Chapter 23: Pediatric Emergencies

Lecture

I. Introduction
	Time: 5 Minutes
	Slides: 1–3
	Lecture/Discussion
A. 	CCTP must remember that the pediatric patient is not a small adult. 
B. 	Pediatric patients differ anatomically, physiologically, and emotionally from adults.
C. 	The types of illnesses and injuries and their responses to them vary across the age span.
D. 	Situations are often complicated by children’s inability to communicate.
E. 	It is imperative to assess the patient and not to rely on the monitors.

II. Anatomy and Physiology 
	Time: 24 Minutes
	Slides: 4–19
	Lecture/Discussion
A. 	Cardiovascular system
1. 	The basic anatomy of the cardiovascular system is the same as adults.
2. 	Different normal ranges for pulse rate and blood pressure
3. 	Children have limited compensatory mechanisms.
B. 	Respiratory system
1. 	The lower airways of children are smaller and more prone to obstruction and collapse.
2. 	Smaller airways cause greater resistance to airflow.
3. 	Mucosa is less adherent to the airways and more prone to the development of edema.
4. 	Children may not be able to ventilate airways distal to an obstruction and may be at a higher risk of atelectasis (lack of inflation).
5. 	Children have a larger tongue in relation to the size of the mouth.
6. 	Infants have highly reactive airways making them more prone to responses to environmental allergens, viral respiratory diseases, and hereditary factors.
C. 	Neurologic system
1. 	Basic brain anatomy and perfusion requirements are similar to that of adults.
2. 	Children do not have a brain that is well compartmentalized, which means there is no room for the brain to move around in the skull.
3. 	The anterior fontanelle closes at 16 to 18 months of age. 
4. 	The posterior fontanelle closes at 2 months of age.
5. 	A normal fontanelle is soft and flat and has a feeling of fullness. 
6. 	A newborn might have a cephalohematoma from forceps or vacuum-assisted delivery.
a. 	The hematoma usually resolves within 6 to 8 weeks and can be associated with linear skull fractures.
7. 	Caput succedaneum is soft tissue swelling and usually resolves in 24 hours.
D. 	Musculoskeletal system
1. 	Children have fewer calcified bones.
2. 	Children’s bones are more porous and tend to respond to kinetic forces by buckling rather than fracturing.
3. 	Epiphyseal-metaphyseal growth plate injuries account for 10% to 15% of all fractures in children.
4. 	The child’s thorax is pliable, so it can stand greater kinetic forces without fracturing.
5. 	If a rib fracture is suspected, this suggests a large source of energy as its cause, possibly indicating a severe pulmonary contusion.
6. 	Ligaments in children are stronger and more resilient to tensile forces. Dislocations are rare.
7. 	The pediatric spine has incomplete ossification, epiphyseal growth plates, and hypermobility. 
a. 	The cervical spine is flexible, and children tend to have avulsions rather than fractures.
E. 	Gastrointestinal system
1. 	Physiologic differences increase the risk of aspiration in children. 
2. 	Children have a smaller stomach capacity, which leads to more frequent meals. 
3. 	The chances of encountering a child with a full stomach in an emergency are high.
4. 	The abdominal muscles are weaker, increasing the risk of injury to internal organs.
5. 	Liver function is immature, resulting in fewer glucose stores. 
F. 	Renal system
1. 	Children have a higher percentage of body water than adults, making them more prone to dehydration.
2. 	Children are unable to concentrate urine as effectively as adults are.
3. 	They may be more prone to electrolyte loss because they have a higher clearance for blood urea nitrogen (BUN), creatine, and electrolytes.
4. 	Urine output
a. 	Infants: 2 mL/kg/h
b. 	Children: 1 mL/kg/h
G. 	Thermoregulation
1. 	Thermoregulation is not fully developed in infants, making them susceptible to hypothermia. 
2. 	Infants have thinner skin and lack a subcutaneous layer of fat. 
3. 	They are unable to shiver and lose heat through the head.
4. 	Children have a large body surface area to mass ratio relative to that of the adult population. 
a. 	They have an ability to dissipate heat quickly. 
b. 	When they are exposed to extremes of cold and heat they can have more problems because they can dissipate heat.
H. 	Metabolism
1. 	Children have a higher metabolic rate than adults. 
2. 	An infant’s consumption of oxygen is twice that of an adult patient.
3. 	The rate of onset of hypercapnia and hypoxemia is also accelerated in this population, warranting close monitoring during transport.
I. 	Glucose requirements	
1. 	Pediatric patients are predisposed to developing hypoglycemia due to secondary factors.
2. 	Infants and children have decreased glycogen reserves and an immature liver that is not capable of stimulating glycogen stores.
3. 	The existing stress from an illness or injury makes the risk of hypoglycemia even higher.
4. 	Treatment depends on the age and weight of the child.

III. Growth and Development
	Time:  6 Minutes
	Slides: 20–23
	Lecture/Discussion
A. 	Physical
1. 	It is common for children to regress during an illness or when recovering from an injury.
2. 	Failure to meet normal developmental milestones may be a sign of an underlying illness, family crisis, or neurologic injury. 
3. 	Parents and other caregivers are the best source of information about how children will react under normal circumstances.
4. 	Communication techniques for children who do not have language skills include using sigh language, observing facial expression, or having the child respond by blinking or moving the eyes from right to left.
B. 	Psychosocial	
1. 	An infant’s primary fear is separation from its parents.
2. 	Children also fear loss of control.
3. 	Preschoolers fear loss of control, bodily injury, the dark, and the unknown.
4. 	Adolescents and teenagers fear loss of control and changes in body image.
5. 	Adolescents are more compliant if they are allowed to participate in decision making.
6. 	Foster trust by speaking at eye level, using first names, and explaining medical procedures using age-appropriate words.

IV. Approach to Parents and Caregivers
	Time: 2 Minutes
	Slide: 24
	Lecture/Discussion
A. 	CCTP should do a self-assessment to ensure they are prepared to deal with pediatric parents.
B. 	CCTP may be distracted by the emotional response of a child or parent.
C. 	CCTP must be sensitive to the needs of parents, guardians, and caregivers.
1. 	Common responses include guilt, frustration, or helplessness.
D. 	Parents often feel fearful, out of control, and uninformed.
E. 	Whenever possible, provide written information and involve parents and care givers in the plan of care.
	
