Paramedics often say that pediatric calls are the call they fear most. Although it is true that children cannot be treated simply as small adults, they are not something to be feared. In this portion of the chapter, the goal is to allay that fear so that you can be more confident when you arrive to the side of a sick infant or toddler.
Allusions were made to a couple specific anatomic and physiological differences earlier in this chapter because they appear in specific age groups. Here, the discussion will focus on the major differences between children and adults and include the impact of the difference on prehospital assessment and treatment. The differences will be listed in head-to-toe order, not necessarily the order in which they would be found during a physical examination and not necessarily in any particular order of importance.
Children’s breathing problems are classified as respiratory distress, respiratory failure, or respiratory arrest.
| Condition | Compensation | Signs and Symptoms | Treatment Options |
|---|---|---|---|
| Respiratory distress | Compensated | Retractions, nasal retractions, sniffing position, and tripoding in older children | High-flow O2 and nebulized albuterol for wheezing |
| Respiratory failure | Decompensated | See-saw breathing in infants, altered mental status, head bobbing, cyanosis, bradycardia, and slowing respirations | High-flow O2 and positive pressure ventilation |
| Respiratory arrest | None | No breathing, marked bradycardia, and cyanosis | Positive pressure ventilation, intubation, and CPR for HR <60 |
Please refer to chapter 3 for information on the following respiratory emergencies: asthma, anaphylaxis, croup, and epiglottitis.
Cystic fibrosis is a genetic disease that often is discovered early in life, usually by the 2nd birthday. Its hallmark is excessive, thick secretions of mucus in the lower airways and a high salt content in sweat. Patients have a difficult time clearing these secretions and often are hospitalized for infections such as pneumonia and bronchiolitis. Treatment for a patient with cystic fibrosis is largely symptomatic and may include bronchodilators, humidified O2, and possibly positive pressure ventilation.
Commonly known as whooping cough, pertussis is caused by an infection with bacteria and transmitted via respiratory droplets. Its symptoms are similar to the common cold, with a runny nose, sneezing, and coughing, but as the disease worsens with time, the cough will take on the characteristic “whoop” sound with inspiration. The coughing can become so severe that the patient presents with respiratory distress and cyanosis. If pertussis is suspected, take airborne precautions, including surgical mask and eye protection.
Bronchiolitis is a swelling of the lower airways similar in nature and presentation to asthma, but it resulting from a viral infection called respiratory syncytial virus. Because asthma is rare in children under 1 year old, the virus is most likely causing the symptoms. Regardless of the ultimate cause, the treatments are identical. Albuterol or nebulized racemic epinephrine should be administered; in severe cases, positive pressure ventilation may be needed as the patient moves from respiratory distress to failure.
Children in respiratory distress often benefit from supplemental O2. With their relatively low tidal volumes and high metabolic O2 demand, any disease process that affects alveolar ventilation or respiration should receive high-flow supplemental O2. A child who is still responsive may not tolerate a face mask despite needing that volume of O2. In this case, blow-by O2 across the nares can be similarly effective without stimulating anxiety in the child. The child’s caregiver can be a resource in a situation such as this because the caregiver may be more successful at holding the tubing near the child’s face.
Initiation of positive pressure ventilation should begin at the 1st sign of a decrease in respiratory effort or level of consciousness. Ensure that the proper size BVM is used for ventilation but avoid overinflation of the lungs. Children’s lungs are more susceptible to barotrauma from forceful ventilation compared with an adult’s lungs, and it is not uncommon for a rescuer to use an adult bag on the child. If this is the case ensure that the ventilation volume is just enough to see the chest rise and that the person providing the positive pressure ventilation is focused on that critical job.
Intubation of children should be performed for any of the following reasons:
Selecting the size of the ETT can be difficult in a child. In children <8, the size of the airway at its narrowest point can be approximated by comparing the size of the ETT to the pinky of the child. The diameter also can be calculated by adding 16 to the patient’s age in years and then dividing the result by 4.
When preparing to intubate, in addition to having suction and other ancillary equipment prepared, always have available a tube 1 size higher and 1 size smaller than the expected size tube.
If the benefit to the child outweighs the possible risks, then the child should be intubated. The risks, in many cases, can be anticipated ahead of time, with steps taken to mitigate them. The risks of intubation include the following:
The child who is intubated should be constantly reassessed specifically for tube displacement and the effects of barotrauma. Use the mnemonic DOPE to assess the child, especially when changes in ventilatory status present.
