As an Emergency Medical Responder, you should be familiar with the anatomical and physiological differences between children and adults.
A child's head is proportionately larger and heavier than an adult's until about 4 years of age. Because the back of a child's head sticks out and children's foreheads are large, these areas are susceptible to injury, especially bruising.
The top and back of an infant's head contain small, triangular openings called fontanels ("soft spots"). These areas will not completely close until about 6 months of age for the rear fontanel and 18 months for the top one. You should assess the fontanels of an infant and a toddler for bulging or a depression. Bulging in a quiet patient suggests increased pressure within the skull, such as fluid or pressure on the brain. A depression suggests the patient is dehydrated.
The necks of infants and toddlers are flexed when they are lying flat because the back of the skull is large. The chin is then angled toward the chest. Proper positioning of an infant's or a toddler's head is an important factor when managing the airway.
A child's nasal passages are very small, short, and narrow. Because newborns are primarily nose breathers, a newborn will not automatically open his or her mouth to breathe when his or her nose becomes obstructed. As a result, any obstruction of the nose will lead to respiratory difficulty. You must make sure the newborn's nose is clear to avoid breathing problems.
Although the opening of the mouth is usually small, a child's tongue is large in proportion to the mouth. The tongue is the most common cause of upper airway obstruction in an unconscious child because the immature muscles of the lower jaw (mandible) allow the tongue to fall to the back of the throat.
In children, the flap of cartilage that covers the opening between the vocal cords, the epiglottis, is larger and floppier than in adults. Therefore, any injury to or swelling of this area can block the airway.
The windpipe (trachea) is softer and more flexible, and has a smaller diameter and shorter length than in adults. The trachea has rings of cartilage that keep the airway open. In children, this cartilage is soft and collapses easily, which can then obstruct the airway.
A child's ribs are soft and more flexible than those of an adult. Therefore, trauma to the chest will be transmitted to the lungs and other internal structures more easily.
Children breathe faster and their hearts beat harder and faster than those of adults. Infants and young children also have a relatively small blood volume. A sudden loss of 1/2 liter (500 mL) of the blood volume in a child, or 100-200 mL of the blood volume in an infant, is considered serious.
Most of an infant's body weight is water, so vomiting and diarrhea can result in dehydration.
Because an infant's skin is thin, with few fat deposits under it, an infant is sensitive to extremes of heat and cold. Infants have poorly developed temperature- regulating mechanisms. They are unable to shiver in cold temperatures and their sweating mechanism is immature in warm temperatures. Because infants and children are at risk for hypothermia, it is very important to keep them warm.
The age classification of infants and children is the following:
Newly born—birth to several hours following birth
Neonate—birth to 1 month
Infant—1 to 12 months of age
Young infant: 0 to 6 months of age
Older infant: 6 months to 1 year of age
Toddler—1 to 3 years of age
Preschooler—4 to 5 years of age
School-age child—6 to 12 years of age
Adolescent—13 to 18 years of age
Your assessment of an infant or a child should begin from across the room. Quickly determine if the child appears "sick" or "not sick." Quickly assess
Appearance. A child should be alert and responsive to the surroundings.
(Work of) breathing. With normal breathing, both sides of the chest rise and fall equally. Breathing is quiet, is painless, and occurs at a regular rate.
Circulation. The visual signs of circulation relate to skin color, obvious bleeding, and moisture. If the child's skin looks pale, mottled, flushed, gray, or blue, proceed immediately to the initial assessment.
Once your general impression is complete, perform a hands-on assessment. In a responsive infant or child, use a toes-to-head or trunk-to-head approach. This approach should help reduce the infant's or child's anxiety.
During your initial assessment, find the answers to these five questions:
Is the child awake and alert?
Is the child's airway open?
Is the child breathing?
Does the child have a pulse?
Does the child have severe bleeding?
If a child is unable to speak, cry, cough, or make any other sound, the airway is completely obstructed. If the child has noisy breathing, such as snoring or gurgling, he or she has a partial airway obstruction. Do not agitate the child. If the child has a foreign body in the airway, agitation could cause the object to move into a position that completely blocks the airway. Encourage the child to cough and allow the child to continue his or her efforts to clear his or her own airway. Continue to watch the child closely. You will need to intervene if the child has a complete airway obstruction.
The most common medical emergencies in children are respiratory emergencies. Upper airway problems usually occur suddenly. Lower airway problems usually take longer to develop. A patient with an upper airway problem is more likely to worsen during the time you are providing care than is a patient with a lower airway problem. You must watch closely for changes in the patient's condition and adjust your treatment as needed.
The three levels of respiratory problems are the following:
Respiratory distress is an increased work of breathing (respiratory effort).
Respiratory failure is a condition in which there is not enough oxygen in the blood and/or ventilation to meet the demands of body tissues. Respiratory failure becomes evident when the patient becomes tired and can no longer maintain good oxygenation and ventilation.
Respiratory arrest occurs when a patient stops breathing.
Most children will present with either respiratory distress or respiratory failure. As an Emergency Medical Responder, you must know how to treat both conditions:
You can assist a child with respiratory distress by doing the following:
Help the child into a position of comfort.