V. Approach to Pediatric Assessment
	Time: 48 Minutes
	Slides: 25–56
	Lecture/Discussion
A. 	Pediatric assessment triangle (PAT)
1. 	This is an assessment tool that uses the child’s appearance, work of breathing, and circulation.
2. 	TICLS
a. 	Tone
b. 	Interactiveness
c. 	Consolability
d. 	Look or gaze
e. 	Speech or cry
3. 	The nature of the child’s airway sounds and signs of increased breathing effort characterize work of breathing.
4. 	Circulation is assessed by observing the child for pallor, mottling, or cyanosis.
5. 	After using PAT, perform a primary assessment:
a. 	Airway patency
b. 	Respiratory rate and quality
c. 	Pulse rate
d. 	Skin temperature and capillary refill time
e. 	Blood pressure
f. 	Neurologic status
i. 	A child’s neurologic status can be obtained by assessing level of consciousness and papillary action.
B. 	FLACC scale
1. 	All children should be assessed for pain.
C. 	History
1. 	Parents can provide information about the child’s history.
a. 	Pertinent questions include those about eating and sleeping patterns, input and output, and activity level.
b. 	Compare this information with information about the child’s normal behavioral patterns.
c. 	The history for infants and chronically ill children will also include perinatal history, delivery history, gestational age, and gestational weight.
d. 	Scene and situation information is also useful.
D. 	Pediatric medication delivery
1. 	Emergency medications are usually prepared using adult formulations.
2. 	Pediatric medications often require the CCTP to make calculations, increasing the likelihood for error.
3. 	Doses of high-alert medications, such as narcotics, heparin, insulin, and potassium chloride require an independent recheck after they are administered.
4. 	Medications can be delivered through an IV push, syringe pump, or infusion pump.
5. 	The best option for administering resuscitation medications is the vascular access device.
E. 	Airway
1. 	Infants can breathe and swallow at the same time. 
2. 	Infants are obligatory nose breathers; they only breathe through their mouths when they are crying.
3. 	Nasal congestion in an infant can be life threatening. 
4. 	Children have a large tongue in relation to the size of their mouths.
a. 	Proper choice of blade size, proper positioning, and effective sweeping of the tongue are essential for successful intubation.
b. 	A twisting technique is sometimes used to insert the tube past the vocal cords.
5. 	The trachea is usually anterior. 
a. 	The upper airway is more easily compressed.
b. 	Placing a child in the sniffing position with the aid of towel rolls helps.
c. 	Pediatric patients also may have large tonsils and have large amounts of oral secretions.
6. 	Upper airway obstruction may be recognized by nasal flaring and by increased inspiratory effort. 
7. 	A child who is losing consciousness may need to be intubated because he or she may no longer be able to protect the airway.
8. 	Order of loss of reflexes
a. 	Swallowing
b. 	Coughing
c. 	Gag reflex
d. 	Corneal reflex
F. 	Breathing
1. 	Children with lower airway obstruction may experience end-expiratory grunting.
2. 	Grunting occurs when a child tries to exhale against a partially closed glottis.
a. 	This is a physiologic positive end-expiratory pressure (PEEP) when they are trying to pop open their alveoli.
3. 	The diaphragm is the chief muscle for ventilation in children.
4. 	Intercostal and accessory muscles are not fully developed until the child is school-aged.
5. 	Tools used to qualify the work of breathing in children include assessment of stridor, snoring, restrictions, head bobbing, accessory muscle use, tripoding, nasal flaring, wheezing, and grunting.
6. 	Children having respiratory difficulties often place themselves in the tripod position.
7. 	The same factors that increase the heart rate can increase the respiratory rate, including pain, fear, and fever.
8. 	As respiratory distress progresses, the respiratory rate may become slower and more irregular.
9. 	CCTP must monitor the patient’s respiratory rate, pattern, oxygen saturations, and electrocardiographic (ECG) waveform for any changes in heart rate or function.
10. 	CCTP can assess child’s respiratory function by watching for chest excursion and by listening to the child’s breathing.
11. 	Measurements commonly used in the field to help determine breathing adequacy include oxygen saturation as measured by pulse oximetry (SpO2) and end-tidal carbon dioxide (ETCO2) values.
12. 	Arterial blood gas (ABG) determinations can help in deciding on whether or not to intubate a child.
G. 	Circulation
1. 	Observe the child’s general appearance and level of consciousness. 
a. 	A child who is well perfused will be watching the CCTP and other activity in the room.
b. 	CCTP can often observe the heart beating through the skin.
c. 	Clubbing is the broadening of the child’s fingers and toes in response to chronically low oxygen levels. 
d. 	Poor cerebral perfusion can be manifested with agitation, confusion, or progressive decrease in response to external stimuli.
e. 	In septic shock or traumatic brain injury, the mean arterial pressure (MAP) is a more effective means of guiding therapy.
2. 	Vital signs
a. 	For infants, it may be easier to listen for the heart by placing the stethoscope over the second intercostal space at the midclavicular line.
b. 	For older children, placing the stethoscope over the fourth intercostal space might be better.
c. 	Cardiac sounds should be absent of rubs, murmurs, gallops, or secondary sounds.
d. 	Doppler ultrasound may be a useful assessment tool if the pulse cannot be felt.
e. 	In children, assess the pulse using the cardiac, radial, femoral, or dorsalis pedis arteries.
f. 	In infants, assess the pulse in the brachial or femoral arteries.
3. 	Stroke volume
a. 	The younger the child, the higher the pulse rate.
b. 	Stroke volume is smaller in children than in adults.
c. 	An increase in heart rate is the chief compensatory mechanism in children to increase end-organ perfusion and to maintain blood pressure.
4. 	Skin condition
a. 	An assessment of the child’s skin is a good indicator of circulation and of whether hypoperfusion exists.
b. 	Early compensatory mechanisms shunt blood from the skin to the vital organs.
c. 	As a child becomes hypoperfused, the skin becomes cool, pale, mottled, or cyanotic.
5. 	Blood pressure
a. 	A child initially compensates well during hypoperfusion.
b. 	Normal blood pressure may be maintained until compensatory mechanisms are depleted.
c. 	A common problem in measuring blood pressure in children is getting the cuff to fit right.
d. 	It may be easier to get an accurate reading from a lower extremity.
6. 	Fluid volume and access
a. 	Any trauma or medical condition that causes fluid loss requires IV access for volume replacement.
b. 	The use of intraosseus (IO) access (into the bone marrow) has become more common in infants or children requiring immediate intervention.
i. 	The most common IO site is the anterior tibia.
ii. 	IO access is obtained using a bone injection gun (BIG).
c. 	Urine output can be an objective guide in measuring pediatric circulatory status.
H. 	Neurologic assessment
1. 	Evaluate the child’s general appearance.
2. 	How is the child responding to the environment?
3. 	Is the child responsive and awake, or unresponsive and lethargic?
4. 	A sunken fontanelle may indicate dehydration.
5. 	The Glasgow Coma Scale (GCS) is the most effective indicator of mental status.
6. 	Check the size of the child’s pupils and their response to light.
a. 	Very constricted or point pupils indicate a narcotics overdose.
b. 	Dilated pupils indicate a brain injury.
7. 	Muscle tone
a. 	Children normally have flexed elbows and knees. 
b. 	Completely flaccid extremities are an abnormal finding.
c. 	Moro reflex: The child jumps or is startled by a loud noise.
d. 	Stepping reflex: The infant moves his or her legs up and down when held in the air.
e. 	Babinski reflex: Flaring toes are normal; toes pointing downward indicate a brain injury.
8. 	In a child with a decreased level of consciousness, the presence of protective reflexes determines whether the child needs intubation.
I. 	Renal assessment
1. 	Parents or caregivers can provide information on child’s fluid intake, wet diapers, stools, frequency of vomiting, etc.
a. 	Asking parents or caregivers if diapers are different may be a more important measurement of a problem.
b. 	CCTP can weigh diapers to determine amount of fluid loss.
2. 	Physical assessment may include fontanelles (infants) skin turgor and presence or absence of tears.
3. 	Fluid overload is less common in children, although it may occur in patients with congenital heart defects or renal insufficiency.
a. 	Fluid overload symptoms include weight gain, edema, and history of fluid intake greater than output.
J. 	Exposure considerations
1. 	Infants are not able to shiver.
2. 	Resuscitation efforts must include efforts to maintain body temperature. 
3. 	Be careful not to overwarm the patient.
4. 	Heat loss can be minimized by replacing blankets on areas of the child that have already been assessed.

