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The main ideas from this information are: - Sterile techniques should be used to prevent infection in burn injuries. - Child abuse should be considered in burn situations. - Children's bones are more prone to fractures, especially green stick fractures. - Extremity injuries in children are managed similarly to adults. - The Wong-Baker FACES scale is used to assess pain in children. - ALS interventions may be needed for pain management in severe cases. - Jumpstart triage is used for children under 8 years old or 100 pounds. - Child abuse can occur in any socioeconomic status and should be documented. - Signs of child abuse include atypical injuries, inappropriate caregiver behavior, evidence of substance abuse, delayed seeking care, and a poor relationship between the child and caregiver. the epidermis, the dermis is more likely to get infected. Sterile techniques should be to always wear gloves and put burn dressings, we have special sterile burn dressings, they're blue or green, and they come in a burn, it says burn dressing and you open it up and you can cut it and shape it and wrap it around the tissue to keep it from getting infection. Consider child abuse in any burn situation, well again, any trauma to a child is potentially child abuse. At a minimum it's neglect, it's lack of supervision, it could be innocuous, my children have gotten hurt before, it's because I wasn't watching them, I take full responsibility for it. So severity can be mild, moderate, or critical to suffer multiple burns. Obtained aortic patients are managed in the same way as adult patients, prevent hypothermia, if the patient shows bradycardia, magnum, usually bradycardia is a sign of hypoxia, it's a sign of low oxygen, so ventilation and monitoring the patient. Children have immature bones with active growth centers, again, the proximal or distal end of each bone has the epiphyseal region, potential weak spot, and small children will develop those green stick fractures where the bone will snap like ours, it kind of splinters like that, just like you're trying to break a stick that's still green, that's why they call it a green stick fracture, you take a branch off a tree, pull it off a tree, it's still healthy, and you try to break it and it doesn't break, it kind of splinters and you can see the green meat inside it, that's the same thing. Generally, ancient extremities, extremity injuries in children are managed the same way as adults, we split them, we immobilize them, we, you know, ice packs, give patients pain meds. Painful deformed limbs with no evidence of broken bones should be splinted, you should splint them anyway. Look for visual clues and use the Wong-Baker FACES scale. What we do with adults and older children, we can say on a scale of 1 to 10. If you take a 3 or 4 year old and you say on a scale of 1 to 10, 10 being the worst pain you've ever had, 1 being the least, what would you say it is? They're going to have pain like that, they've never done that before. So the Wong-Baker FACES you can pull up on your phone, it's in your protocol book too, and it's got a series of five FACES, from mild discomfort to really bad discomfort. So you show the child the FACES and you say, show me which FACES is yours. And then it has a range, like 1 to 2, 3 to 4, 5 to 6, and then you put that down. You don't pick the FACES, they pick the FACES. Interventions are limited to positioning, ice packs, extremity elevation, and splinting. ALS intervention may be needed for pain management, although I've found that unless it's like open fracture, I've found that splinting, ice, immobilization, oxygen, and talking to the patient goes a long way in controlling pain. Jumpstart triage is intended for children younger than 8 years or 100 pounds. My son is 12 and he's about 110, so a 100 pound 8 year old is a big 8 year old. I go with the weight more than I go with the age, because kids have a great compensatory mechanism. They recover well. So I like the 100 pounds. So you're looking like 11 or 12, right? Oh, you look less than 100 pounds, so I'm going to go with the jumpstart. And all the jumpstart triage states is that a normal black or gray, I shouldn't say black, because it goes green, which is walking movement, yellow, which is delayed, red, which is immediate, and you have gray, which is patients that are pulseless and or apneic and or pulseless that look viable if we work them. They go gray, and then black is absolutely heads over here, bodies over here. So what happens is in normal triage, if I check you and you have no pulse, no breathing, I move on to the next patient. I leave you, because it's going to take a lot of work to resuscitate you. But in children, I'll open the airway and maybe deliver a couple of breaths to see how you respond. Children do respond. Give them a couple of breaths and all of a sudden they stop breathing or you feel a pulse. Boom, now they're red. Does that make sense? So if I open