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The information discusses various aspects of pediatric assessment and care. It mentions the importance of using car seats to immobilize infants and the potential complications of gastric distension and colic. It explains that lung sounds are easier to hear in children due to their thinner chest walls. It also provides heart rate ranges for different age groups and discusses how children compensate for decreased perfusion. The information highlights the vulnerability of the pediatric nervous system and the risks of head injuries and shaken baby syndrome. It emphasizes the higher demands of the pediatric brain and the importance of prompt treatment for fractures. The information also touches on the unique characteristics of pediatric skin, the higher ratio of body surface area to internal mass, and the need for age-appropriate assessment and equipment. It concludes with a reminder to ensure scene safety and standard precautions when treating pediatric patients. in the car seat, because the car seat puts you immobilized. It's one of the perfect ways to do it. We used to use a kit. A kit is a good thing to do too. You can put a kit in a kit, and it sticks right up to the whole thing. Gastric distension can interfere with the movement of the diaphragm and lead to hypoventilation. Colic. Colic is gas. Gas can cause swelling or expansion in the GI tract, and it can impede breathing. Breast sounds are more easily heard on children because of their thinner chest walls. I can hear good lung sounds in the front on an infant, small child. Not an adult, because we have all the mammary tissue, and we have the muscle spillage on the front. So we have better lung sounds on the back in an adult. But for a child, especially a small child or infant, the kid will sit on the front. Detection of poor air movement or complete absent breathing may be more difficult because they more shallowly breathe. Their breathing is more subtle to what we see. Infant's heart rate can be at 160 or more, as the American Heart Association states. 60 to 100 for an adult. 80 to 120 for a child. 100 to 140 for an infant, as high as 205. It can go up to 200. Anything above 200 is questionable, but you can have a child's heart rate in the high 180s. That's possible on infant, I mean. Children are able to compensate for decreased perfusion by constricting blood vessels to the skin. You'll find that's one of the main ways they become tachycardic and they shunt blood to the core in times of need. That's one of the first things that they do. Signs of age constriction include pallor, or early signs, weak pulse, hand extremities, tap water refill, and cool hands and feet. In an adult, if you have a weak or absent distal pulse, that's a sign of decompensated shock. They're circling the toilet. In an infant, weak or absent peripheral pulses is a sign of compensated shock. They do that. They shunt blood to the core. That's the first thing they do. In an infant or a small child, I'm not worried about weak distal pulses. If I get that in an adult, that's a bad sign. These are your pediatric heart rates. The range is there. You can see that once you get about 10 years old, they pretty much level off to adult. Pediatric nervous system is immature, undeveloped, and not well protected. Their head-to-body ratio is larger. They're born with a head 60% the adult size. It takes about 18 months before all the bones are fused together. They have soft spots in the skull, which can lead to injuries. The occipital region of the head is larger, which causes them to hyperflex. The subarachnoid space is relatively small, leaving less cushion for the brain. The subarachnoid space is the space below the arachnoid space of the pia mater. There's not a lot of space in there. That's one of the reasons why infants have weak vasculature, weak neural connections. What happens is we can get shaken baby syndrome, because the brain doesn't have a lot of room to move. It causes significant damage. Pediatric brain requires higher cerebral blood flow, oxygen, and glucose. There is a secondary brain end. Remember how I told you in an adult, you have the primary injury, and then the secondary injury, which is the hypoxia-hypotension. One bout of secondary brain injury, hypoxia-hypotension, can cause a four-fold increase in morbidity and mortality. Unfortunately, children are at higher risk for that, because they have a higher oxygen and glucose demand. It's easier for them to become hypoxic, hypovolemic, hypoglycemic. Spinal cord injuries, again, are less common. More likely to be a ligamental injury from a fall, because, again, you ain't got no necks and no bones. Bones, again, are very flexible. Unlike in adults, as we get older, our bones calcify. They harden. In children, they don't. They give. We don't have infant C collars. We just secure them in the car seat. We secure them with their head straps. But we do have small infant C collars. Abdominal muscles are less well-developed. So, therefore, they don't have the musculature