VI. Transport Considerations
	Time: 11 Minutes
	Slides: 57–63
	Lecture/Discussion
A. 	Equipment
1. 	It is essential to ensure that appropriate equipment is available when transporting pediatric patients. 
2. 	ECG monitoring with SpO2 and ETCO2 is the standard of care for all intubated pediatric patients. 
3. 	It is important to carry various sizes of ECG leads, pulse oximetry probes, and blood pressure cuffs to ensure accurate vital sign values. A transport ultrasound device may be helpful in verifying the presence of peripheral pulses in poorly perfused children. 
4. 	The transport environment should be latex-free, including barriers such as gloves and monitoring and resuscitation equipment.
5. 	IV fluid administration should be done with an infusion pump that delivers calibrated infusions.
6. 	Fluid boluses and medications for resuscitation should be delivered with a syringe and stopcock technique.
7. 	Fluid and medication formulas should be standardized and calculated prior to transport.
8. 	It is also important to carry equipment for thermoregulation, such as a disposable gel-heated mattress or an incubator.
9. 	Know the capabilities of the transport ventilator for your service. Common requirements for ventilating children include pressure modes of ventilation, capacity for pediatric ventilator settings, and pediatric circuits.
B. 	Interfacility considerations
1. 	Information needed by CCTP
a. 	Age and weight
b. 	Diagnosis
c. 	Reason for transfer
d. 	Physical exam findings
e. 	Diagnostic test results
f. 	Treatment recommendations
2. 	Communication tools such as SBAR (situation, background, assessment, recommendations) help standardize the exchange of information.
C. 	Mode of transport
1. 	Children must be adequately restrained.
2. 	Necessary interventions should be completed prior to transport whenever possible.
3. 	Air transport may be contraindicated in cases where the child’s condition may be worsened by altitude.
D. 	Accompanying parents and caregivers
1. 	Presence of a parent or caregiver decreases a child’s anxiety and emotional distress
2. 	The situation must be assessed for the caregiver’s comfort level and the potential disruption of care during transport. 
3. 	No child should ever be held in a caregiver’s lap during transport. 

VII. Airway Management Devices
	Time: 9 Minutes
	Slides: 64–69
	Lecture/Discussion
A. 	Flow-inflating bag
1. 	Used routinely for anesthesia
2. 	Requires an outside gas source to inflate
3. 	Pressure gauges ensure safety.
B. 	Self-inflating bag
1. 	Requires more experience and manipulation of the equipment to achieve adequate ventilation
2. 	Not recommended outside an environment where health care professionals lack adequate training
3. 	Do not require a compressed gas source
C. 	Oxygen hood
1. 	Useful for children younger than 1 year
2. 	Older children cannot fit into the device.
3. 	Allows oxygen to be concentrated to 80% to 90%, as well as for air to be warmed and humidified
D. 	Shortened tracheal tube
1. 	May be used as an alternative to a nasal tube
2. 	Rigidity of the tube can be responsible for more tissue trauma with insertion
E. 	Blade options
1. 	The Miller blade is a straight blade and is the best choice for infants and small children.
2. 	The Macintosh blade is curved; it is the choice for older children because it displaces the tongue.

