer, DIAZEPAM 0.25 mg / kg up to 5 mg slow IV push, titrated to effect. Diazepam may also be administered Per Rectum (PR) in pediatric patients.\n 6.Perform rapid glucose determination. If glucose less than 60 mg / dL or clinical signs and symptoms indicate hypoglycemia, refer to the Hypoglycemia protocol\n 7.Establish an IV of normal saline at KVO.\n 8.Place patient on cardiac monitor (sometime life-threatening dysrhythmias can cause seizure-like activity).\n 9.Consider placing the patient in the recovery position during the postictal period.\n10. Transport and perform ongoing assessment as indicated.",
        "generalized seizure types": "Absence (Petit -Mal)\n Atonic (Drop Attack)\n Myoclonic (Brief bilateral jerking)\n Tonic-Clonic (Grand - Mal)",
        "simple partial seizure types": "Focal / Local: Localized twitching of hand, arm, leg, face, or eyes. Patient may be conscious or unconscious",
        "complex partial seizure types": "Temporal Lobe\n Psychomotor",
        "pediatric dosage information table": "Age Pre- Term Term 3 month 6 month 1 year 3 years 6 years 8 years\nWeight (lb / kg) 3.3 lb 1.5 kg 6.6 lb 3 kg 13.2 lb 6 kg 17.6 lb 8 kg 22 lb 10 kg 30.8 lb 14 kg 44 lb 20 kg 55 lb 25 kg\nMidazolam IV 0.15 mg 0.3mg 0.6mg 0.8 mg 0.1mg 1.4mg 2mg 2.5mg\nMidazolam IN *1/2 dose per nostril* 0.3 mg 0.6mg 1.2mg 1.6mg 2mg 2.8mg 4mg 5mg\nDiazepam IV (5.0 mg / ml) 0.3 mg/kg 0.1 ml 0.2 ml 0.4 ml 0.5 ml 0.6 ml 0.84 ml 1.2 ml 1.5 ml\nDiazepam PR (5.0 mg / ml) 0.5 mg / kg 0.15 ml 0.3 ml 0.6 ml 0.8 ml 1.0 ml 1.4 ml 2.0 ml 2.0 ml",
        "pearls": "1. Respirations during an active seizure should be considered ineffective and airway maintenance should occur per assessment.\n2. Status epilepticus is defined as two or more consecutive seizures without a period of consciousness or recovery. This is a true emergency requiring rapid airway support, treatment, and transport.\n3. Grand Mal seizures are generalized in nature and associated with loss of consciousness, incontinence, and possibly tongue trauma.\n4. Focal seizures affect only a specific part of the body and are not usually associated with loss of consciousness.\n5. Jacksonian seizures are seizures, which start as focal in nature and become generalized.\n6. Petit Mal seizures may be localized to a single muscle group or may not involve visible seizure activity all. Always examine pupils for nystagmus, which would alert provider to continued seizure activity.\n7. Be prepared for airway problems and continued seizures.\n8. Investigate possibility of trauma and substance abuse.\n9. Be prepared to assist ventilations as dosages of benzodiazepines are increased."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Diabetic Hyperglycemia",
        "overview:": "- Diabetes mellitus is the most common endocrine disorder of childhood, affecting approximately 2/1,000 school-age children in the United States.\n- Symptomatic hyperglycemia is defined as a blood glucose level > 300 mg/dl with signs of severe dehydration, altered mental status, and/ or shock.\n- Hyperglycemia is usually the result of an inadequate supply of insulin to meet the body's needs.\n- Most pre -hospital care should be focused around the treatment of severe dehydration and support of vital functions.",
        "hpi": "- History of diabetes\n- Onset of symptoms\n- Medications",
        "signs and symptoms": "- Anxiety, agitation, and / or confusion\n- Dry, red, and / or warm skin\n- Fruity / acetone smell on breath\n- Kussmaul respirations\n- Dry mouth, intensive thirst\n- Abnormal/ hostile behavior\n- Tachycardia\n- Dizziness / headache",
        "considerations": "- Hypoxia\n- Brain trauma\n- Alcohol intoxication\n- Toxin / substance abuse\n- Medication effect / overdose",
        "procedure": "1. Perform general patient management.\n2. Support life -threatening problems associated with airway, breathing, and circulation.\n3. Assess for signs of trauma. Provide spinal immobilization as necessary.\n4. Administer oxygen to maintain SPO2 94 - 99%\n5. For altered mental status, perform rapid glucose determination.\n6. If glucose > 300 mg / dL, start an IV of normal saline.\n7. For signs and symptoms of hypovolemic shock or dehydration, follow the Pediatric Shock protocol.\n8. If glucose level is > 300 mg / dL, and no signs of shock are noted, administer maintenance Normal Saline infusion:\n    - 4.0 ml / kg for first 1 - 10 kg of weight.\n    - Add 2.0 ml / kg for next 11 - 20 kg of weight.\n    - Add 1.0 ml / kg, for every kg of weight, > 20 kg.\n    - Multiply total amount x 2= total hourly hyperglycemic maintenance amount.\n9. Place on cardiac monitor and obtain / interpret 12 lead ECG per assessment.\n10. Transport and perform ongoing assessment as indicated.",
        "pearls:": "1. Know your specific agency's glucometer parameters for a \"HI\" and \"LO\" reading.\n2. It is estimated that 2 - 8% of all hospital admissions are for the treatment of DKA, while mortality for DKA is between 2 - 10%. Published mortality rates for HHS vary, but the trend is that the older the patient and higher the osmolarity, the greater the risk of death."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Nausea/Vomiting",
        "overview": "The pre-hospital provider should be very careful to ensure that patients who present with vague complaints such as nausea and vomiting are thoroughly evaluated. The patient\u2019s symptoms and recent history must determine the most appropriate care. Frequently, treatment of an underlying cause and limiting movement may resolve or greatly reduce these complaints. However, persistent nausea and vomiting of unknown etiology may respond well to pharmaceutical therapy. All patients presenting with nausea and vomiting should be screened for potential life-threats initially. Anti-emetic treatment should occur only as a secondary priority.",
        "hpi": "Age\n Time of last meal\n Last bowel movement, emesis\n Improvement, worsening with food or activity\n Duration of signs and symptoms\n Other sick contacts\n Past medical, surgical history\n Medications\n Menstrual history (pregnancy)\n Travel history\n Recent trauma\n Pain\n Character of pain (constant, intermittent, sharp, dull, etc.)",