that we have, erectus abdominis and obliques, which means impact to the abdomen can cause more internal injury. And not only that, their organs are larger proportionally and closer to the surface. They have less musculature, which means they can take more of an impact, or more injury from impacts. Open growth plates allow bones to grow. This results in children's bones are softer, more pliable, making them prone to stress fractures. Remember that. Epiphyseal regions, the proximal and distal of each bone, is softer, and that's where the bone grows from. It doesn't grow from the middle out, it grows from the edges out. Bone-like discrepancies can occur if there's an injury to the growth plate. That's why fractures in children really should be seen by a pediatric orthopedic surgeon or orthopedic specialist. They should make the determination of how best to splint it and or surgically repair it. Because if it doesn't heal properly, it can cause lifelong deformities. Bones in the infant's head are soft and flexible. You've got the fontanels. And I covered these before. Hint, hint, wink, wink, nudge, nudge. I remember these because we're going to see these again. Your sphenoid fontanels close up in about 1 to 3 months. Your mastoid fontanels close up in about 3 to 6 months. Your posterior fontanel close up in about 6 months. And your anterior fontanel closes in about 18 months. Now, use those fontanels to your advantage. Increased intracranial pressure, you'll see a bulging. So you'll see that bulging. If they're sunken fontanels, that could be a sign of dehydration. The rachet cage is highly plastic and pliable, which means that you get hit with a baseball bat, you're two years old, that bat will hit the ribs. They'll bend in and pop out, and they may not break. So you palpate the ribs. Oh, nothing wrong, these ribs are solid. That doesn't mean that the underlying organs weren't injured because the bones are very pliable. Ribs and vital organs are less protective. There's not as much muscle. The skin is thinner. They have less subcutaneous fat, so they're more likely to suffer hot and cold weather injuries. Composition of skin is thinner and tends to burn more deeply. Our skin gets kind of tough as we get older, right? Especially if you've been outside a lot, when you have one of those sunburns at first, right? Your skin gets a little thicker, a little tougher. But an infant has very soft skin, very supple skin. That's why they call it, ooh, the baby skin. Everybody loves holding babies because the skin is so soft, right? Now, prop, unfortunately, that makes their skin, gives their skin less tensile strength and less resistance to thermal burns. They have a higher ratio of body surface area to internal mass. So, in other words, they have more surface area to their internal volume, which means that that's one of the reasons why they shunt blood to the core because they have so much external surface area. It's one of the reasons why children in burns less than five years old, it makes it more critical of a burn just because of the age, because they have less internal surface, less volume to external surface. It is possible that with an infant, with an infant, a newborn, they might only have that much blood circulating in their body, maybe 125 to 250 milliliters. Not that much. That's why bleeding can be very significant. So, prepare mentally for approaching and treating an infant or a child. If you go into a child, always try to find out the age, the approximate age of the child. Get that from the dispatch, because that will begin your thought process of what kind of injuries, right? If I'm going to a 12-month-old, I know I'm not going to a bicycle accident. I know I'm not going to, you know, that kind of thing. Plan for pediatric size up, equipment, and age-appropriate physical assessment. In the ALS, we carry a PD bag because there's a lot of medicine equipment that we have to do. In the BLS, you'll have pediatric equipment, but it's kind of intermixed with the adult medication, with the adult equipment. You'll also get what they call the Roslo tape, or pediatric tape. What you do is you lay the infant down and you open up the tape, put it at the head, and run it to the feet. And wherever the foot stops, it'll show an approximate age. It'll have the color code. They have red, green, yellow, blue. And whatever that age is, it'll tell you vital signs, approximate vital signs for that age, approximate weight, approximate height. It'll tell you medication dosages. It'll tell you, you know, equipment sizes. It's called the Roslo tape, or the pediatric tape. Pediatric assessment tape. Roslo is just a brand name. Collect age and gender of the child, location of the scene, mechanism of nature of illness, or mechanism of injury, You may have to get it from dispatch, but when you get it on scene, you may have to get it from the parent or caregiver. The child may not be able to tell. So ensure proper scene safety, and standard precautions. Believe me, you can get all kinds of, you can get the same diseases