VIII. Respiratory Conditions
	Time 32 Minutes
	Slides: 70–90
	Lecture/Discussion
A. 	Types of respiratory conditions that lead to respiratory failure
1. 	Upper airway obstructions
a. 	Most commonly caused by foreign body aspiration or infection
2. 	Lower airway conditions
a. 	May involve the trachea, mainstem bronchi, and peripheral airways
3. 	Peripheral airway diseases
a. 	Include asthma, bronchiolitis, and bronchopulmonary dysplasia
4. 	Parenchymal diseases
5. 	Abnormal control of ventilation
B. 	Croup
1. 	A common viral infection of the upper airway that affects the larynx but may extend into the trachea and bronchi
2. 	Most common in children under 3 years
3. 	Symptoms include a low grade fever and a “barking seal” cough.
4. 	Management starts with creating a calm environment.
5. 	Administer humidified oxygen.
6. 	If obstruction is severe, consider intubation. 
C. 	Epiglottitis
1. 	A bacterial infection caused by Haemophilus influenzae that most commonly occurs in children aged 3 to 5 years
2. 	Symptoms include rapid onset of fever, stridor, and pronounced signs of toxicity.
3. 	Children are at risk of acute and complete airway obstruction.
4. 	Invasive measures should be kept at a minimum.
D. 	Foreign body airway obstruction
1. 	Removal of foreign body should only be attempted in the prehospital setting following the guidelines set forth by the American Heart Association and the American Academy of Pediatrics (AAP).
2. 	Using guidelines, options include chest thrusts, Heimlich maneuver, and laryngoscopy with Magill forceps
a.	Only use back blows on children younger than 1 year.
3. 	Direct visualization of the trachea and removal of the foreign body should only be considered in the event of impending respiratory failure.
E. 	Inflammation
1. 	General inflammation of the upper airway may be the result of inhalation burns or allergic and/or anaphylactic reactions.
F. 	Asthma
1. 	A chronic inflammatory disorder of the lower airways, resulting in inflammation, bronchospasm, and edema
2. 	May be triggered by allergens, exercise, emotions, infections, or cold air
3. 	Reactive airway disease (RAD): Term often used synonymously with asthma
a. 	Most common in children under 3 years
b. 	May progress to asthma
4. 	When parents request a transport for these conditions, it usually means traditional treatments have usually failed and additional therapies are necessary.
5. 	Obtain history when possible from parents or caregiver
6. 	Management includes use of oxygen therapy and bronchodilators.
7. 	Corticosteroids are anti-inflammatory medications often used in conjunction with other therapies.
G. 	Bronchiolitis
1. 	A viral infection most commonly caused by the respiratory synctial virus (RSV) but may also be caused by other viruses
2. 	Primarily affects infants and young children
3. 	Treatment involves administration of supplemental oxygen and IV fluids.
4. 	Bronchodilators should be used with caution.
5. 	Ribavirin may be administered to reduce the need for mechanical ventilation.
H. 	Bronchopulmonary dysplasia (BPD)
1. 	This is a chronic lung disease that develops in preterm neonates who have been treated with oxygen and positive-pressure ventilation (PPV).
2. 	Neonates at risk include those born before 30 weeks of gestation and weighing less than 1200 g at birth.
3. 	Children with this condition are at risk of severe symptoms and death.
4. 	Treatment consists of bronchodilators, corticosteroids, and antibiotics.
I. 	Mechanical ventilation 
1. 	Pressure-cycled ventilation evaluates the inspiratory tidal volume for assessing lung compliance.
a.	A tidal volume of 7 to 10 mL/kg is recommended.
2. 	Volume-cycled ventilation evaluates the peak inspiratory pressures (PIP) to assess lung compliance.
a. 	The initial PIP setting should be the lowest possible value that results in adequate chest excursion.
b. 	Most children can be adequately ventilated with a PIP of 20 to 30 cm.
3. 	Physiologic PEEP (positive end expiratory pressure) for infants and children is 3 to 5 cm. 
a. 	Many critical care practitioners will consider an alternative type of mechanical ventilator if the patient requires PEEP values of greater than 12 cm.
4. 	In infants and children with severe lung disease, an oscillator may be more appropriate. 
a. 	An oscillator delivers smaller tidal values with rapid respiratory rates.
J. 	Ventilator setting changes 
1. 	In both pressure- and volume-cycled ventilation, increasing FIO2, inspiratory time, and PEEP will all improve oxygenation. 
2. 	Increasing PIP and tidal volume within the target range will also improve oxygenation.
3. 	The strategies to improve ventilation depend on the patient’s initial rate. 
4. 	In patients with a rate of 20 breaths/min or less, increasing the rate will improve ventilation and lower the carbon dioxide value. 
5. 	In patients with a higher respiratory rate, increasing the rate may actually worsen ventilation because the expiratory time will be decreased.
K. 	Pneumonia
1. 	A parenchymal lung disease that occurs in the lung itself.
2. 	The younger the child is, the less tolerance he or she has for the condition.
3. 	Transport treatment includes a vigilant assessment of the work of breathing and hydration status.
4. 	Antibiotic therapy is necessary.
L. 	Acute respiratory distress syndrome
1. 	Regardless of the underlying cause, the cardinal determinant is intrapulmonary shunting that has minimal or no response to oxygen therapy.
2. 	Management is primarily supportive, including mechanical ventilation and the use of PEEP and cardiac support.
M. 	Near-sudden infant death syndrome
1. 	A life-threatening, acute episode of apnea
2. 	Often accompanied by choking, gagging, skin color change, and a change in muscle tone
3. 	Causes are often unknown, but they can include gastroesophageal reflux disease, viral lower respiratory infections, seizures, sepsis, and meningitis.
4. 	Requires supportive care and immediate transport
N. 	Sudden infant death syndrome
1. 	Sudden death of an infant younger than 1 year that remains unexplained even after an autopsy
2. 	Incidence is highest during the first 4 months of life 
3. 	Incidence has decreased with a campaign to get parents to put babies on their backs to sleep
4. 	If the baby dies during transport, the parent may become the patient.
5. 	CCTP should attempt to provide emotional support to the parent and make sure support is available at the medical center on arrival.

