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caregiver. You can ask the child if they can speak. You can ask them certain questions. You're just trying to get most of it from the caregiver, obviously. Adolescents, you might get most from the child. Questions, addressing the parents or child about immediate illness or injury should be based on the child's chief complaint. Questions to ask, based on the chief complaint. The nature of illness or the mechanism of what happened. What are the illnesses? What are the signs and symptoms for the mechanism of injury? What happened to the child? Length of illness, injury or illness. That could be a key indicator too, like a delay in seeking care is a sign of child abuse. Oh, I got hurt three days ago and I didn't really take them to the hospital. Why? Key events leading up to the illness or injury, presence of a fever. Fever is a sign of infection. Effects of illness on behavior, patient's activity level and recent input-output. Eating and drinking, pooping and peeing. Is it normal or not normal? Changes in bowel and bladder habits, especially infants. How many diapers should an infant go through in a day? Six to ten. So if you've got a mother that says, yeah, my baby's only produced two wet diapers all day, it's been very dark and foul and strong smelling. That's dehydration. Presence of vomiting, diarrhea and abdominal pain. Understand that two hours of vomiting and diarrhea without taking anything in can lead to hyperbulimia in an infant. Presence of a rash, especially that petechial rash, that pinpoint hemorrhage, which could be meningitis. Obtain name and phone number of the caregiver if you're not able to come to the hospital. Let's say you're just taking a child from a daycare center, taking a child from a school. Get the name and phone number of the caregiver or family member or parent and bring it with you to the hospital. So that way the doctors can contact you by cell phone. Sample history, same as adults, but they've got to be age appropriate or you're going to ask a caregiver, an adult for that. OTCRST, again, the same thing, but it's got to be age appropriate. The OTCRST really kind of has to rely on the child, so you're going to have to find a way to communicate so you're going to get reasonable information. Physical examination, secondary assessment, the entire body should be used when the patient is unresponsive or a significant mechanism of injury. I'll be honest with you, I have a small child, I'm going to do a head to toe assessment no matter what. I mean, unless it's a broken finger, I'm going to do a head to toe assessment. It only takes a few minutes, a couple of minutes, it's worth it to do it. Focus assessments should be performed on patients without life threats. I can focus on the chief complaint, right? Most of your children are going to be focused assessments. They're not going to be severely injured. Infants, toddlers, and preschool children should be assessed starting at the feet and working to the head. Again, about four to five, you can go from head to feet by that time. The idea is if you start at the feet, you work your way up. If you develop a lot of agitation in the child, you can stop, but you'd assess most of the body before you get to the head. That's the reason why. School age children and adolescents should be assessed like an adult. Head, if you have a bruising, swelling, or hematomas, assess the fontanels. Again, bulging fontanels is a sign of intracranial pressure, whereas sunken fontanels is a sign of dehydration. Nose, nasal protrusion and mucus can cause respiratory distress in an infant. Have a bowl syringe available. Ears, drainage from the ears, especially like a pinkish fluid, may be caused by a skull fracture. Battle signs indicate a skull fracture. Presence of pus may indicate an infection. Look at the mouth for active bleeding and loose teeth. Smell of breath. Obviously, babies really don't have bad breath. Kids don't develop bad breath until the teeth really start coming in, so about 12 months or so. Children shouldn't have a bad breath, so if you have a child that has a really strong bowel breath, it might be a sign of an infection or a sign of an ingested toxin or something. The neck, examine the trachea area for swelling or bruising, right? We check for tracheal deviation and jugular venous distension. Note if they cannot move their neck and have a high fever. Ask the child to put their chin to their chest, and if they go, I can't, it hurts, and they have a fever, that's a sign of knuckle rigidity, which is meningeal irritation, that's a sign of meningitis. Chest, examine for penetrating trauma, lacerations, bruises, or rashes. Feel the clavicles and every rib. Any penetrating trauma from the neck to the umbilicus, circumferentially around, we put a booster dressing on, it's automatically a high priority patient. Don't play with kids. Transport. Back, inspect the back for lacerations, penetrating injuries, bruises, or rashes. Listen for lung sounds. Inspect the abdomen, looking for distension, rigidity, and rebound tenderness. Two-throat abrasions and motor vehicle crashes. Just like an adult, I'm not one to really want to palpate the abdomen. If a child tells me, my belly hurts, I believe you. But if you don't know, you have to palpate it. Palpation. Assess all four extremities, looking for symmetry. As I say, if you're assessing a child, an assessment for a child is the same as an assessment for an adult. You guys did patient assessment, right? We talked about it, I demonstrated it, so you know what I'm talking about. Prepare both sides for color, warmth, size