from a kid as you can get from an adult. So make sure you use proper precautions. Note the position in which the child was found. Ask somebody to snap a picture of the scene. Don't post it on Facebook, but you can definitely take a picture This is the area where we found the child. Look for the possibility of safety threat. The patient may be a safety threat if he or she has an infectious disease. It could be that the person that inflected the injury on them is going to come after you. So be aware of that. And do an environmental assessment. Another mnemonic. Son of a... Alright. So this is the pediatric assessment triangle, which I talked about. Work of brain in circulation to skin and appearance. It's a 30 second assessment as I approach the patient from the doorway. Pay attention. As I approach the patient from the doorway, right? So I'm looking at work of breathing, circulation to skin, and the appearance. Does not require you to touch the patient. And you can tell, if you're good, you know, maybe not in your first year, but once you've done a few, had a few pediatric assessments under your belt, you can do the pediatric assessment triangle and know if your patient is a high priority patient. You know this patient is going to go. It really doesn't take a pediatrician to look at a child and say, you look sick. Children should be active, they should be alert, they should be joking, or whatever. They shouldn't be listless. Especially when a stranger is standing over them with equipment. They shouldn't just be lying there. That's a bad sign. Does not require equipment. The appearance work of breathing and circulation to skin. Appearance, note the level of consciousness. Interactiveness and muscle tone. They should be able to hold themselves up. You know, they should be able, they should have an age appropriate response. Listlessness, unresponsiveness, obtundation, these are all bad signs. Use your apple, and modify as necessary for the pediatric age. So obviously I can't take a two year old and tell him, person, place, time, or event. What's your date of birth? Who's the president? Yeah, good luck. Maybe if it's Elon Musk. So what do we do? We ask them age appropriate things. What's your favorite cartoon? What's your favorite dessert? What's mommy and daddy's name? What is the name of your pet? What games do you like to play? And if they can give you legitimate answers, normal level of consciousness, act appropriately for age, exhibit good muscle tone, and maintain good eye contact. These are normal, these are good appearances. You can use the tickles mnemonic to identify if a sick or not sick. Tone, the muscle tone, how well they can maintain their posture. Interactiveness, consolability, look or gaze, speech or cry. So you can use the tickles mnemonic. I don't really start and teach it, but if you want to use it, it's a good, like the pediatric assessment triangle, it's a good assessment tool if you feel the need to. Work of breathing. On your PCI, you're going to write W-O-B. And if you put an arrow up before it, that means increased work of breathing. That's a bad sign. Increase in the body's attempt to compensate for abnormalities in oxygenation and ventilation. It can manifest as abnormal noise, airway noise, accessory muscle use, retraction. Head bobbing and nasal flaring is common. When kids have trouble breathing, they have nasal flaring and head bobbing. Like that. And sometimes they grunt. My son, when he has an asthma attack, he'll actually have a hacking dry cough. He won't wheeze, per se. Tachypnea and tripod position. Again, it doesn't take a pulmonologist to look at a two-year-old kid and say, that kid's having trouble breathing. Remember, cardiac arrest, respiratory arrest leads to cardiac arrest in infants and children. They haven't been smoking and joking and eating McDonald's cheeseburgers for 20 years. So they're more likely to go into cardiac arrest from respiratory arrest, which means that if we step in and avoid respiratory arrest, we should be able to stop cardiac arrest. So when cardiac output fails, the body shunts blood from areas of lesser need to areas of greater need. Leading to that weak distal pulses, which is what they do in compensated shock, unlike adults. Pale skin and mucous membranes may be seen in compensated shock. So if I see cyanosis to an adult, that's more serious than in a child, although we don't want children to have that either. But that's what they do when they're compensating for shock. Kids have a great compensatory mechanism. They compensate much better than we do. Modeling is a sign of poor perfusion. That's that blotching of the skin where you have blood trapped in the capillary veins. That's a bad sign. Modeling is a sign of poor general impression. Cyanosis obviously reflects decreased oxygen levels. Children are more likely or more rapidly going to cyanosis than adults go because they have higher oxygen levels. From the pediatric assessment triangle findings, you will decide if the patient is stable or requires urgent care. And