IX. Cardiac Conditions
	Time: 36 Minutes
	Slides: 91–114
	Lecture/Discussion
A. 	Different types of cardiac conditions
1. 	Known cardiac defect
2. 	Unknown or suspected cardiac defect
3. 	Cardiac arrhythmia
4. 	Shock
B. 	Shock
1. 	A child in early or moderate stages of shock will be able to maintain perfusion.
2. 	Once the compensatory system fails, the child will fail quickly.
3. 	Indicators
a. 	Blood pressure
b. 	Level of consciousness
c. 	Heart rate
d. 	Skin temperature
e. 	Respiratory rate and pattern
f. 	Urinary output
4. 	Hypovolemic shock
a. 	Most common form of shock in children
b. 	Characterized by inadequate intravascular volume
c. 	Most commonly caused by trauma
d. 	Fluid loss by vomiting and diarrhea is often underestimated
e. 	Stages
i. 	Stage 1: Child appears asymptomatic.
ii. 	Stage 2: Child attempts to compensate for fluid losses, but compensatory mechanisms are maximized.
iii. 	Stage 3: Child is no longer able to compensate and hypotension occurs, along with mental status changes and decreased urine output.
iv. 	Stage 4: Death is imminent if volume loss is not eliminated and fluid replacement does not occur.
f. 	Regardless of cause, replacing lost fluids in the top priority.		
5. 	Cardiogenic shock
a. 	Causes include congenital heart defects, drug toxicity, metabolic causes, hypovolemia, myocarditis, and arrhythmias
b. 	Child will present with traditional signs of shock including tachycardia, tachypnea, hypoxia, mental status changes, and changes in skin condition.
c. 	Child often also has pulmonary congestion resulting in rales that can be heard with a stethoscope and jugular venous distension.
d. 	Transport principles concentrate on improving cardiac function with fluid resuscitation and inotropic (agents that change the force of muscular contractions) support.
6. 	Distributive shock
a. 	Major treatment goals include stopping the vasodilatation, returning volume to the intravascular space, and improving tissue perfusion.
b. 	Neurogenic shock
i. 	Volume replacement and vasoactive medications are the primary treatments.
c. 	Anaphylactic shock
i. 	Children will often present with general body edema, hypotension, rash, urticaria, anxiety, and warm, flushed skin.
ii.	Treatment modalities include removing the allergen, volume replacement, and epinephrine.
d. 	Dissociative shock
i. 	Caused by the hemoglobin molecule being unable to give up oxygen to the tissues. 
ii. 	Tissue perfusion is normal, and the release of oxygen is abnormal.
iii. 	Examples include carbon monoxide poisoning, cyanide poisoning, methemoglobinemia, and dyshemiglobinemia.
iv. 	Treatment is early recognition, removal of the cause, oxygen administration, and support therapy.
e. 	Septic shock
i. 	Caused by an overwhelming release of proinflammatory mediators, which are initially released to help damaged cells be repaired
ii. 	The response is so large that it causes more tissue and capillary injury. 
iii. 	Treatment focuses on managing hypovolemia and cardiogenic shock and on removal of infectious agent, if there is one.
iv. 	Conditions of clinical diagnosis include suspected infection manifested by hypothermia or hyperthermia and clinical signs of inadequate tissue perfusion
v. 	Warm phase–patient presents with vasodilation or the appearance of well-perfused organs
vi. 	Cold phase–patient will feel cold to the touch
C. 	Cardiac anomalies
1. 	Cardiac defects that do not cause cyanosis
a. 	Ventricular septal defect (VSD): A hole in the septum between the ventricles. Blood in the left ventricle flows into the right ventricle.
b. 	Atrioventricular canal defect: A hole in the atrial septal wall that allows blood to flow from the left side of the heart into the right side of the heart
c. 	Atrial septal defects: Occur as a hole in the septal wall that allows blood to flow from the right atrium into the right atrium
d. 	Aortic stenosis: A narrowing of the aortic valve
e. 	Pulmonary stenosis: A narrowing of the pulmonary valve
f. 	Patent ductus arteriosus (PDA): A condition in which the ductus arteriosis does not transition as it should after birth to become the ligmentum arteriosum
2. 	Left heart obstruction defects
a. 	Persistent pulmonary hypertension (PPHN): Caused by abnormally elevated pulmonary resistance, resulting in hypoxia
i. 	Typical presentation consists of low APGAR scores, hypoglycemia, and congenital diaphragmatic hernia.
ii. 	Extracorporeal membrane oxygenation (ECMO): A short supportive intervention that is used for patients with PPHN and congenital diaphragmatic hernia
iii. 	Involves moving the patient’s blood through a heart-lung machine and then transfusing it back to the patient
b. 	Hyperplastic left heart system (HLHS)
i. 	Underdevelopment of the aorta, aortic valve, left ventricle, and mitral valve
ii. 	This cardiac lesion is dependent on a PDA, patent foramen ovale (PFO)/ASD for survival. 
c. 	Coarctation of the aorta (CoA): A pinching or narrowing of the aorta that obstructs blood flow from the heart to the systemic circulation
3. 	Cardiac defects that cause cyanosis
a. 	Tetralogy of Fallot (TOF)
i. 	Consists of four defects: ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and overriding aorta
ii. 	Most common defect seen beyond infancy
iii. 	TET spells present with marked cyanosis, irritability, tachypnea, pallor, and loss of consciousness.
b. 	Transposition of the great arteries (TGA)
i. 	TGA is a defect in which the great vessels are reversed.
ii. 	The aorta is connected to the right ventricle, thereby perfusing the body with deoxygenated blood.
iii. 	The pulmonary artery is connected to the left ventricle, carrying oxygenated blood back to the lungs.
iv. 	As the PDA closes, the neonates will present with classic symptoms of cyanosis, especially when crying or feeding.
D. 	General management priorities
1. 	All pediatric patients with congestive heart failure, regardless of age, require diuretics.
2. 	If these don’t work, a vasopressor may be used.
3. 	Any cardiac lesion that is dependent on the ductus arteriosis requires the administration of a prostaglandin E1 (PGE1 [Prostin VR]) infusion. 
E. 	Pediatric ECG interpretation
1. 	The interpretation of an ECG rhythm in children is different from that in an adult. 
2. 	To decrease the amount of respiratory artifact, it is helpful to avoid placing the ECG leads at the level of the diaphragm. 
3. 	The leads may be placed on the lower abdomen or on the patient’s thighs. A 12-lead ECG is not as common in children but is obtained for children with abnormal findings on the rhythm strip, arrhythmias, congenital heart disease, acquired heart disease, chest trauma, or suspected cardiotoxic ingestions. Figure 23-24 
4.  	Steps
a. 	The first aspect of rhythm strip interpretation is assessing whether the rate is appropriate for the child’s age. 
b. 	The next step is evaluating the components of the rhythm, including the PR interval and the width of the QRS complex. 
c. 	Normal values for these components vary with age. A general guideline for children is a PR interval of 0.16 or less and a QRS complex of 0.08 or less. 
d. 	A PR interval of greater than 0.1 indicates a first-degree heart block. 
e. 	A QRS complex of greater than 0.08 indicates a wide complex arrhythmia.