of the joints as they're smaller. Tenderness, put each joint through its full range of motion. Move the arms, move the shoulders, move the legs, move the hips. Especially infants, how are they moving? Vital signs, you're going to do vital signs by hand. If you have automatic vital sign measurement device, make sure you do your first set manually. Pulse oximetry, sometimes you have to put it on the thumb or the big toe, and it works. Sometimes the hands are too small, and it doesn't work at all. Blood pressure is usually not done in less than three years of age. We usually do that capital letters and so on. You can, we have infant blood pressure cuffs. They have infant, child, small adult, large adult vital signs. Assessment of the skin is a better indicator of a pediatric patient's circulatory status. Use the appropriate size cuff. Again, it should be two-thirds the size of the upper arm, and it should fall within that range, that guide range on the cuff. Formulation for children. This goes from, I know it says one to ten, but really one to eighteen. Two times the age plus 70. So, an 18-year-old, 36 plus 70 is 106. That's not bad. And this is what we call low normal systolic. So, I don't want it to go below, I really don't want them below this reading. So, 70 plus two times the patient's age. For pulse and vibrations, we count 30 and double it times two. In infants or those younger than three, we can assess breathing by looking at the abdomen. The abdomen, remember, they're oblique belly breathers. Assess a pulse for at least a minute. In patients who are hypothermic or patients who are really sick, get a good one-minute pulse. Normal pediatric vital signs vary with age. We know that all vital signs drop as we get older, except for blood pressure. Blood pressure is directly proportional to weight. So, all vital signs drop except for the blood pressure. The blood pressure increases with age. Evaluate pupils and pulse oximetry. Same vitals every 15 minutes on a stable, every five minutes on an unstable. Again, you're not going to have these kids more than 20 minutes. Do them every five. Continually monitor your patient. Have a conversation with your patient. Sit down where you're placing. Play games with them. You know, whatever. Intervention parents and caregivers may be able to assist you by calming and reassuring the patient. They may be able to assist you with actual treatment or stabilizing of the patient. Communicate and document all relevant information to the ED and you're going to do a good PCR, including a good narrative. Respiratory problems are the leading cause of cardiopulmonary arrest in pediatric populations. Respiratory arrest leads to cardiac arrest in infants and children because they haven't spoken and joked and eaten McDonald's cheeseburgers for 20 years. In early stages, you may notice changes in behavior. They might become mad or restless or have anxiety. Obviously, anxiety is difficult to judge because children should be apprehensive of strangers, of EMS personnel. But you can tell the difference between normal anxiety and just anxious overall. Signs of increased work of breathing are nasal flaring, abnormal breath sounds. Breath sounds should be clear. You shouldn't hear rales, ronchi, or wheezes. You especially shouldn't hear rales or ronchi in a small child. Accessory muscle use in tri-part positions. As pediatric patients progress into possible respiratory failure, the effort of breathing decreases. They start breathing less effectively and they're working less to breathe. And it's not they're working less to breathe because they're getting better. They're becoming more altered. Their heart rate is going up, but their breathing effort is going down. Chest rise is less of an inspiration. Body has used up all its energy stores. No longer support the breathing and the patient will eventually go into respiratory arrest pretty quickly. This is respiratory failure. We recognize this and we reverse it with a BVM immediately. I'd rather ventilate somebody than do CPR on them. Changes in behavior and eventually altered mental status. They go from confusion to combativeness, anxiety, obfoundation, lethargy, obfoundation, and unresponsiveness. The patient will experience periods of apnea. If you're noticing a child is stopping breathing for a period of time and it's starting again, you should already be bagging that patient. That isn't the, oh, I need to start bagging my patient. I'm using my BVM. They shouldn't even get to that point. Heart becomes hypoxic. Heart rate slows. It becomes weak and then it eventually stops. Respiratory failure does not always indicate AOA obstruction. It could be other things causing it. It could be toxicological. It could be metabolic. It could be neurological. Conditions can progress from respiratory distress to failure at any time. Again, they compensate well, but they decompensate like that. I get something out of a cabinet and turn it back around and the kid that was just laughing at me is unresponsive. They go that fast. The child or infant needs supplemental oxygen. Absolutely don't be afraid to put it on. Bag them and allow the patient to remain in a comfortable position as you're recovering. Airway obstruction. Children can obstruct the airway with any object they can fit in their mouth. See all the little things. We used to have a box at Boston Medical Center. We had a box of things that kids would, you know, choke on and we'd kind of show it to the parents. If a kid came in with an AOA obstruction, we'd show the parents the kind of things that kids choke on. We used to have another box of things