their airway, give them a couple of breaths and they don't respond, they stay pulseless or apneic, then we move on. That's one of the hardest things you could probably ever do, is leave a child and move on to somebody else. But that's the nature of the game in triage. So breathing is minor, not in need of immediate treatment. They're able to walk, except infants. Infants are automatically yellow, because they don't walk. So we automatically just put them in yellow. Yellow is delayed presence of spontaneous breathing with peripheral pulses responsive to painful stimulus. Not unresponsive. They have some response. They don't have to be awake, but they're not unresponsive. Red, immediate response. Black, patients who are unresponsive. Apnea responding to positioning or rescue breathing, respiratory failure, breathing but without a pulse or inappropriate painful response. These are patients that are immediate. We treat them right away. And then gray is patients who are pulseless and or apneic, but do not respond to positioning and ventilating for about a few seconds. Black is absolutely not going to work with them anyway. And this is, I think, I don't know what page this is on, but this 35-39 is just the algorithm for it. Just read it over and familiarize yourself with all the things that come up. Page 1335. Page 1335. Child abuse and neglect. I will tell you that it runs the gamut. It spans the entire span of humanity. Every race, creed, color, socioeconomic background, religion, doesn't matter. It's everywhere. And they say that over half a million children are victims of child abuse annually. That's those that are reported. They believe it may be two or three times that number because those that go unreported. Includes physical, sexual, neglect, and emotional abuse. Many children suffer life-threatening injuries and long-term psychological and physical problems, right, to include PTSD. Most of your really severe psychiatric issues, you know, mental health issues are usually PTSD-related, and we can see that in their history. Child abuse occurs in every socioeconomic status. Be aware of patient surroundings and document the findings. And it could be, don't confuse it with, you know, you can have a good family that just are socioeconomically depressed, right? They, mom and dad work, you know, 40, you know, 80, 90 hours a week just to put food on the table. The house is barren, it's boxed, it's forested, it's not clean. It's like I feel uncomfortable walking into it. I wouldn't want my kids in it. It doesn't mean that they're abusive. It could be that they just need help. So sometimes that's important. Like when you bring the child into the hospital, the nurse and the doctor don't know what the house is like. They don't know what the family lives like. So give that report to the nurse. Hey, they could really use some services. Or the house is really squalor, in squalor, or it's, you know, the house was cold or it didn't need them. And sometimes they can get services. They can get, you know, a DYS in there, or they can get some form of services to help maintain the house. It's not uncommon to find latchkey children. You know what a latchkey kid is? That's a kid that's left home while the parents go to work. Three and four and five year old kids are locked in the bedroom while the parents go to work and they're home alone. Not uncommon. So ask yourself, look at the child, is the injury typical for the child's age? A three year, a three, a 12 month old, is it riding a bicycle? Can't fall off a bicycle. Mechanism of injury reported consistent with the injury. You know, you've got bruises on the butt and the kid supposedly was wrestling around. Doesn't make any sense. Caregiver behaving inappropriately. Is the caregiver, the caregiver should show concern, not be overly defensive. Right? If the kid, if every time you ask the question the caregiver is defensive, like you're abusing them or something when you're just asking a question, that's questionable. Or if the caregiver is apathetic, like watching TV while, you know, the kid's sitting there holding a bloody towel on their head, that's apathetic. I wouldn't expect that either. Evidence of drinking or drug use at the scene. If I walk into a scene, I have an injured child and I find alcohol bottles or drug paraphernalia, automatically I'm going to report it. Because that, and don't get me wrong, I've had drinks with my children at home. Parents do that. But when you do that, you run the risk that you're not going to give your child proper supervision. Delaying seeking care. Three days ago, yeah, he fell off his bike three days ago. I didn't think it was a big deal, but now he needs to go to the hospital. Why did you wait three days? If it was that bad three days ago, if it's this bad now, who was that bad three days ago? Good relationship between the child and the caregiver. If the child is afraid or apprehensive of the parent, every time that you ask a question to the child, they look