        "signs and symptoms": "Distention\n Constipation\n Diarrhea\n Anorexia\n Radiation\n Associated symptoms (helpful to localize source)\n Fever, headache, blurred vision, weakness, malaise, myalgias, cough, dysuria, mental status changes, rash",
        "considerations": "CNS (increased pressure, headache, lesions, trauma, hemorrhage, vestibular)\n Drugs (NSAIDs, antibiotics, narcotics, chemotherapy)\n GI or renal disorders\n Gynecological disease (ovarian cyst, PID)\n Infections (pneumonia, influenza)\n Electrolyte abnormalities\n Food or toxin induced\n Medications, substance abuse\n Pregnancy\n Psychologic",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation.\n3. Administer oxygen to maintain SPO\u2082 94 - 99%\n4. Allow the patient to lie in a comfortable position.\n5. Establish an IV of normal saline per patient assessment.\n6. Assess for signs of shock. If shock is suspected, follow the Pediatric Shock protocol.\n7. For severe nausea or vomiting, if available, give ONDANSETRON (ZOFRAN).\n*If only IV formulation is available, administer 0.1 mg / kg IV / IM up to 4 mg over 2 to 5 minutes.*\n8. In lieu of IV ONDANSETRON, may administer 4 mg PO ONDANSETRON OTD tablet for patients over 44 lbs (20 kg).\n9. May repeat Ondansetron PO or IV dosing after 10 minutes, if needed.\n10. Perform ongoing assessment as indicated and transport.",
        "ondansetron dosing table": "Ondansetron IV (0.1 mg/kg) is not specified for term infants (6.6 lb/3 kg) or 6-month-olds (17.6 lb/8 kg). For a 1-year-old (22 lb/10 kg), administer 1.0 mg; for a 3-year-old (30.8 lb/14 kg), 1.5 mg; for a 6-year-old (44 lb/20 kg), 2.0 mg; for an 8-year-old (55 lb/25 kg), 2.5 mg; for a 10-year-old (75 lb/34 kg), 3.5 mg; and for both 12-year-olds (88 lb/40 kg) and 14-year-olds (110 lb/50 kg), 4.0 mg.",
        "pearls": "1. Nausea and vomiting has many subtle, sometimes life-threatening causes. Do not minimize its importance as a symptom.\n2. Ondansetron may not be as effective for vertigo and labyrinthitis related nausea and vomiting.\n3. For nausea and vomiting associated with dehydration, fluid replenishment may be sufficient in improving patient comfort and reduce the need for medication administration.\n4. Ensuring that you have reasonably addressed possible causes, will help minimize the potential that you are overlooking a life-threat and/or concern that should receive priority over anti-emetic treatment.\n5. In cases of toxic ingestion, including alcohol, poisons, and drug overdoses, vomiting is an internal protective mechanism and should not be prevented with pharmacological therapy in the pre-hospital environment. Care should be given to prevent aspiration.\n6. Ondansetron is also safe and effective for nausea and vomiting in trauma patients and can be used in conjunction with pain management.\n7. Proper documentation should include the mental status and vital signs before and after medication administration."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "General \u2013 Fever",
        "overview": "Fever is a common chief complaint of children encountered in the pre-hospital environment. Patients with fever present in many different ways, depending on the age of the patient, the rate of rise of the temperature, the magnitude of the fever, the etiology of the fever, and the underlying health of the patient. The patient\u2019s skin will be warm to the touch and may be flushed on observation. The patient may also complain of being warm and perspiring. It is important to recognize that fever represents a symptom of an underlying illness, and the actual illness must be determined and treated. Flu-like symptoms may accompany fevers, but it should not be assumed that fevers with these symptoms are minor, as there may be a serious underlying medical condition. Febrile seizures usually are self-limiting and typically occur once from a rapid rise in temperature, usually above 101.8 \uf0b0F / 38.7\uf0b0C. If more than one seizure occurs, causes other than fever should be suspected. The first occurrence of a seizure warrants the most concern because the benign nature of the illness has not been established.",
        "hpi": "- Age\n- Duration of fever\n- Severity of fever\n- Any previous decrease or elevation of fever since onset\n- Past medical history\n- Medications\n- Immunocompromised (transplant, HIV, diabetes, cancer)\n- Recent illness or socialization with others with illness\n- Vaccinations\n- Poor PO intake\n- Urine production, decrease in diapers\n- Last acetaminophen dose",
        "signs and symptoms": "- Altered mental status\n- Unconsciousness\n- Hot, dry, or flushed skin\n- Tachycardia\n- Hypotension, shock\n- Seizures\n- Nausea, vomiting\n- Weakness, dizziness, syncope\n- Restlessness\n- Loss of appetite\n- Decreased urine output\n- Rapid, shallow respirations\n- Associated symptoms (helpful in localizing source): myalgias, cough, chest pain, headache, dysuria, abdominal pain, mental status changes, rash",
        "considerations": "- Infection, sepsis\n- Neoplasms, cancer, tumors, lymphomas\n- Medication or drug reaction\n- Connective tissue disease\n- Vasculitis\n- Thermoregulatory disorder\n- Hyperthyroid\n- Heat stroke\n- Drug fever",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation.\n3. Administer oxygen to maintain SPO2 94 - 99%\n4. If the patient is having a seizure, refer to the Pediatric Seizure protocol.\n5. If temperature is greater than 106 \uf0b0 F / 41\uf0b0C, refer to Hyperthermia Patient Care Protocol.\n6. Begin passive cooling by removing excess and constrictive clothing. Avoid overexposure.\n7. Obtain blood glucose sample. If glucose is < 60 mg / dL or > 300 mg / dL, refer to Pediatric Hypoglycemia or Hyperglycemia Patient Care Protocol.\n8. Establish an IV of normal saline at KVO. Titrate to a systolic pressure appropriate for child:\n- Birth to 1 month - 60 mmHg\n- 1 month to 1 year - > 70 mmHg\n- Greater than 1 year - 70 + [2 x Age (years)]\n9. If hypoperfusion is suspected, refer to the Pediatric Shock protocol.\n10. Perform ongoing assessment as indicated and transport promptly.",