Shock in any person regardless of age is the lack of perfusion to end organs. Children can experience the same types of shock as an adult. The major difference between children and adults is that children will be able to remain in compensated shock for longer period of time. However, when the time comes that the child can no longer maintain blood pressure, it is because the child has completely exhausted every compensatory mechanism available. The blood pressure drops alarmingly fast, often without warning; if the child is not already receiving aggressive pressure support therapy, irreversible shock is imminent.
Compensated shock is characterized by tachycardia in the child. Young children do not sweat nearly as readily as older children and adults. Pallor centrally and mottling of the skin peripherally should be concerning because both indicate shunting of blood from the peripheral circulation to the central circulation. Capillary shunting in children is more successful than in adults, so seeing this should alert the paramedic to begin treatment.
As the shock progresses and compensated shock becomes decompensated, the child will become lethargic. As the child becomes lethargic, he or she begins to no longer respond to familiar surroundings. Children will no longer cry when they are taken away from their parents or regular caregivers. If they can still make a sound, it will be a weak whimper that is short lived after a painful stimulus. Peripheral pulses will no longer be palpable, and central pulses will remain strong before fading later. A child who is first encountered in this state should receive aggressive fluid resuscitation and pressor support as soon as possible with vascular access most likely started with an intraosseous line.
Hypotension will be profound as the child begins to decompensate. The minimum SBP in a child can be calculated based on the child’s age. The minimum blood pressure is calculated by adding 70 to twice the age in years.
Anything approaching this value should be concerning because it will become significant shock. Anything below this value should be treated aggressively.
The cornerstone of shock treatment in the child is fluid resuscitation. Therefore, vascular access in the child in shock is essential. The access may be intravenous or intraosseous, and fluid should be able to flow freely or with pressure added to the intravenous bag. For the child in symptomatic shock who is tachycardic with other signs such as pale cool mottled skin or altered mental status, fluid should be given as a bolus of 20 mL/kg. This dose may be repeated up to 3 times before blood or blood products are required.
Once the vascular access has been obtained and the fluids are being administered, treatment should be targeted to the cause or type of shock.
Altered mental status in children can be caused by any of the same reasons that adults can experience AMS. The mnemonic AEIOU-TIPS lists the major reasons for a person present with an altered mental status.
| A | Alcohol |
| E | Epilepsy and endocrine electrolytes |
| I | Insulin |
| O | Opiates |
| U | Uremia |
| T | Trauma temperature |
| I | Infection |
| P | Poisoning psychogenic |
| S | Shock and stroke |
Treatment for any of these reasons is largely the same as in the adult population. Every patient with an altered mental status should be checked for low blood sugar even if there is no history of diabetes.
Overdoses and poisonings in children can be widely varied and can be either accidental or intentional. Younger children are more likely to have accidentally overdosed on medications thinking that they are candy. These overdoses can be catastrophic and should be treated symptomatically with appropriate supportive care. Older children are more likely to intentionally overdose on prescription medications or street drugs. Older children also may do this with the intent of achieving a euphoric state or to execute a plan of suicide. Again, these should be treated symptomatically.
Seizures in children can be caused by a number of factors. Hypovolemia, sepsis, underlying abnormalities, epilepsy, and fever are all common reasons for a child to seize. It may not be possible to determine the exact cause in the field. Febrile seizures are most common, but the child should be assessed to rule out other causes for seizures, including head injuries and stroke.
A febrile seizure occurs when a child’s temperature rises very quickly, often as the result of an infection rather than environmental hyperthermia, although hyperthermia is possible as well. Febrile seizures occur in children between the ages of 6 months and 6 years. A child who has had a febrile seizure in the past is predisposed to having another febrile seizure.
Treatment for this type of seizure most often is supportive. This type of seizure seldom requires intervention because it typically lasts less than 5 minutes, and the child returns to normal within an hour of the event. Anticonvulsants are not usually indicated for this reason. Rapid, active cooling often is contraindicated as well because the resulting rapid drop in core body temperature could precipitate another seizure. If the child is bundled up or under multiple blankets, removing the child from the blankets is all the cooling that would be recommended in this situation.
Children having an epileptic seizure, on the other hand, will require more aggressive interventions. These children should receive O2 to maintain a pulse oximetry reading of >95%, and high-flow O2 during ongoing seizures regardless of the pulse oximetry. Establishment of an intravenous line is recommended as soon as the seizure activity subsides. Anticonvulsant medications should be administered according to the patient’s weight. It is best to use a length-based tape to determine the doses of the medications.