to the parent, or the parent interjects automatically, those are bad times. A child that is overly affectionate. Three, four, five-year-old kid that comes up and gives you a big hug and a kiss and wants to sit on your lap. You don't know me. I'm an EMT in uniform. You should be scared of me. If you're walking up and you feel comfortable with me sitting on my lap, that could be the sign of sexual abuse. Are there multiple injuries in different stages of healing? I was accident prone as a kid. I used to get hurt all the time. But I'm surprised my mother didn't get investigated the number of times I was in the ER. But that is questionable. Any unusual marks or bruises that can be caused by cigarettes, heating grates, or branding. Kids don't burn themselves with cigarettes. They don't brand themselves. They don't burn themselves with electric wires. Are there different types of injuries? Are there bruises and cuts and scrapes in different various stages of healing? Burns on the hands and feet involving glove distribution. That's all the way. Like I immersed my hand. Kids don't immerse their hands in a pot. They don't immerse both feet in a hot tub, right? Or you get the feet, the glove burned around the feet and then the bottom of the buttocks. They lowered a child into a tub. The child with the feet in the tub got burned. Lifted the feet up and they kept lowering the child in and burned the buttocks. Is there an unexplained decreased level of consciousness? That's common with shaken baby syndrome. I don't know what happened. I put the baby to bed and the baby won't wake up. And you go to assess the bed and the baby. And the baby's got dilated pupils or disconjugated gaze. Patient is breathing erratically. Maybe seizure activity. Maybe unresponsive. Maybe even with a pulse. Are they clean and appropriate weight for their age? I remember this is Chicago. But there was a man, God bless you, that had, I don't remember the story. Something about, I don't know if his wife had died. But he had children with his daughter. And the children, they were all kept in the basement. And one of the children escaped once for years. One of the kids escaped one day and went over to a neighbor. And the neighbor went over and called the police and they rescued the kids. And they were looking at the different kids and they were speaking to one of the kids. And the kid, they thought he was like 10 years old. He came out to be 17. He thought he was 10. He was so malnourished for so long that he looked like he was 10 years old at 17. Is there any rectal, any injuries leading to any private areas? Rectum, genitals, that's automatically subject. It could be innocuous, but it's automatically subject. Does the home look clean, dirty, warm or cold? Is there food? Does it look like it's well maintained? Does it look unsafe? If you have a cousin, a brother, sister, friend, young kid that you love, would you bring them to that house? If you say, I wouldn't let them walk through the door, maybe there's some services that need to be done there. Under Massachusetts law, any situation like this, you are a mandatory reporter. It's called 51A. You have to go and report it. And basically what you're doing is you're saying in the report, this is what I saw and it needs to be investigated. You're not accusing anybody. You're not saying anything. You're subjectively explaining exactly what you saw on the call. That's up to them to investigate. You can't be held liable for slander or libel. That's not it because you're not accusing anybody. Child abuse mnemonic. This mnemonic will help you assess possible child abuse. First of all, C, consistency of injury of the child's developmental age. Does the injury fit the age of the child? History inconsistent with injury. They tell you one story. Especially if the child tells you one story and the parent tells you something else. Or the child tries to tell you something and the parent interjects. Inappropriate parental concerns. Apathy or overly defensive. Lack of supervision. Again, if a child is hurt, it's lack of supervision. Delay in seeking care. Affect. That's the child, the parent or the child's reaction. Flat affect. You'll see that in mental health terminology. Means that you kind of sit there. Apathy for the adult. Bruises of various ages of healing. Unusual injury patterns. Suspicious circumstances in any environment. What you see around the house. Any signs that there was an abuse. Bruises. Observe color and location. New bruises are pink or red. And over time, they turn blue, green, yellow, brown as they fade. Right? So you see some pink or red. Some blue. Some green. In various parts of the body. Especially on the back, on the buttocks. Those are usually signs of abuse. Defensive wounds are usually the forearms or the shins. Whereas the back and the buttocks are usually inflicted wounds. Burns. Again, burns to any genital area is automatically suspect. Again, it can be inaccurate. The kids spilled soup on themselves. But