        "pearls": "1. Fevers with rashes are abnormal and should be considered very serious.\n2. Fevers in infants \u2264 3 months old should be considered very serious.\n3. Patient may seize if temperature change is rapid, be cautious and prepared to manage both seizure activity and airway at all times.\n4. If fever is present with hypotension, it may indicate the patient is in septic shock.\n5. Febrile seizures are more likely in children with a history of febrile seizures.\n6. It is important to know if an elevation in temperature signals the abrupt onset of a fever or represents the gradual worsening of a long-term fever.\n7. Cooling in the pre-hospital environment with water, alcohol, or ice is discouraged.\n8. Fevers in children of 104 \uf0b0F / 40\uf0b0C for greater than 24 hours should be considered serious.\n9. A common error in the treatment of fever is to wrap the patient in multiple layers of clothing and blankets. This only contributes to the rise in temperature."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "General \u2013 Universal Patient Care/Initial Patient Contact",
        "overview": "Few encounters cause greater anxiety for medical providers than a pediatric patient experiencing a life-threatening situation. Although pediatric calls only account for approximately 10% of all EMS calls, they can be among the most stressful. Pre-hospital providers need to be prepared to face these challenges, as prompt recognition and treatment of potentially life-threatening diseases in children in the field may have a significant impact on the outcome of the patient. Of the 10% of EMS calls that involve pediatric patients, fewer than 5% are for life- or limb-threatening situations. When EMS does respond to a pediatric call, treatment such as administering oxygen, starting an IV, or performing endotracheal intubation can be involved in more than 50% of the cases.",
        "primary assessment": "Approach to the pediatric patient varies with the patient's age and the nature of illness or injury. It is critical that EMS providers be cognizant of the emotional and physiological needs of a child throughout the assessment. It is equally important to identify the needs of the child's family members. In this stressful environment, family members will be trying to find the cause of injury or illness in their child and may be unruly when the answers they seek are not available or are contrary to what is expected. The key to pediatric assessment in EMS is to identify and manage immediate life threats. It is often easy to determine whether a child is sick just by looking at him. Sick kids look sick. If a child is active, appropriate and alert, he is not sick. The opposite is true as well. If a child is inactive and non-interactive, assume he is sick until proven otherwise. The most widely accepted approach to forming a general impression in a child is using the Pediatric Assessment Triangle. This tool is especially useful because the assessment criteria are determined during the general impression. This assessment can be performed from across the room, before contact with the patient is ever made.",
        "airway": "The patient\u2019s airway should be assessed to determine whether it is patent, maintainable, or not maintainable. For any patient who may have a traumatic injury, cervical spine precautions should be utilized while the airway is evaluated. Assessment of the patient\u2019s level of consciousness, in conjunction with assessment of the airway, provides an impression of the effectiveness of the patient\u2019s current airway status. If an airway problem is identified, the appropriate intervention should be initiated. The decision to use a particular intervention depends on the nature of the patient\u2019s problem and the potential for complications during transport. Specific equipment, such as a pulse oximetry or capnography, help provide continuous airway evaluation during transport. In addition, it is important to also be able to identify differences between adult and pediatric anatomy and physiology. The anatomical and physiologic variations between adults and children can cause confusion if the EMS provider does not fully understand these differences",
        "summary of primary airway assessment": "Airway: Patent, maintainable, un-maintainable\nLevel of consciousness\nSkin appearance: Ashen, pale, gray, cyanotic, or mottled\nPreferred posture to maintain airway\nAirway clearance\nSounds of obstruction",
        "differences in the pediatric airway": "Larger tongue in relation to free space in oropharynx.\nTrachea is more pliable and smaller in diameter with immature tracheal rings\nEpiglottis is large and is more u-shaped or oblong\nLarynx is at the level of the 1st or 2nd vertebrae\nMain stem bronchi has less angle",
        "breathing": "The assessment of ventilation begins with noting whether the patient is breathing. Patients presenting with apnea or severe respiratory distress, require immediate intervention. If the patient has any difficulty with ventilation, the problem must be identified and the appropriate intervention initiated. Emergent interventions may include manual ventilation of the patient via bag valve mask, endotracheal intubation, and / or needle thoracentesis.\nNormal respirations in an infant can be irregular and, as a result, respiratory rates should be assessed over a minimum of 30 seconds, but ideally 60 seconds. The variability of respiration in infants may not produce an accurate rate when only observed for 15 seconds. It is important to note that the variable rate of respiration in infants may include cessation in breathing for up to 20 seconds. Anything greater than 20 seconds should be considered abnormal and will require intervention.",