Reposition the child's airway for better airflow if necessary.
Provide oxygen if it is available and you have been trained to use it.
If the child shows signs of respiratory failure or respiratory arrest, assist the child's breathing with a bag-valve-mask device. If a bag-valve-mask device is not available, assist breathing using a mouth-to-mask device. Bag-valve-mask or mouth-to-mask breathing is also appropriate if you are uncertain about the child's degree of respiratory difficulty.
Cardiopulmonary arrest results when the heart and lungs stop working. When respiratory failure occurs together with shock, cardiopulmonary failure results. Cardiopulmonary failure will progress to cardiopulmonary arrest unless it is recognized and treated promptly.
A seizure is a temporary change in behavior or consciousness caused by abnormal electrical activity in one or more groups of brain cells. Status epilepticus is a seizure that lasts longer than 30 minutes. Alternately, it is a series of seizures that occurs over a 30-minute period in which the child remains unresponsive between seizures. Status epilepticus is a medical emergency that can cause brain damage or death if it is not treated.
It is most likely that, once you have arrived at the scene, the seizure will be over. Obtaining a good history is very important when treating these patients. If you witness the seizure, you will need to be able to describe what it looked like to responding EMS personnel.
Comfort, calm, and reassure the patient while waiting for additional EMS personnel to arrive. Protect the patient's privacy. Do not put anything in the patient's mouth. Make sure that suction is available because the child may vomit during or after the seizure.
As soon as the seizure is over, make sure the child's airway is open. Place the child in the recovery position if there is no possibility of spinal trauma. Gently suction the child's mouth if secretions are present. Provide oxygen if it is available and you have been trained to use it. Report your assessment findings to the EMS personnel arriving at the scene.
The period after a seizure is called the postictal phase. During this recovery period, the child often appears limp, has shallow breathing, and has an altered mental status. This phase may last minutes to hours.
The most common causes of an altered mental status in a pediatric patient are a low level of oxygen in the blood, head trauma, seizures, infection, low blood sugar, and drug or alcohol ingestion. Any patient with an altered mental status is in danger of an airway obstruction. Anticipate the need to place the patient in the recovery position (if no trauma is suspected). Be prepared to clear the patient's airway with suctioning.
Sudden infant death syndrome (SIDS) is the sudden and unexpected death of an infant. The cause of SIDS is not clearly understood. Approximately 90% of all SIDS deaths occur during the first 6 months of life. Boys are affected more often than girls. Most SIDS deaths occur at home, usually during the night after a period of sleep.
Injuries are the leading cause of death in infants and children.
When arriving on the scene, complete a scene size-up. Consider the mechanism of injury and form your general impression of the patient. Complete an initial assessment of all patients. Comfort, calm, and reassure the patient while awaiting additional EMS resources.
If the child is not alert or the mechanism of injury suggests that the child experienced trauma to the head or neck, stabilize the child's spine. Making sure the child's airway is open and clear of secretions is the most important step in managing a trauma patient.
Control obvious bleeding if present. Check for signs of shock by assessing the child's mental status, heart rate, and skin color.
Extremity injuries should be stabilized by immobilizing the joint above and below the fracture site. Remember to assess pulses, motor function, and sensation in the affected extremity before and after immobilization. Update the EMS unit responding to the scene with a brief report of the child's condition by phone or radio.
As an Emergency Medical Responder, you must be aware of the signs of child abuse and neglect:
Child maltreatment is an act or a failure to act by a parent, a caregiver, or another person as defined by state law that results in physical abuse, neglect, medical neglect, sexual abuse, and/or emotional abuse. It is also defined as an act or a failure to act that presents an impending risk of serious harm to a child.
Physical abuse refers to physical acts that have caused or could have caused physical injury to a child. Examples of physical abuse include burning, hitting, punching, shaking, kicking, beating, or otherwise harming a child.
Neglect is the failure to provide for a child's basic needs. Neglect can be medical, physical, educational, or emotional. Medical neglect is a type of maltreatment caused by a caregiver's failure to provide for the appropriate healthcare of the child although financially able to do so.
Sexual abuse is inappropriate adolescent or adult sexual behavior with a child. To be considered child abuse, these acts have to be committed by a person responsible for the care of a child (for example a babysitter, parent, or daycare provider) or a person related to the child. If a stranger commits these acts, it is considered sexual assault and is handled solely by the police and criminal courts.
Psychological maltreatment is a pattern of caregiver behavior that conveys to children that they are worthless, flawed, unloved, unwanted, endangered, or only of value in meeting another's needs. This type of maltreatment includes verbal abuse, emotional abuse or neglect, psychological abuse, and mental injury.
When providing care for an infant or a child who is ill or injured due to neglect or abuse, show a professional and caring attitude toward the patient. Report known or suspected child abuse as required by law in your state. Carefully document your physical exam findings, as well as your observations of the child's environment. Document the caregiver's comments exactly as stated and enclose them in quotation marks. Your documentation must reflect the facts, not your opinion of what may or may not have occurred. Report your findings to the EMS personnel responding to the scene. After the call, assess your own emotional needs. A discussion with other personnel involved in the call may be helpful.