that adults inserted in certain orifices. You don't want to mix little boxes up when you're talking to parents. In a case of trauma, teeth may have been dislodged and dropped in the airway. A tooth can actually occlude an airway. Blood-vomiting sort of secretions can cause severe airway obstruction, especially if you're blocking the nose and you have gas or kind of a constricted abdomen. Infections should be considered if a patient has congestive fever drooling or cold symptoms. Usually a child will, after about, believe it or not, after about two to three months, at about two to three months, they start teething and they start breaking those teeth through before they get a breakthrough. You'll see the gums become kind of whiter. What happens is children will develop a low-grade fever, congestion, mucus buildup, they get a little cranky. Croop is an infection in the airway below the level of the vocal cords. Epiglottitis is above the level of the vocal cords of the epiglottis. This is a viral infection of the whole airway, whereas this is a bacterial infection of just the epiglottis. Bacterial is always much worse. So this would be epiglottitis, whereas croop would be an infection of the entire airway. This would be epiglottitis. Obstruction by foreign objects may involve the upper and lower airway. It could be partial or complete. If the child has a cough, if they're moving air, if they're talking, try to encourage them to cough if they can. If they have a high-pitched whistling sound, if they're moving very little air, they can't talk, consider that a complete obstruction. Best way to also take breast sounds and pediatric patient is to listen to both sides of the chest at the armpits. What we know when we're listening for his apices and bases in an adult, but in a child, the bases we listen up here, because again, the lungs, everything's higher up because our organs grow into us. Immediately begin to treat any airway obstruction. How do we do foreign body airway obstruction in a child? If they can stand, what do we do? If they can't stand, if there isn't, back to the chest. If the patient is not able to forcibly remove it during a cough, then you have to do something. If you see a severe obstruction, you want to do, again, ineffective cough, inability to cry or speak, increased respiratory difficulty, stridor, you'll see that cyanosis and loss of consciousness, possibly loss of consciousness, hopefully before loss of consciousness, you clear the airway. Back blows and chest slaps are the highest you can do it if they can stand. Use the head tilt, chin lift, and you can do a finger sweep if you can see something. Do not do blind finger sweeps. We only go in the mouth if we can see something and possibly access it. Use chest compressions if you cannot relieve the airway obstruction and the child becomes non-responsive. Asthma, also called reactive airway disease. It's a constriction of the bronchioles, or small air passages, by the release of, by the eosinophils, degranulizing and releasing histamine 2. Histamine 2 causes bronchiole constriction. So asthma is really like an allergic reaction. Asthma is caused by the immune system, but reaction of the respiratory system. Remember that was a question on a test. It is a true emergency if not properly identified and treated. Patients, 5,000 people a year die from anaphylactic reactions. Many of those are children. Most of the time it's because there's a delay in seeking care. Oh, it's not that bad. And then they wait too long. Asthma can be caused by other respiratory infections, such as, or lower respiratory infections, pneumonia, flu, bronchitis. Exercise, exposure to cold, smoke, or even emotional stress. Wheezes as the patient exhales. Stage 1 is that exhalation wheezes. Stage 2 includes inhalation wheezes, and this can be the sign of that mucous hardening. And then stage 3 is when that mucous hardens. Very few patients recover from a stage 3 asthma. Subcaseous airways completely blocked with no air movement heard. What's the worst lung sound of all? Abnormal. And that's the scary thing when you have a 5-year-old with no lung sounds. Sinuses and respiratory arrests may quickly develop, and the patient will be sitting in a tripod position. There'll be grunting, nasal flaring, head-bobbing, cyanosis. Those are all signs of respiratory failure. Allow the patient to assume a position of comfort, apply high-flow oxygen, use their metadose inhaler or nebulizer treatment. The pediatric dose for albuterol is 125 milliliters in one and a half, 125 milligrams in one and a half milliliters of solution. Basically, you take that saline, that albuterol bullet, and you only squirt half in the nebulizer in the medication chamber. I don't do that. I give the patient a full dose. My son was 2 years old with asthma. I gave him a full dose. I find that the half a dose just isn't enough. So, just give him a whole dose. But just so you know, all pediatric medication doses in the BLS are half the adult dose, under 55 pounds per ventilator. Consistent ventilations, use slow, gentle breaths. Again, just until just right. Don't jam at home. You can actually produce lung damage. Pneumonia is the leading cause of death worldwide in children. Pneumonia, it can be caused by bacterial, fungal, or viral infection. Often secondary, one of the most common causes of pneumonia is the flu, influenza. It can occur from chemical ingestion which can cause irritation and mucus build up which can become bacteria-laden. Diseases causing immunodeficiency in children increase the risk. Incidence is greater during the fall and winter months. Again, because