remember, I might ask you, I don't know, I might show up as an extra credit. What is the pediatric assessment triangle and what are we assessing? So if I might say, what is the PAT and what does it assess? So I want to see pediatric assessment triangle, triangle, work of breathing, appearance, circulation of the skin. That might be an extra credit. I don't know. I'm thinking about it. If stable, continue with the remainder of the assessment process. Not every child is load and go, but I will tell you right now, you are never wrong for going high priority in a rapid transport if you feel it is warranted. Nobody's ever going to say, if you felt it was necessary, you feel uncomfortable, absolutely call. High priority. Call ALS. Don't be afraid to call ALS. Or medical control. Hey doc, I got this kid here. I don't know what to do. I don't know what I'm looking at. Don't be afraid to call. That is what they are there for. Hands-on, bleeding, airway, breathing, circulation. Assess and treat any life threats as you identify them in the X, A, B, C, D, E format. Stop the bleed. Even minor bleeding. Assess their airway, breathing, circulation, disability, what isn't working. What seems to be a disability and then expose. We can't fix what we can't see and EMS is where most of medicine, the part of the body we don't check if the part of the body with the problem. So expose and then cover the patient up. So that's why they say A, B, C, D, E. Airway, if the airway is open or main is open, assess respiratory adequacy. I love a crying baby because a crying baby tells me the kid's got a good pain in the airway and knows what's going on. It's pissed off and unhappy. I don't like it at 2 o'clock in the morning when I'm trying to sleep and it's my granddaughters. But in an ambulance, love it because I know the patient's got a good pain in the airway and knows what's going on. If a patient is unresponsive or has difficulty keeping their airway open, ensure that it's properly positioned and clear of vomitous blood. Children are more likely to aspirate and have suction available. Airway positioned always positioning the airway in a neutral sniffing position. Remember how we did the head tilt chin look for kids? Like in adults? Like in those mannequins, you're freaking shoving the head all the way back. For children, it's not. Think of a kid sniffing. All you move in the head, that little bit. Try to keep it in a neutral position. You might have to tip it a little bit but the more you hyperextend the head, the more likely you are to sink the airway. Remember the airway is very flexible. Maintain that proper alignment. Establish whether the patient can maintain their airway and if they can't, do it for them. NPAs, OPAs. Children, OPAs, NPAs are great in children. Put a properly sized NPA in a child and they'll leave it in. If you tell them not to touch it, they won't touch it. They tolerate them well. For the most part. So listen, you've got to inspect osculate and palpate. IPA. Inspect, palpate, osculate. That's how we do all patients. Place both hands on the chest to feel the rise and fall of the chest. Belly breathing in infants is adequate. If I see their belly moving, that's what I'm expecting to see. Their pelvic and belly movements. Vaginaepenia is an ominous sign and indicates intending respiratory arrest. Again, this means very slow breathing. Slow breathing leads to no breathing, which leads to cardiac arrest. Many times an infant will go into cardiac arrest before they stop breathing. They'll have such bad brain anemia that they'll end up going into cardiac arrest. So we want to stop that before. You've got a kid that's not breathing very quickly, not breathing adequately, have your DVM ready. We can ventilate infants with room air first. And then actually infants in room air first and then if that doesn't work, then we'll start ventilating them with oxygen. We don't want to throw high flow oxygen on an infant right away because of the potential for oxygen toxicity blindness. But life overlay. To turn up the patient as the pulse is bleeding or in shock, the infants palpate the brachial or femoral pulse. In an adult, this is a peripheral pulse. In an infant, this is a central pulse. So this and this are central pulses. We can't find, you could probably dig for the carotid pulse, but I wouldn't want them. Again, they ain't got no neck, so what do we do? We go for the brachial. In children older than a year, any child that's big enough to walk, if they've got a neck, go for the carotid. Strong central pulses usually indicate the child is not hypotensive. Like I said, children shunt blood to the core, so weak peripheral pulses means that the child is compensating. Weak peripheral pulses in an adult means decompensation. Weak peripheral pulses indicate decreased perfusion, tachycardia. It's an early sign of hypoxia. They'll increase their respiratory rate, increase their heart rate, and shunt blood to the core. That's their early response. Interpret pulses in the context of the overall history in the PAT. Evaluate