X. Renal Disorders
	Time:  18 Minutes
	Slides: 115–126
	Lecture/Discussion
A. 	Prerenal
1. 	These are the most common renal disorders in children.
2. 	Primarily caused by dehydration or decreased renal perfusion
3. 	Patient may present with nausea, vomiting, diarrhea, diabetic ketoacidosis, shock, and burns. 
B. 	Intrarenal
1. 	The proximal cells of the kidneys have high metabolic demands that make them susceptible to ischemic insults.
2. 	Occlusion of the renal arteries from emboli or thrombosis causes infarction as a result of decreased renal blood flow. 
3. 	Hemolytic uremic syndrome (HUS)
a. 	This is a serious condition in which the patient develops acute renal failure (ARF). 
b. 	It is thought to be caused by several bacterial and viral infectious organisms.
c. 	The primary pathology is thought to be related to endothelial cell injury in the renal cortex that leads to localized vascular coagulation and fibrin deposits.
d. 	Presentation typically follows a gastroenteritis-type illness, and symptoms include vomiting, abdominal pain, and bloody diarrhea. 
e. 	As the gastrointestinal symptoms subside, the child becomes acutely ill, presenting with irritability, pallor and signs of fluid overload.
f. 	Treatment includes maintaining fluid and metabolic balance, control of hypertension, transfusion of packed RBCs and platelets if required, and aggressive treatment of renal failure with possible dialysis (peritoneal) in the hospital. 
4. 	Acute glomerulonephritis (AGN)
a. 	This condition is associated with edema, hypertension, and hematuria.
b. 	AGN results from the deposits of circulating immune complexes in the kidney basement membrane, which ultimately causes reduced glomerular filtration. This syndrome can be induced by a variety of organisms, but the most common is group A beta-hemolytic streptococci.
5. 	Acute poststreptococcal glomerulonephritis (APSGN)
a. 	This condition follows an infection by streptococci, either as a skin infection or as a pharyngeal infection. 
b. 	APSGN occurs most commonly in school-aged children and more commonly in males than females.
c. 	Presentation typically manifests 1 to 2 weeks after the streptococcal infection, and a classic symptom is gross hematuria with urine the color of tea. 
d. 	Treatment of severe APSGN is primarily supportive and includes fluid restriction of IV solution to avoid promoting peripheral and pulmonary edema. 
6. 	Acute tubular necrosis (ATN)
a. 	This is a condition that results in damage to the tissue of the kidneys’ tubules. 
b. 	The condition has many different causes; the most common cause is renal ischemia precipitated by hypovolemia.
c. 	Tubular damage can also occur following a toxic insult, such as heavy metal poisoning or as a result of myoglobin or hemoglobin accumulating in the tubules following a severe crush injury, burn, or hemolytic crisis.
d. 	The renal tubular cells die when they do not get enough oxygen or if they are exposed to a toxic drug. 
e. 	ATN is clinically defined in three phases. 
i. 	The oliguric phase involves a decrease in the volume of urine that lasts about 10 days.
ii. 	The diuretic phase occurs when there is passage of large volumes of isothenuric urine containing sodium levels of 80 to 150 mEq/L. 
iii. 	In the recovery phase, signs and symptoms resolve rapidly as a result of regeneration of tubular epithelial cells.
C. 	Postrenal
1. 	Postrenal or obstructive failure has many causes.
2. 	Flank and/or abdominal pain is often present. 
3. 	Prolonged, unrelieved obstruction causes irreversible parenchymal damage because of infection and increased hydrostatic pressure.
4. 	Obstruction of urine outflow in the renal system causes an increase in hydrostatic pressure at the proximal tubule and glomerulus, resulting in a decrease in glomerular filtration and renal function.
D. 	Complications
1. 	Hyponatremia is caused by low sodium levels and is often treated with fluid restrictions.
a. 	Severe hyponatremia may cause seizures and is managed by infusing a hypertonic (3%) saline solution.
2. 	Hypocalcemia is caused by hyperphosphatemia and is not usually treated unless symptoms such as tetany, seizures, or decreased cardiac contractility are present. 
a. 	Rapid correction of hypocalcemia may result in the deposit of calcium salts in body tissues. 
b. 	Treatment includes oral dosing of calcium carbonate or, in emergent cases, cautious administration of IV calcium gluconate (10%) at a dose of 50 to 100 mg/kg.
3. 	Hyperkalemia
a. 	This condition has can cause life-threatening arrhythmias by producing membrane excitability. 
b. 	ECG changes may include a peaked T wave, a widened QRS complex, and eventual bradycardia. 
c. 	An elevated serum potassium level is treated based on lab values and the presence of ECG abnormalities.
d. 	Management may include careful monitoring and the removal of potassium chloride from IV fluids, pharmacologic treatments, and dialysis.
 
XI. Meningococcal Infections
	Time: 3 Minutes
	Slides: 127–128
	Lecture/Discussion
A. 	The symptoms of meningitis usually onset suddenly.
B. 	Presentation of symptoms depends on the age of the child, the type of organism, and the child’s state of health.
C. 	Presenting symptoms include fever, chills, nuchal rigidity, vomiting, photophobia, headache, back pain, and seizures.
D. 	Younger children may also show those symptoms, but they may also experience poor feeding, marked irritability, and agitation.
E. 	Kernig sign
1. 	Positive if patient has pain or resistance to knee straightening on both sides
2. 	A positive result indicates a meningeal infection.
F. 	Brudzinski sign
1. 	Should not be attempted in patients who might have a cervical spine injury.
2. 	Patient lies in a supine position while the examiner tries to get the patient to touch the chin to the chest.
3. 	An abnormal response includes flexion of the legs and hips. 
G. 	CCTP should inquire about infant’s feeding and sucking ability. 
H. 	Universal precautions should be taken with patients who have suspected infections.