        "summary of primary breathing assessment": "Rate and depth of respirations\nCyanosis\nWork of breathing\nUse of accessory muscles\nFlaring of nostrils\nPresence of bilateral breath sounds\nPresence of adventitious breath sounds\nAsymmetric chest movements\nOxygen saturation measured with pulse oximetry",
        "circulation": "Palpation of both the peripheral and the central pulse provides information about the patient\u2019s circulatory status. The quality, location, and rate of the patient\u2019s pulses should be noted along with the temperature of the patient\u2019s skin being assessed while obtaining the pulses. Observation of the patient\u2019s level of consciousness may also help evaluate the patient\u2019s perfusion status initially.\nAlthough the pediatric and adult hearts share identical anatomy, several important distinctions need to be made between the adult and pediatric cardiovascular systems. First, the adult heart increases its stroke volume by increasing inotropy (strengthening contractions) and chronotropy (increasing heart rate). In contrast, the pediatric heart can only increase chronotropy in an attempt to increase stroke volume. The pediatric heart has low compliance as it relates to volume; therefore, it cannot compensate well by increasing stroke volume. Consequently, heart rate should be seen as a significant clinical marker when monitoring cardiac output in the fetus, neonate and pediatric patient. When the pediatric patient becomes bradycardic, it should be assumed that cardiac output has been drastically reduced. Bradycardia is most commonly caused by hypoxia. Bradycardia may be an early sign of hypoxia in the neonate; however, it is an ominous sign of severe hypoxia in the infant and child.\nCapillary refill time is typically quite accurate in children and considered to be reliable in most cases. Just as in the adult patient, environmental factors like cold ambient temperatures can influence capillary refill times and should be taken into consideration. For this reason, capillary refill time should be assessed closer to the core in areas like the kneecap or forearm. Normal capillary refill time is less than two to three seconds.",
        "summary of primary circulation assessment": "Pulse rate and quality\nSkin appearance: Color\nPeripheral pulses\nSkin temperature\nLevel of consciousness\nUrinary output\nBlood Pressure\nCardiac monitor\nInvasive monitor",
        "disability": "The basic, primary neurological assessment includes assessment of the level of consciousness, the size, shape, and response of the pupils, and motor sensory function. This simple method shows if AVPU should be used to evaluate the patient\u2019s overall level of consciousness. The Glasgow Coma Scale (GCS) provides assessment of the patient\u2019s level of consciousness and motor function and may serve as a predictor of morbidity and mortality after brain injury. If the patient has an altered mental status, it must be determined whether the patient has ingested any toxic substances, such as alcohol or other drugs, or may be hypoxic because of illness or injury. A patient with an altered mental status may pose a safety problem during transport. Use of chemical sedation or physical restraint may be necessary to ensure safe transport of the patient and EMS providers",
        "summary of primary disability (neurological) assessment": "A - Alert, V - Responds to verbal stimuli, P - Responds to painful stimuli, U - Unresponsive",
        "glasgow coma scale (gcs)": "For infants under one year, the Glasgow Coma Scale scores are as follows: Eye Opening\u2014Spontaneous (4), To voice (3), To pain (2), No response (1); Verbal Response\u2014Coos, babbles (5), Irritable cry, consolable (4), Cries persistently to pain (3), Moans to pain (2), No response (1); Motor Response\u2014Spontaneous (6), Withdraws to touch (5), Withdraws to pain (4), Decorticate flexion (3), Decerebrate extension (2), No response (1). For children aged 1\u20134 years, the scores are: Eye Opening\u2014Spontaneous (4), To voice (3), To pain (2), No response (1); Verbal Response\u2014Speaks and interacts socially (5), Confused speech but consolable (4), Inappropriate and inconsolable (3), Incomprehensible and agitated (2), No response (1); Motor Response\u2014Spontaneous (6), Localizes pain (5), Withdraws to pain (4), Decorticate flexion (3), Decerebrate extension (2), No response (1).",
        "exposure": "As much of the patient\u2019s body as possible should exposed for examination, depending on complaint, with the effects of the environment on the patient kept in mind. Discovery of hidden problems before the patient is loaded for transport may allow time to intervene and avoid disastrous complications. Although exposure for examination is emphasized most frequently in care of the trauma patient, it is equally important in the primary assessment of the patient with a medical illness.\nThe pre-hospital provider should always look under dressings or clothing, which may hide complications or potential problems. Clothing may hide bleeding that occurs as a result of thrombolytic therapy or rashes that may indicate potentially contagious conditions. In inter-facility transport, intravenous access can be wrongly assumed underneath a bulky cover. Once patient assessment has been completed, keep in mind that the patient must be kept warm. Hypothermia can cause cardiac arrhythmias, increased stress response, and hypoxia.",
        "summary of primary exposure assessment": "Identification of injury, active bleeding, or indication of a serious illness.\nAppropriate tube placement: o Endotracheal tubes, o Chest tubes, feeding tubes, o Naso-gastric or oro-gastric tubes, and urinary catheters.\nIntravenous access: o Peripheral o Central o Intraosseous",