trends of increasing and decreasing pulse rate. We can only do this if we do multiple sets of vital signs. One set is a snapshot in time. I have to do multiple sets every five minutes to tell if my patient's getting better or getting worse. Feel the temperature, feel the skin for temperature and moisture, and estimate the capillary refill. The younger you are, the more efficient and effective the capillary refill is. Capillary refill is great under three. All I've got to do is grab the body set and let it go. That's better than a blood pressure. So capillary refill is great as we get older. Perfusion reduces, and so I wouldn't do a capillary refill on a seven-year-old like I would on a seven-year-old. Use ABPU and a pediatric GCS. And a pediatric GCS just means the same GCS. Lasko, Comascale, everybody else uses, but I'm going to tailor my verbal to the child to make it appropriate. I'm not going to ask a six-month-old what's your favorite cartoon. They're not going to be able to tell me. And if they can, hand tap it. Check pupil air response. Look for symmetrical movement of the extremities. If pain is present with most type of injuries, just with adults, assessment of pain must consider developmental age of the child. Hands-on ABCs require the caregiver to remove the patient's clothing. They're right down to the diaper. But remember, as you remove the clothes, remember the child is going to get cold. Make sure you cover them up. If you're prone to hypothermic events, you should be kept warm during your transport. Turn the heat up on high in the ambulance. Make sure you warm any equipment before you put it on the patient. Determine whether rapid transport to the hospital is indicated. Again, you're not going to go wrong. If you feel something's not right, hands are standing up on the back of your head, something in the back of your head is going, I really should do high priority. Do it. Rapid transport, things like significant mechanism of injury. You know, a fall three times a patient's height, ten feet, right? If a child is on a bicycle and gets hit by a car or falls down the stairs, things like that. Significant mechanism. History compatible with serious illness. High fever, you know, altered mental status, lethargy, especially that petechial hemorrhage could be a sign of meningitis. Physical abnormality noted. Children don't generally, infants less than two years old, they generally don't break long bones because they're very flexible and they're short. They take a lot of force to break them. So, broken humerus, broken femur, almost consider that automatically being child abuse. Because they don't break like that normally. Matter of fact, I had a friend of mine who used to teach for me, took my ENT class like, took it like three times, took it twice for me, but he finally passed it. And he was a firefighter for years. He was ENT. He did talk for me. And his child fell off a high bed and had a femur fracture. And so, they investigated him. Child Protective Services investigated him. I know what you're doing. Did I get it? I understand. I'm in the field. I know. It turned out it was innocuous. Kid really fell off the bed. But that's unusual. Normally long bone fractures are questionable automatically. Significant pain or an abnormal level of consciousness. Again, look at a kid. Kid should be pissed off. They should be scared of you. If kids are just lying like this and you're talking to the kids, picking them up, playing with them, moving around, and they're just lying there, that's a bad sign. Also, consider a type of clinical problem. Is it a respiratory issue? Is it a cardiac related issue? Is it an infected related issue? Is it something that could lead to a serious declining of the patient? Benefit or ALS treatment? Benefit is supposed to be benefits of ALS treatment in the field. Don't be afraid to call ALS. If your patient can warrant ALS medication, can benefit from ALS level care, you're supposed to give it to them. You're supposed to call right away. Whatever your local protocol is, your comfort level and transport time to the hospital. If the patient's condition is urgent, initiate emergency transport to the closest appropriate facility. So, any ER can take care of a pediatric if they're unstable. But if they're stable, and they can handle the transport, you really want to go to a pediatric hospital. What is the pediatric hospital? UMass University. UMass University has a pediatric ER with a pediatric trauma room. They can handle level 1 trauma in UMass. Haywood also can handle level 2 trauma in UMass. They can handle level 3 trauma in a pediatric as well. But they would be a level 2 hospital. Level 3 hospital. Transport decision. Less than 40 pounds. Less than 40 pounds. I think less than 5. Younger than 5. Less than 40 pounds. They belong in a car seat. A PDMA is meant from 10 pounds to 40 pounds. And it's like a leather strapping system that you strap onto the stretcher, and then you put the baby in it. It turns your stretcher into a car seat. You sit in the car seat all day.