XII. Trauma
	Time: 36 Minutes
	Slides: 129–152
	Lecture/Discussion
A. 	Head injuries
1. 	Head injuries are the leading cause of morbidity and mortality in children.
2.  	The main sources of head trauma include motor vehicle accidents, sports, falls, and abuse.
3. 	Primary injuries occur at the moment of impact and cause physical and mechanical destruction.
a. 	They can include parenchymal injury, diffuse axonal injuries, and cerebral edema.
4. 	Secondary injuries involve a complicated cascade of cellular destruction.
a. 	If not addressed, secondary brain injury can lead to irreversible brain damage and death.
B. 	Increased intercranial pressure (ICP)
1. 	Most common causes are trauma or a failed cerebral spinal fluid shunt
2. 	Signs and symptoms include: 
a.	Irritability
b.	Fever
c.	Nausea
d.	Projectile vomiting
e.	Lethargy
f.	Visual changes
g.	Unsteady gait
h.	High-pitched cry
i.	Bulging fontanelle
j.	Papillary dilation
k.	Seizures
l.	Cushing’s triad
3. 	Treatment modalities may include inserting a monitor to measure ICP. 
4. 	Management
a.  	Mild hyperventilation (PaCO2 between 30 and 35 mm Hg)
b. 	Maintain the cerebral perfusion pressure at greater than 50 to 60 mm Hg 
c. 	Place the stretcher so that the patient’s head is raised 15° to 30° to promote cerebral venous drainage.
d. 	Normothermia or mild hypothermia to decrease metabolic rate
e. 	Administer mannitol (0.5 to 0.75 mg/kg/dose) (must administer with a filter)
C. 	Concussion
1. 	Most commonly seen head injury
2. 	There may be a brief loss of consciousness and posttraumatic injury.
3. 	The role of the CCTP in transporting a pediatric patient is to provide support en route to the medical center.
4. 	Document the patient’s pain level and tolerance of the transport process.
D. 	Cerebral contusion
1. 	Occurs at the point of impact and/or on the side opposite the impact.
E. 	Epidural hematoma
1. 	Epidural hematomas typically include arterial bleeding from contusions or lacerations, most commonly of the middle meningeal artery. 
2.	Accumulation of blood in these injuries does not “touch” the brain tissue.
3. 	The classic pattern of an epidural hematoma includes a lucid period followed by rapid neurologic deterioration. 
4.  	Children may never have a loss of consciousness or a lucid period.	
F. 	Subdural hematoma
1. 	A subdural hematoma is 5 to 10 times more common than an epidural hematoma. 	
2. 	This injury is caused by shearing forces that slide the brain tissue over the base of the skull. 
3. 	The hematoma occurs just below the dura, and as a result, blood comes into contact with brain tissue. 
4. 	Subdural hematomas are usually caused by a disruption of bridging veins or venous sinus beneath the dura. 
5. 	A subdural hematoma can be a result of child abuse such as shaken baby syndrome. 
G. 	Risk assessment and management
1. 	Many children who experience closed head trauma may have only minor injuries. 
2. 	Children who have low-risk injuries are often asymptomatic, with normal neurologic findings on exam.
3. 	Management at home with responsible adult supervision may be all that is necessary.
4. 	Children with moderate-risk injuries will present with an altered level of consciousness, progressive headache, or vomiting, and may have an associated injury. 			
a. 	They often require basic trauma care, including basic wound management and cervical spine immobilization with radiologic evaluation.
5. 	Children with high-risk injuries will present with a depressed level of consciousness, possible neurologic deficits, or signs of increased ICP. 
a. 	These children often immediate surgical interventions. 
6. 	As with any traumatic injury, initial management involves stabilization of the cervical spine, airway, breathing, and circulation.
7. 	Proper sedation and analgesia should be administered to prevent spikes in ICP.
8. 	Any source of bleeding in the head, including the brain, face, mandible, and scalp, can cause significant blood loss. 
9. 	Hypovolemia is of great concern, particularly in infants, who have a larger amount of blood volume in their heads. 
10. 	Maintaining the patient’s head at 30° and midline improves venous outflow from the head.
11. 	The most life-threatening situation involves herniation syndromes in which increased cranial pressure causes the brain to shift. The brain may be shifted laterally or down through the foramen magnum.
H. 	Spinal cord injuries
1. 	Mortality from spinal cord injuries is twice that of adults. 
2. 	Serious neurologic injuries are more common in older children. 
3. 	Injury can occur from a primary insult or from a secondary insult.
4. 	Top priority is immobilizing the head and spine
5. 	Frequent assessment must be made during transport to detect the possibility of ascending lesions. 
6. 	Methylprednisolone has been used clinically to minimize the progression and treat the inflammation of spinal cord injuries.
7. 	Children have weak spinal ligaments and increased spinal mobility. They can sustain damage to the spinal cord and ligaments without damage to the vertebrae. This damage is called spinal cord injury without radiographic abnormalities (SCIWORA). 
8. 	SCIWORA should be suspected when there are clinical signs or symptoms of spinal cord injury in the presence of normal cervical spine radiographs.	
I. 	Breathing abnormalities
1. 	Facial trauma and soft-tissue swelling can block the upper airway. 
2. 	There may be direct trauma to the upper airway in the example of hanging injuries or “clothes-line” injuries.
3. 	Hanging injuries occur in the toddler population from crib accidents and window cords. 
4. 	Hanging injuries may also occur in adolescents as a method of suicide, or during a “choking game.” 
5. 	Head injury may cause a decrease in the level of consciousness and result in the patient’s tongue obstructing the airway. 
J. 	Tension pneumothorax
1. 	Treatments for tension pneumothorax include a 14 to 16-gauge angio-needle decompression for older children and adolescents in the second to third intercostal space, midclavicular on the affected side. 
2. 	For infants, treatment is a 22 to 23-gauge butterfly needle inserted anterior at the fourth intercostal space (nipple line). 
3. 	The needle is then attached to a stopcock and a 20-mL syringe. The chest is emptied of air or fluid until the condition improves.
K. 	Hemothorax
1. 	Treatment for a hemothorax includes inserting a chest tube in the fifth intercostal space and withdrawing the blood.
2. 	Ideally, blood can be collected and autotransfused back to the patient.
a.  	As long as the blood does not become contaminated by an open wound, it can be returned to the child’s circulation.
b.  	If autotransfusion collection is not possible, there is controversy in the literature regarding how much blood should be accumulated before clamping the thoracostomy tube.
3. 	Adequate fluid resuscitation must be maintained to keep the child from going into hypovolemic shock.
L. 	Circulation abnormalities
1. 	Patients should be assessed for bleeding, hypovolemia, arrhythmias, and pericardial tamponade.
2. 	Pericardial tamponade is an emergency condition in which fluid accumulates in the pericardium. 
a. 	It is usually the result of a blunt or penetrating injury to the chest and sternum.
3. 	The appropriate treatment during transport is a rapid IV fluid bolus. 
M. 	Fractures
1. 	Children have less calcified bones. 
2. 	Children’s bones tend to respond to force by buckling rather than fracturing. 
3. 	If a fracture is evident, look for organ injury.
4. 	The ligaments in children are stronger and more resilient to tensile forces.
5. 	The pediatric spine has incomplete ossification and epiphyseal growth plates that may contribute to hypermobility. 
a. 	As a result, the cervical spine in children is highly flexible and young children tend to have avulsions (the tendon pulling away from the bone) rather than fractures. 
6. 	Rapid deceleration injuries resulting in hyperflexion and torsion forces are most commonly seen in children.
7. 	Pelvic fractures can cause massive internal hemorrhaging and can lead to profound deterioration. 
a. 	CCTP can stabilize the pelvis by wrapping a sheet around it or by using a SAM splint.  
b. 	With pelvic fractures, a significant amount of blood can be located in the retroperitoneal cavity. 
c. 	The CCTP must be prepared for a rapid decline in the patient’s condition from blood loss.
8. 	A femur fracture is rare in children, but it can lead to significant blood loss.
a. 	Older children and adolescents are most at risk for femur fractures. 
b. 	The two most common causes are motor vehicle collisions and pedestrian injuries. 
c. 	For a femur fracture in the very young child who has not started walking, traction splinting may not be necessary.
9. 	Other techniques for immobilization for transport include an air splint, rigid splint, PASG, or simple padding using pillows or blankets. Figure 23-
N. 	Abuse and neglect
1. 	The primary responsibility of the transport crew is to their own safety first, and then to provide a safe environment for their patient. 
2. 	Forms of abuse that the CCTP must be aware of while caring for the pediatric population include psychological (emotional) abuse, physical abuse, economic (financial) abuse, sexual abuse, and neglect.
3. 	When there are no obvious signs of abuse, such as bruises or broken bones, the patient may have suffered neglect. 
4.  	CCTP should observe the child’s behavior closely. 
a. 	Children younger than 6 years who have experienced neglect usually appear markedly passive to their environment.
b. 	Children 6 years or older may seem aggressive on initial evaluation.
5. 	CCTP must adhere to agency protocol regarding the reporting of suspected abuse or neglect. 
6. 	All measures should be taken to preserve evidence.
7. 	Transfer documentation must reflect findings from the physical exam and statements made by the victim or suspected perpetrator. 
8. 	CCTP may be called to testify in court regarding cases of abuse and neglect.