        "secondary focused assessment": "The secondary assessment is performed after the primary assessment is completed and involves evaluation of the patient from head to toe. Illness specific information is collected by means of inspection, palpation, and auscultation during the secondary assessment. Whether the patient has had an injury or is critically ill, the pre-hospital provider should observe, and listen to the patient. The secondary assessment begins with an evaluation of the patient\u2019s general appearance. The pre-hospital provider should observe the surrounding environment and evaluate its effects on the patient. Is the patient aware of the environment? Is there appropriate interaction between the patient and the environment? Determination of the amount of pain the patient has as a result of illness or injury is also an important component of the patient assessment. Baseline information should be obtained about the pain the patient has so that the effectiveness of interventions can be assessed during transport. Pain relief is one of the most important interventions for prehospital patient care providers."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Respiratory Distress/Asthma/COPD/Croup/Reactive Airway RESPIRATORY DISTRESS/ASTHMA",
        "overview": "Respiratory distress is characterized by a clinically recognizable increase in work of breathing while respiratory failure is characterized by ineffective respirations with a decreased level of consciousness. Acute respiratory emergencies in the pediatric patient are common. When not properly treated, respiratory distress can result in significant morbidity and mortality. One of the common causes of respiratory distress is asthma. The treatment of patients in severe asthmaticus must be prompt and efficient. Decisive intervention is mandatory to insure the best outcome. Appearance of the child reflects the adequacy of oxygenation and ventilation. An increased effort to breathe may indicate an airway obstruction or lack of oxygenation. Decreased breathing effort may indicate impending respiratory failure.",
        "hpi": "* Time of onset\n* Possibility of foreign body\n* Medical history\n* Medications\n* Fever or respiratory infection\n* Other sick siblings\n* History of trauma",
        "signs and symptoms": "* Wheezing or stridor\n* Respiratory retractions\n* See-saw respirations\n* Diaphoresis\n* Tripod position\n* Increased heart rate\n* Altered LOC\n* Anxious appearance",
        "considerations": "* Asthma\n* Aspiration\n* Foreign body\n* Infection\n* Pneumonia, croup, epiglottitis\n* Congenital heart disease\n* Medication or toxin\n* Trauma",
        "procedure": "1. Perform general patient management.\n2. Support life -threatening problems associated with airway, breathing, and circulation.\n3. Administer oxygen to maintain SPO2 94 - 99%. Support respirations as necessary with a BVM.\n4. Place patient in a position of comfort, typically sitting upright.\n5. If stridor present and croup is suspected, refer to Croup & Epiglottitis Protocol 9-11\n6. Monitor Capnography , if available.\n7. Assist patient with prescribed METERED DOSE INHALER (MDI). If no dosing schedule is prescribed, repeat in 5 to 10 minutes as needed.\n8. If in critical respiratory distress, provide BVM ventilation with patient\u2019s spontaneous efforts. If patient becomes unresponsive, perform BVM ventilation with an airway adjunct. If BVM ventilation is inadequate, secure airway with a n alternative airway or endotracheal tube [P only].\n  For patients in respiratory distress:\n9. Give ALBUTEROL via nebulizer :\n   Pt. <10kg : use 2.5 mg\n   Pt > 10kg: use 5.0 mg and IPRATROPIUM 0.5 mg via small volume nebulizer.\n   a. Greater than or equal to 4 years of age \u2013 nebulizer with mouthpiece or facemask.\n   b. Repeat ALBUTEROL every 10 minutes up to 4 treatments if respiratory distress persists and no contraindications develop. Note: IPRATROPIUM bromide is only administered with the 1st treatment.\n10. Start an IV of normal saline.\n11. If greater than 2 years of age and wheezing present, administer DEXAMETHASONE 0.6mg/kg IV/IM/PO to max of 10 mg.\n12. Administer CPAP with 5 - 10 cm H20 PEEP for moderate to severe dyspnea.\n13. In the asthmatic patient, for severe respiratory distress that is non -responsive to standard medications, consider administration of MAGNESIUM SULFATE 40 mg / kg IV over 20 minutes (max dose of 2 grams).\n14. In the asthmatic patient, for severe respiratory distress that is non -responsive to standard medications, consult Medical Control to consider administration of EPINEPHRINE 1:1,000 0.01 mg / kg up to 0.3 mg IM.\n15. Place on cardiac monitor and obtain 12 lead ECG per assessment.\n16. Transport and perform ongoing assessment as indicated.",
        "pearls": "1. The most important component of respiratory distress is airway control.\n2. Any pediatric patient presenting with substernal and intercostal retractions is in immediate need of treatment and transport. Do not delay on scene with treatments that can be completed enroute.\n3. Intramuscular epinephrine administration assists with bronchodilation throughout lung tissue. In children < 8 years of age, it should be administered in the lateral thigh for optimal drug delivery. In children > 8 years of age, the deltoid can be used.\n4. With repeated nebulized treatments, patients will become tachycardic. Benefits of further treatments should be weighed against the risks of tachycardia. Don\u2019t hesitate to call medical control for concerns or questions.\n5. Dexamethasone can be diluted with a small amount of juice (3-5mL) when administered orally."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Airway \u2013 Obstruction/Foreign Body",