you have to question that. Burns that have a glove distribution. Suspect child abuse if the child has cigarette burns or grid pattern burns. Kids don't touch griddles and they don't touch cigarettes. They generally, if they do, they don't burn themselves with it. They don't touch themselves with a cigarette. That's the general rule. Fractures of the humerus or femur do not occur without major trauma. It's got to be a significant trauma. Especially the younger they are. Falls from beds do not cause long bone fractures. My buddy, it did. My buddy, it did. He had a high bed. For some reason, it did. But it's a general rule. Falls from beds. So somebody says, oh, he fell out of his bed. You put him in his bed and it's two feet off the ground and he's got a femoral fracture. Uh-uh. That ain't playing. Infants may sustain life-threatening head trauma from being shaken or struck. If I take a four-year-old and go, ah, playing around, that's probably not going to do anything. But I do the same shaking to an infant, tear blood vessels, tear neural pathways, and the child will end up being severely brain damaged or dead. Infants can be found unconscious without evidence of external trauma. They just don't wake up. I don't know what it is. You just won't wake up. And then the neurologist does their assessment and realize shaken babies. You can find it. It's very easy to find. Good luck. Usual refusal or failure to provide life-threatening necessities. Water, clothing, shelter, personal hygiene, medicine, comfort, or personal safety. Again, does it look like the child has a nice home, well cared for? Is the child unkempt? I mean, I've gone to homes where the child was running around in a diaper and the diaper was hard as a rock. Where the baby had shape marks because the stool had hardened because they didn't change the baby's diaper. I've gone to crawls. What happens is very common. Go to Great Fork Valley for the wandering child. This is a child running around. Nobody knows where they are or where the kid belongs. Not an uncommon thing to happen. Abused children may appear withdrawn, fearful, or hostile. Be concerned if the child does not want to discuss how an injury occurred, especially in the presence of a parent. Now remember, you want that child at the hospital. So don't get into a brouhaha with the parent. Don't give any suspicious activity. Don't look at them on a cross-eyed. You say, yeah, my kid's accident prone. He gets hurt like this all the time. Let's do this. I'm going to pick him in the ambulance. We're going to bring him to the hospital. Why don't you follow in the car, follow behind this, because you're going to need to bring him home. He's probably going to be released in an hour probably. Okay. And then once you get the kid back in the ambulance, now you can say, look, I see something that leads me to believe that you feel unsafe. Do you feel safe? I might not tell you anything, but it doesn't matter. You reported it anyway. Parents may reveal a history of accidents. Be alert for conflicting stories. Abuser could be a parent, caregiver, relative, family, or friend. It could be a neighbor. Who knows? EMTs in all states must report suspected abuse. Mandatory report 51A. Supervisors are generally forbidden from interfering with a report. If you're working for me and you come to me and say, Grant, should I fill out a report on this? I'm going to tell you two things. Number one, I can't tell you one way or the other. And number two, if you're questioning, fill it out. If you have any doubts whether you should fill it out or not, fill it out. Most of the time people don't fill it out because they don't want to, because it's paperwork. If you come up to me and say, hey, I have this patient who, you know, his father said he knows you. He's a friend of yours. I don't care if it's my best friend. I don't care if it's my brother. If you want to file a report, I can't tell you not to. I can be criminally liable for that. I can go to jail for that. Law enforcement and child protective services will determine whether there is abuse. And sometimes you fill out a 51A and nothing's done. You did your job. You reported it. That's all you have to do. You can't go beyond that. Sexual abuse. Children of any age and gender can be victims of sexual abuse. Maintain a high index of suspicion. It's often long-standing. Children usually are not going to go to first-time assault of a child. It can happen, but as a general rule, it's been happening for a while. Limited. Your assessment is limited to determine the type of dressings required if there's an injury. I don't want to go and do any probing or any investigating or any physical assessment because I don't want to ruin any evidence. Treat bruises and fractures. Do not examine the genitalia unless there's evidence of bleeding. Do not. This is where I can stop. I can say no to this. Under the age of 18, I can say you can't wash, urinate, definitely brush your teeth, change your clothes, anything