viruses don't like warm weather. That's why we don't see viruses in the summertime. That's why viruses come out in November and they hang around until April. Because viruses function better in a cooler environment. They don't last well in heat. Presentation in pediatric patients, usually rapid breathing, sometimes grunting or wheezing, nasal flaring, tachypnea. They'll have fever. They might actually have a cold body temperature. The elderly and children can actually develop hypothermia in response to an infection. Unilateral diminished breath sounds on one side. You'll hear crackles. They might have a productive cough with discolored sputum, abdominal pain, lethargy. These are all signs, just like in adults, of pneumonia. So your primary treatment will be supportive. Put them on oxygen. If they have really bad breathing, you can nebulize them. Just be careful. The problem is you want to make sure it's not poop. Because if you nebulize a patient with poop, you'll kill them. So don't do that. So make sure it's pneumonia. Pneumonia usually doesn't affect, doesn't produce wheezes, doesn't produce crackles or fluid in the lungs. Monitor the airway and breathing. Supplemental oxygen. If the patient is wheezing, again, a bronchodilator, you can nebulize them. Diagnosis of pneumonia needs to be done in a hospital with an x-ray, with a chest x-ray. I don't know if you've ever seen how infants get chest x-rays. Oh, no, it's horrible. It's horrible. You hold the kid up, and I call it the Iron Maiden. They strap this kid in this thing, and you've got to hold the arms up. And the kid's crying. And the kid's screaming and looking at you. And the x-ray tech will be like, oh, no, that's good. Let the cry over something. Almost made me cry when I had to get my son's x-ray. Poop is an infection of the airway below the level of the vocal cords, usually caused by a virus, typically seen in children between three months and six months and three years. Easily passed between children. This goes through daycare centers and schools like wildfire. Starts with a cold, cough, and low-grade fever that develops over two days. They get that barking, seal cough. And they feel like a seal every time they cough. Usually it's self-limiting. It's a virus. As long as they stay home and rest with plenty of fluids, Tylenol for aches and fever, usually it goes away pretty soon. But sometimes they can develop asthma, or they can develop congestion, and they have to go to the hospital. If a parent calls, we transport. You're not going to tell them, oh, you're fine, just stay home. You call, we walk. Poop often responds well to humidified oxygen. You can nebulize poop with a saline bullet. That's just normal saline in the nebulizer. You can do that. Sometimes that clears up the mucus and helps. Don't use albuterol. Just saline. So if you're not sure, just don't do it. So would you say if somebody with keratopoietin also has asthma, and they're using their asthma inhaler? That can be failed. Yeah. You don't do that. Okay. It depends on the dose of albuterol. It depends on how much fluid they have in their lungs. It can be very serious. Bronchodilators are not indicative of poop. They'll make the child worse. Epiglottitis, bacterial infection of the soft tissue around the vocal cord, i.e. the epiglottis. Incidence decreased since development of a vaccine. They actually have a vaccine for epiglottitis. So if you go in, you're showing signs of epiglottitis, they can hit you with the vaccine. It can swell to two or three times the normal size, and it can swell by irritation. Ma'am, can you open up your mouth when you look in? I stick a tongue depressor in to look at you, and I touch that epiglottis. Epiglottis swells right up. They go to the airway. Child will look ill, report a very sore throat. They'll drool because they're first swallowed. They'll have a high fever sitting in tripod position. And this comes on very rapidly. This isn't like a swell producing cold or flu. It's like all of a sudden, like wham. All of a sudden, they wake up in the middle of the night with this high-pitched whistling sound and drooling and a fever. And they'll look tired and sick, lethargic. Bronchiolitis. Well, you've heard of bronchitis, which is an inflammation in mucus in the upper bronchi. But this is in the smaller air passages that are affected by asthma. It's called bronchiolitis. Same thing. Mucus, constriction of the bronchioles with mucus production. Usually caused by a viral cause. Most commonly caused by RSV, respiratory syncytial virus, which usually pops up in the winter months, like in November and December. We'll see a resurgence. Last year, we had a really bad bout of RSV. Haven't heard so much about it yet, which is good. Do these viruses just go dormant in the bodies? And then that's how they... They just... From the cold, they just can't breathe? They don't spread. They don't do well. Yeah, they find places to hide, I guess you'd say. They do stay dormant within the body because they don't like the heat. But once it starts getting cold, things start to replicate. They're in the air. They're on surfaces. If someone has RSV and asthma, could that be linked to complications? No, you could use a nebulizer with RSV. That's different from cold. Highly contagious. It spreads through coughing and sneezing. RSV goes from daycare centers and nursing homes like wildfire. It can spread on surfaces like a common cold. Again, you've got kids playing with toys. They're putting it in their mouths like a group. They've got RSV. And then you take the toy and you're playing with it. And that's kind of how it goes around.