        "overview": "Airway obstruction is one of the most readily treatable yet immediately life-threatening emergencies faced by pre-hospital providers. Approximately 3000 deaths occur each year in the United States from choking. Most of these deaths are in children younger than four years of age. In children, you should consider the possibility of foreign body aspiration in any patient who presents with ongoing respiratory distress or resolved respiratory distress. The child may have a history of a sudden onset of respiratory distress with choking and cough, by an absence of symptoms and then followed by delayed stridor or wheezing. This cycle occurs when the foreign body is not cleared from the airway but passes distally into the smaller airways. In children, a foreign body may also lodge in the esophagus, causing stridor. Patients may present with any degree of obstruction from simple hoarseness cleared with a cough to complete obstruction requiring a surgical airway, such as a cricothyrotomy. Significant airway obstruction can occur at any time. Early recognition and treatment is essential to a successful outcome. Because of this, it is important to distinguish this problem from more serious conditions that cause sudden respiratory failure, but are treated differently.",
        "hpi": "* Age\n* What was happening at onset? (Missing Toys?)\n* Past medical / surgical history\n* Medications",
        "signs and symptoms": "* Fever\n* Traumatic mechanism\n* Improvement or worsening with movement\n* Stridor, hoarseness, wheezing\n* Ineffective respirations\n* Universal sign of choking\n* Tachycardia\n* Tachypnea\n* Flushing, cyanosis, chills, diaphoresis\n* Presence of drooling, trismus, angio-neurotic edema",
        "considerations": "* Croup\n* Epiglottitis\n* Angio-neurotic edema\n* Traumatic obstruction\n* Chemical or thermal injury\n* Abscesses\n* Tumors and cysts",
        "fbao conscious patient gte 1 year of age": "1.For the suspected conscious choking victim, quickly\nask, \u201cAre you choking?\u201d If the victim indicates \u201cyes\u201d\nby nodding his head without speaking, this will verify\nthat the victim has severe airway obstruction.\n2.Apply abdominal thrusts (Heimlich maneuver) in rapid\nsequence until the obstruction is relieved. \na.Note: If the patient has a mild obstruction and\nis coughing forcefully ; do not interfere with the\npatient\u2019s spontaneous coughing / breathing\neffort. \n3.If the patient becomes unresponsive, carefully\nsupport the patient to the ground and follow the\nFBAO \u2013 UNCONSCIOUS PATIENT GREATER\nTHAN OR EQUAL TO 1 YEAR OF AGE protocol.\n4.Transport and perform ongoing assessment.",
        "fbao conscious patient lte 1 year of age": "1.Assess the patient to determine the extent of the\nobstruction. When the airway obstruction is mild, the\ninfant can cough and make some sounds. When the\nairway obstruction is severe, the infant cannot cough\nor make any sound.\n2.If FBAO is mild, do not interfere. Allow the victim to\nclear the airway by coughing while you observe for\nsigns of severe FBAO.\n3.If the FBAO is severe (i.e., the victim is unable to\nmake a sound), deliver 5 back blows (slaps) followed\nby 5 chest thrusts.\n4.If the patient becomes unresponsive, follow the\nFBAO \u2013 UNCONSCIOUS PATIENT LESS THAN 1\nYEAR OF AGE protocol.\n5.Transport and perform ongoing assessment.",
        "fbao unconscious patient gte 1 year of age": "1.If the patient was previously conscious with an airway\nobstruction, carefully support the patient to the\nground.\n2.Use head -tilt, chin lift or jaw thrust (suspected\ntrauma) to open airway. Look for an object in the\npatient\u2019s mouth. Use a finger sweep only when you\ncan see solid material obstructing the airway.\n3.Assess the patient\u2019s breathing.\n4.If respirations are absent, deliver 2 breaths. If chest\nrise is not detected, reposition the airway, make a\nbetter mask seal and try again.\n5.If unable to deliver rescue breaths, start CPR.\n6.Each time the airway is opened during CPR, look for\nan object and remove if found with a finger sweep. \n7.If the FBAO is not relieved by BLS maneuvers,\nattempt direct visualization of the airway via\nlaryngoscopy. If the obstruction is visualized, use\nforceps to remove the obstruction.\n8.If the FBAO is not relieved by BLS maneuvers or\nlaryngoscopy, perform a cricothyrotomy . For children\nyounger than 12, a needle cricothyrotomy with\npercutaneous transtracheal (jet) ventilation is the\nsurgical airway of choice.\n9.Transport and perform ongoing assessment.",
        "fbao unconscious patient lte 1 year of age": "1.If the patient was previously conscious with an airway\nobstruction, carefully position the patient for CPR.\n2.Use head -tilt, chin lift or jaw thrust (suspected\ntrauma) to open airway. Look for an object in the\npatient\u2019s mouth. Use a finger sweep only when you\ncan see solid material obstructing the airway.\n3.Assess the patient\u2019s breathing. \n4.If respirations are absent, deliver 2 breaths. If chest\nrise and fall is not detected, reposition the airway,\nmake a better mask seal and try again.\n5.If unable to deliver rescue breaths, start CPR. \n6.Each time the airway is opened during CPR, look for\nan object and remove if found with a finger sweep.\n7.If the FBAO is not relieved by BLS maneuvers,\nattempt direct visualization of the airway via\nlaryngoscopy If the obstruction is visualized, use\nforceps to remove the obstruction.\n8.Transport and perform ongoing assessment.",
        "fbao pearls": "1. Abnormal auscultative sounds are more inspiratory if the foreign body is in the extra-thoracic\ntrachea. If the object is in the intra-thoracic\ntrachea, noises will be symmetric but sound more\nprominent in the central airways. The sounds are a\ncoarse wheeze (sometimes referred to as an inspiratory\nstridor) heard with the same intensity over the entire chest.\n2. Once the foreign body passes the carina, the breath sounds are usually\nasymmetric. However, remember that the chest of\nyounger patients transmits sound well, and the\nstethoscope head is often bigger than the lobes being\nauscultated. A lack of asymmetry should not dissuade\nthe provider from considering the diagnosis."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Allergic Reaction/Anaphylaxis",