like that. Pick you right up, put you on the stretcher, wrap you like a burrito in a blanket, and take you to the hospital. Ensure an EMT or police officer of the same gender remains with the child. Make sure you call that same report. And if it's a child, you can say patient X. The protocol, what you say is protocol X. So you call, what's the C-Med? What's the C-Med? This is MedStar 38 looking for an entry note to university pediatrics protocol X. You say that, they know exactly what that means. They pick up the phone. You can say the university, this is MedStar 38, we'll issue a facility with a five-year-old female protocol X. That's all you have to say. And then the vitals. They know exactly what you're talking about. Decade of compassion. Professional composure. Assume a caring, considerate approach. Shield the child from onlookers. Do not punch the caregiver in the face. You're going to want to. And I've come close. But do not do it. Obtain as much, because the worst thing you can do is have the parents say, you know what, never mind. I'll take him to the hospital. And you know the kid's not going to go. Understand that abuse in many situations escalates. It doesn't get better. It gets worse until there's a final outcome of death. In most abusive situations, it gets worse before it gets better. Obtain as much information as possible from the child and any witnesses. Transport the child, transport all children of any questionable abuse. It is a crime to cooperate with law enforcement. SIDS, sudden unexpected death, refers to a sudden unexpected death where the cause is not known until an investigation is conducted. One of the causes of SIDS is SIDS, which is results in death that cannot be explained by any other means. So SUDs, S-U-I-D, is a death that happens and they don't know what caused it, but they figure it out. A subset of that is SIDS, where the death happens and they don't have any explanation for it. They say that 3,500 deaths until infants die a year are SIDS. It usually happens between six weeks and six months. And they did, back in the 70s, they did a back-to-sleep program where they told parents to put their children on their back, remove all blankets and pillows, no toys in the bed, and that reduced SIDS deaths by about 40%. So that had something to do with it. But we still have SIDS deaths. They think it might have something to do with severe gastroesophageal reflux disease, spasming of the airway, things like that. So babies should be placed on their back in a firm mattress, free of blankets, pumpers, and toys. Babies should sleep in the same room but not in the same bed. And I'm bad. All of my children slept with me in bed and that's so bad. I have done CPR on babies because mom fell asleep and rolled over on the baby. And it's the most horrific thing you could deal with because mom killed her baby and didn't mean to. She just was tired and fell asleep. If you ever know anybody who's sleeping in bed with their baby, no, no, no, no, no. I don't care. And don't say, I'm a late sleeper. Don't do that. Just don't do that. Breastfeeding and use of pacifiers may lower the risk. Risk factors. Mothers younger than 20. Teenage mothers have a higher risk of SIDS. Mothers who smoke during pregnancy. Mothers who use alcohol or illicit drugs during pregnancy or after birth and low birth weight. And it can occur any time of the day. It doesn't just happen overnight. You are faced with three tasks. Assess the scene. Assess and manage the patient. And communicate support with the family. If you suspect child abuse, do not let the family near the child to say, hey, you know, we have to wait for the police to come. If you don't suspect child abuse, if it's a true SIDS, allow the family member to hold the child. It begins the grieving process, right? You want to make sure. And this is the thing with the SIDS. If you come up to a baby and it looks viable and there's no rigor, work it. Transport it to the hospital. Even though you don't think the baby's going to make it. Because getting the patient there also gets the family there. And the family probably needs services. But do not resuscitate an obviously dead baby. If the baby's blue, cold, and stiff. Not going to make it. SIDS babies are usually blue or pale, not breathing, and are responsive. Many times just shaking them, baby, baby, and wakes them up sometimes. They call those ALT, life-altering, or whatever they call it. Other causes could be overwhelming infection, child abuse, airway obstruction, meningitis. Could be some congenital defect, cardiac defect. Accidental or intentional poisoning, hypoglycemia. Provide your necessary interventions. Remember that if the patient's not going to make it, who is the patient now? The family members and caregivers. Depending on how much time has passed, the patient may show post-mortem signs. If they're stiff, if they're cold, if they're blue, you're not going to work them. Call medical controls before you decide not to do anything.