XIII. Environmental Emergencies
	Time: 3 Minutes
	Slide: 153–154
	Lecture/Discussion
A.	Hypothermia
1. 	Exists when the patient’s body core temperature is 95ºF (35ºC) or less
2. 	Can result from:
a.	Systemic disease process
b.	Prolonged environmental exposure
c. 	When heat production is less than heat loss by convection, conduction, or radiation
3. 	The pediatric population is at an increased risk for hypothermia.
a.	Relatively larger body surface area
b.	Proportionally large head
c.	Immature temperature-regulating mechanisms
d.	Decreased energy stores
e.	Less body fluid volume and protective fat
4.	Low birth-weight (premature) infants, newborns, and children involved in trauma are at high risk for hypothermia.
5.	Management is the same as with adults (see Chapter 18: Environmental Emergencies).
B.	Heat stroke
1.	Classified as a life-threatening emergency in the field with morbidity rates ranging from 17% to 70%
2.	Results from a mixture of:
a.	Metabolic activity
b.	The environment
c.	Vigorous exercise
3.	The pediatric population acclimates more slowly to heat production from exercise than the adult populace.
a.	Greater skin surface area
b.	Decreased sweating capacity
c.	Inability to shunt heat via the blood from the core to the periphery
4.	Underlying conditions may contribute
a.	Immature thermoregulation of the newborn
b.	Burns
c.	Cystic fibrosis
5.	Management is the same as with adults (see Chapter 18: Environmental Emergencies).

XIV. Drowning
	Time: 5 Minutes
	Slides: 155–157
	Lecture/Discussion
A. 	Drowning is a top cause of death for the pediatric populations between the ages of 1 and 14 years.
B. 	The primary insult is hypoxemia. Wet drowning accounts for 85% of incidents. 
1. 	Hypoxemia is followed by metabolic acidosis, hypothermia, and cardiac compromise. 
C. 	The less time the child spends submerged and the more rapidly he or she is resuscitated, the better.
D. 	Secure the airway early, provide PPV, and add PEEP early. 
E. 	Rewarm the patient and work to reverse metabolic acidosis.
F. 	Approximately 10% to 15% of drowning incidents are related to dry drowning. 
1. 	Dry drowning occurs when the patient has a laryngospasm that prevents water from entering the lungs. 
2. 	The duration of the laryngospasm determines the extent of the hypoxemia. 
3. 	Death from dry drowning is the result of asphyxiation instead of aspiration.

XV. Patients With Special Needs
	Time: 2 Minutes
	Slide: 158
	Lecture/Discussion
A. 	The frequency of a CCTP having to take care of a special needs child is increasing. 
B.  	Children are cared for at home with ventilators, apnea monitors, nagogastric tubes, gastrostomy tubes or buttons, jejunostomy tubes, and ventriculoatrial or ventriculoperitoneal shunts. 
C. 	Parents and caregivers are the best resource for understanding their child’s illness and using the specialized equipment. 
D. 	CCTP might encounter special needs children either on a transport to the hospital before surgery or on a transport back to a tertiary hospital after surgery. 
E. 	CCTP might also encounter these children if equipment malfunctions or as the time nears for the child’s next surgery. 
F. 	If possible, let the parent/caregiver help during transport. It will help comfort both patient and parent.

XVI. Flight Considerations
	Time: 2 Minutes
	Slide: 159
	Lecture/Discussion
A. 	The most important point to remember is that children are not small adults. 
B. 	CCTP should be familiar with age-specific development and deviations from the norm.
C. 	The parent or caregiver should be allowed to ride with the patient whenever possible.
D. 	As with adults, never lie to children.