        "overview": "Acute respiratory emergencies in the pediatric patient are common. When not properly treated, respiratory distress can result in significant morbidity and mortality. Anaphylaxis in children commonly results from insect stings and, less frequently, from food or medications. Signs of shock as well as upper and lower airway obstruction are frequently present. If the reaction involves the respiratory system, signs similar to severe asthma may be present (cyanosis, wheezing, and respiratory arrest). Patients with allergic reactions frequently have local or generalized swelling while anaphylaxis can be characterized by wheezing, airway compromise, and/or hypotension.",
        "hpi": "* Onset and location\n* Insect sting or bite\n* Food allergy / exposure\n* New clothing, soap, detergent\n* Past history of reactions\n* Medication history",
        "signs and symptoms": "* Itching or hives\n* Coughing / wheezing or respiratory distress\n* Chest or throat constriction\n* Difficulty swallowing\n* Hypotension or shock\n* Edema",
        "considerations": "* Urticaria (rash only)\n* Anaphylaxis (systemic effect)\n* Shock (vascular effect)\n* Angioedema (drug induced)\n* Aspiration / airway obstruction\n* Vaso -vagal event\n* Asthma",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation.\n3. Administer oxygen to maintain SPO2 94 - 99%\n4. Administer DIPHENHYDRAMINE 1 mg / kg up to 50 mg IM or IV. The IV route is preferred for the patient in severe shock. If an IV cannot be readily established, give diphenhydramine via the IM route.\n5. If the patient is experiencing respiratory distress with wheezing, refer to the Respiratory Distress protocol.\n6. Transport as soon as possible.\n7. For severe symptoms such as airway compromise, severe respiratory distress, or hypotension:\n   a. If available, administer epinephrine via an epinephrine autoinjector.\n   b. If epinephrine autoinjector is unavailable; give EPINEPHRINE 1:1,000 0.01 mg / kg up to 0.3 mg IM. Call Medical Control if no improvement.\n8. Establish an IV of normal saline at KVO. Titrate to a systolic pressure appropriate for child:\n   a. Birth to 1 month - 60 mmHg\n   b. 1 month to 1 year - > 70 mmHg\n   c. Greater than 1 year \u2013 70 + [2 x Age (years)]\n9. If hypoperfusion persists following the first dose of epinephrine, consider administration of 20mL/kg normal saline IV. While administering a fluid bolus, frequently reassess perfusion for improvement. If perfusion improves, slow the IV to KVO and monitor closely. If patient develops fluid overload respiratory distress (dyspnea, crackles, rhonchi, decreasing SpO2), slow the IV to KVO.\n10. Transport and perform ongoing assessment as indicated.",
        "epinephrine and diphenhydramine dosage": "Epinephrine is supplied as a 1:1,000 solution (1 mg/mL), dosed at 0.01 mg/kg, and diphenhydramine is dosed at 1 mg/kg. For a term infant weighing 6.6 lb (3 kg), the epinephrine dose is 0.03 mg and the diphenhydramine dose is 3.0 mg. At 6 months (17 lb/8 kg), the epinephrine dose is 0.08 mg and the diphenhydramine dose is 8.0 mg. At 1 year (22 lb/10 kg), the epinephrine dose is 0.1 mg and the diphenhydramine dose is 10.0 mg. At 3 years (30 lb/14 kg), the epinephrine dose is 0.14 mg and the diphenhydramine dose is 14.0 mg. At 6 years (44 lb/20 kg), the epinephrine dose is 0.2 mg and the diphenhydramine dose is 20.0 mg. At 8 years (55 lb/25 kg), the epinephrine dose is 0.25 mg and the diphenhydramine dose is 25.0 mg. At 10 years (75 lb/34 kg), the epinephrine dose is 0.3 mg and the diphenhydramine dose is 34.0 mg. At 12 years (88 lb/40 kg), the epinephrine dose remains 0.3 mg with diphenhydramine at 40.0 mg, and by 14 years (110 lb/50 kg), the epinephrine dose is still 0.3 mg while diphenhydramine is 50.0 mg.",
        "pearls": "1. The most important component of respiratory distress is airway control.\n2. Any pediatric patient presenting with substernal and intercostal retractions is in immediate need of treatment and transport. Do not delay transport with treatments that can be completed en route.\n3. Avoid intravenous initiation or medication administration into same extremity as bite or allergen site."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Respiratory Distress/Asthma/COPD/Croup/Reactive Airway (Respiratory Distress \u2013 Croup/Epiglottitis)",
        "overview": "Croup (or laryngotracheobronchitis) is an acute viral infection of the upper airway, leading to swelling and the classical symptoms of a \"barking\" cough, stridor, and hoarseness. It may produce mild, moderate, or severe symptoms, which often worsen at night. It is often treated with a single dose of oral steroids; occasionally nebulized epinephrine is used in more severe cases. Epiglottitis is swelling of the epiglottis, which leads to breathing problems. Swelling of the epiglottis is usually caused by the bacteria Haemophilus influenza (H. influenza), although it may be caused by other bacteria or viruses. Upper respiratory infections can lead to epiglottitis. Medicines or diseases that weaken the immune system can make adults more prone to epiglottitis. Epiglottitis is most common in children between 2 and 6 years old. Respiratory Syncytial Virus (RSV) is a very common virus that leads to mild, cold-like symptoms in adults and older healthy children. It can be more serious in young babies, especially to those in certain high-risk groups. RSV is the most common germ that causes lung and airway infections in infants and young children. Most infants have had this infection by two years of age. Outbreaks of RSV infections typically begin in the fall and run into the spring.",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation.\n3. Administer oxygen to maintain SPO2 94 - 99%. Support respirations as necessary with a BVM.\n4. Place patient in a position of comfort, typically sitting upright.\n5. Obtain 12 lead ECG per assessment. a. Place on cardiac monitor and interpret\n6. If barking cough is present and croup is suspected, and age >1 year, administer Dexmethasone 0.6mg/kg IV/IM/PO to max of 10 mg.\n7. For resting stridor or respiratory distress in age >1 year, administration nebulized RACEMIC EPINEPHRINE (2.25%) 0.5mL AND 3mL of Normal Saline via nebulizer.\n8. Transport in position of comfort."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "General \u2013 Pain Control",
        "overview": "The practice of pre- hospital emergency medicine requires expertise in a wide variety of pharmacological and non- pharmacological techniques to treat acute pain resulting from a myriad of injuries and illness. One of the most essential missions for all healthcar e pr oviders should be the relief and /or prevention of pain and suffering.  Approaches to pain relief must be designed to be safe and effective in the organized chaos o f the pre-hospital environment.  The degree of pain and the hemodynamic status of the patient will determine the rapidity of care.",
        "hpi assessment points": "- Age\n- Location\n- Duration\n- Severity (1 -10)\n- Past medical history\n- Medications\n- Drug allergies",
        "signs and symptoms assessment points": "- Severity (pain scale)\n- Quality (sharp, dull, etc)\n- Radiation\n- Relation to movement,respiration\n- Increased wit h pal pation of area",
        "pain source considerations": "- Musculoskeletal\n- Visceral (abdominal)\n- Cardiac\n- Pleural, respiratory\n- Neurogenic\n- Renal (colic)",
        "procedure": "1. Perform general patient management.\n2. Administer oxygen to maintain SPO 2 94 -99%.\n3. Determine and document patient\u2019s pai n score assessment.\n4. Place patient on cardiac monitor per patient assessment.\n5. Establish IV of normal saline per patient assessment.\n6. Determine if pain is acute or chronic (3 weeks or more). If chronic, attempt to identify cause (cancer/palliative care).\n7. If pain is mild, moderate, or chronic (cancer/palliative care excluded), consider use of non- opioid treatment. If age > 10 yrs, may alternatively consider one of the following, if available :\n    - Nitronox (via patient administered dosing system)\n    - Acetaminophen 10 -15 mg/kg PO\n    - Nonsteroidal such as ibuprofen 4-10 mg/kg PO (avoid in pts with open fractures or suspected hip/femur fractures)\n    ***OMD Option***\n    ***OMD Option***\n    ***OMD Option***\n    ***OMD Option***\n8. If NO nonsteroidal administered, for mild, moderate, or chronic pain (cancer/palliative care excluded), consider TORADOL 15 mg IV or 30 mg IM. Avoid use i f age less than 10 years or patients with history of renal disease.\n9. A. If significant pain, administer FENTANYL 2mcg/kg INTRANASAL (max first dose of 100 mcg) half dose in each nostril. May consider additional dose of up to 100mcg after 5 minutes if pain persists \u2013 OR-FENTANYL 1 mcg / kg IV, or IM (max single dose of 100 mcg).\n   B. FOR I/P LEVEL ONLY If significant pain, administer KETAMINE 0.1mg/kg IV/IM/IN up to max single dose of 15mg, with a maximum of 2 doses. If any additional doses are needed, contact medical control. Contact Medical Control for any patients under 2 years old or under 25kg.\n10. If Fentanyl or Ketamine are unavailable, administer MORPHINE SULFATE 0.1 mg / kg IV or IM (max single dose of 5.0 mg). Sickle cell patients may be given higher doses up to 10 mg IV or IM.\n11. Repeat the patient\u2019s pain score assessment.\n12. If indicated based on pain assessment, repeat pain medication administrati on after 10 minutes of the previous dose. Maximum total dose of Fentanyl is 200 mcg and Morphine Sulf ate is 20 mg for non-sickle cell patients. Sickle ce ll patients may have up to a total of 400 mcg of Fentanyl or 40mg of Morphi ne Sulfate. Maximum total dose of Ketamine is 30 mg.\n13. Transport in position of comfort and reassess as indicated.",
        "universal pain assessment tool details": "Verbal Descriptor Scale\n- No pain\n- Mild pain\n- Moderate pain\n- Severe pain\n- Very severe pain\n- Excruciating pain\n\nWong - Baker Scale\n- Alert\n- SmilingNo humor\n- Serious, flat\n- Furrowed brow\n- Pursed lips\n- Breath holding\n- Wrinkled nose\n- Raised upper lip\n- Rapid breathing\n- Slow blink\n- Open mouth\n- Eyes closed\n- Moaning\n- Crying\n\nActivity Tolerance Scale\n- No pain\n- Can be ignored\n- Interferes with tasks\n- Interferes with concentration\n- Interferes with basic needs\n- Bed rest required\n\nSpanish\n- Nada de dolor\n- Un poquito de dolor\n- Un dolor leve\n- Dolor fuerte\n- Dolor demasiado fuerte\n- Un dolor insoportable\n\nChart Courtesy of Richmond Ambulance Authority",
        "medication dosage guidelines chart": "Age  Term  Weight (lb / kg)  Fentanyl IM  Fentanyl IN  Morphine Sulfate  Toradol  Ketamine\n- 6 month 6.6 lb 3 kg 3mcg 6mcg N/A N/A N/A\n- 1 year 17.6 lb 8 kg 8mcg 16 mcg N/A N/A N/A\n- 3 years 22 lb 10 kg 10mcg 20 mcg 1.0 mg N/A N/A\n- 6 years 30.8 lb 14 kg 14mcg 28 mcg 1.4 mg N/A N/A\n- 8 years 44 lb 20 kg 20mcg 40 mcg 2.0 mg N/A N/A\n- 10 years 55 lb 25 kg 25mcg 50mcg 2.5 mg N/A N/A\n- 12 years 75 lb 34 kg 34mcg 50mcg 3.5 mg N/A 2.5 mg\n- 14 years 88 lb 40 kg 40mcg 50mcg 4.0 mg N/A 3.5 mg\n- 50 kg 50 mcg 50 mcg 5.0 mg 25 mg 4.0 mg",
        "clinical pearls and cautions": "1. Pain severity (0 - 10) is a vital sign that should be recorded before and after IV or IM medication administration and upon arrival at destination.\n2. Contraindications to opiate administration include hypotension, head injury, and respiratory depression.\n3. All patients should have drug allergies ascertained prior to administration of pain medication.\n4. Patients receiving narcotic analgesics should be administered oxygen.\n5. Narcotic analgesia was historically contraindicated in the pre -hospital setting for abdominal pain of unknown etiology. It was thought that analgesia would hinder the ER physician or surgeon\u2019s evaluation. Recent studies have demonstrated opiate administration may alter the physical examination findings, but these changes result in no significant increase in management errors.1\n6. Fentanyl is contraindicated for patients who have taken MAOIs within past 14 days, and used with caution in patients with head injuries, increased ICP, COPD, and liver or kidney dysfunction.\n7. Be aware that when administering ketamine, patients can experience lucid dreams and altered states of consciousness."
    }
]