Infants & Children
Special Considerations
An Ill or injured child will be frightened. This will be caused by the injury/illness and the feeling and discomfort associated with it. You too, even as ambulance staff, will frighten that child due to being a stranger, and we all know strangers may have evil intentions to harm the child (Well in his/her eyes anyhow).
The sick or injured child will only be able to communicate with you up to their understanding of vocabulary. This throws in some challenges from the word 'GO'. You may not be able to get any conversation due to a young child unable to speak or a child that is howling in pain, this also adds anxiety and confusion to the child. (Not getting any easier I hear you thinking)
Parents and relations might be acting in a manner which may be driven by a feeling of helplessness. These parents or relations may also become frustrated and almost 'aggressive' towards you by what may seem a relaxed manner by you while dealing with the incident. A parent wants you to take control straight away and to be seen doing something constructive with their child. It may seem like a big task.
Guidelines for Dealing with a Sick Child
Very little time is spent learning and dealing with paediatrics so even experienced staff can become less confident when dealing with a child.
Following these guidelines will make you job of dealing with a sick child a little easier.
- Stay calm
- Come down to the child's level. If they're lying down, you lay down too. Don't tower over a child.
- Who are you? Explain to the child who you are (Name) and that you are their to help
- Ask mum or dad to hold child.
- Has the child got a favourite toy you could give them?
- Be patient and gentle. Take your time if no life threatening injuries are present
- If possible keep the patient with the parent/carer
- If you have to carry out any procedures explain them to the child and parents
- Do Not Lie - If something will hurt tell the child it will hurt or their trust in you will be lost
- Remember to constantly reassess the Ill or injured child
Paediatric Assessment Triangle (PAT)
The paediatric assessment triangle is a good tool to assist you in the early recognition of the ill child. The triangle is split into three sections. These are:
- Appearance
- Work of Breathing
- Circulation to skin
PAT benefits
Allows the ambulance crew to develop a general impression of the child from across the room.
Assists in determining the level of severity, urgency for life support, and the key physiologic problems.
PAT can be completed in 30 to 60 seconds; the three components can be assessed in any order.
Components of the PAT
Appearance
. Reflects the adequacy of ventilation, oxygenation, brain perfusion, body homeostasis, and central nervous system function.
. Assess from across the room; allow child to remain on the parents/caregivers lap.
. Use bright lights or toys to assess alertness.
. Have parent assist with assessment if appropriate
| Characteristic: | Features to look for: |
| Tone | Extremities should move spontaneously, with good muscle tone; should not be flaccid or move only to stimuli |
| Alertness | Should respond to environmental stimuli or presence of a stranger; should not be listless or lethargic |
| Consolable | Easily comforted or calmed by caretaker (i.e., speaking softly, holding child, or offering a pacifier) |
| Look/Gaze | Should maintain eye contact with objects or people; should not have a “nobody home” or glassy-eyed stare |
| Speech/Cry | Should be present, strong and spontaneous; should not be weak, muffled, or hoarse |
| GOLDEN RULE: The child’s general appearance is the most important thing to consider when determining how severe the illness or injury is, the need for treatment, and the response to therapy. | |
Work of Breathing
· Is a more accurate, quick indicator of oxygenation and ventilation than respiratory rate or chest sounds on auscultation.
· Reflects the child’s attempt to make up for difficulties in oxygenation and ventilation.
| Characteristic: | Features to look for: |
| Abnormal airway sounds | Gasping, hoarse speech, stridor, grunting, wheezing |
| Abnormal positioning | Sniffing position, tripoding, refusing to lie down |
| Retractions | Supraclavicular, intercostal, or substernal retractions of the chest wall; head bobbing in infants |
| Flaring | Nasal flaring - Seen in infants with respiratory distress |
| Respiratory Rate | Outside of normal range for age group (see below) |
Normal Respiratory Rates (Dependant on which publication you read)
| Age | Respiratory Rate |
| < 1 Year | 30 - 40 bpm |
| 1 - 2 Years | 25 - 35 bpm |
| 2 - 5 Years | 25 - 30 bpm |
| 5 - 12 Years | 20 - 25 bpm |
| > 12 Years | 15 - 20 bpm |
Circulation to Skin
· Reflects the adequacy of cardiac output and core perfusion, or perfusion of vital organs.
· Cold room temperatures may cause false skin signs, i.e., the cold child may have normal core perfusion but abnormal circulation to the skin.
· Inspect the skin (i.e., face, chest, abdomen) and mucous membranes (lips, mouth) for colour in central areas.
. Capillary Refill - Applying gentle pressure to the forehead or sternum for 5 seconds and then release and see the time taken for capillary refill. If the time is >2 seconds then this indicates poor perfusion. Although this can be influenced by factors such as the cold.
· In dark skinned children, the lips and mucous membranes are the best places to assess circulation.
| Characteristic: | Features to look for: |
| Pallor | White or pale skin or mucous membrane coloration |
| Mottling | Patchy skin discoloration due to vasoconstriction |
| Cyanosis | Bluish discoloration of skin and mucous membranes |
Normal Heart Rates (Dependant on which publication you read)
| Age | Heart Rate |
| < 1 Year | 110 - 160 bpm |
| 1 - 2 Years | 100 - 150 bpm |
| 2 - 5 Years | 95 - 140 bpm |
| 5 - 12 Years | 80 - 120 bpm |
| > 12 Years | 60 - 100 bpm |
Apgar Score
The Apgar score was devised in 1952 by Virginia Apgar as a simple and repeatable method to quickly and summarily assess the health of newborn children immediately after childbirth.
The Apgar score is determined by evaluating the newborn baby on five simple criteria on a scale from zero to two and summing up the five values thus obtained. The resulting Apgar score ranges from zero to 10.
The five criteria of the Apgar score:
| Score 0 | Score 1 | Score 2 | |
|---|---|---|---|
| Heart rate | absent | <100 | >100 |
| Respiration | absent | weak or irregular | strong |
| Muscle tone | none | some flexion | active movement |
| Reflex irritability | no response to stimulation |
grimace/feeble cry when stimulated |
sneeze/cough/pulls away when stimulated |
| Skin colour | blue all over | blue at extremities | normal |
The test is generally done at 1 and 5 minutes after birth, and may be repeated later if the score is, and remains, low. Scores below 3 are generally regarded as critically low, with 4 – 7 fairly low and over 7 generally normal.
Sudden Infant Death Syndrome (SIDS)
Sudden Infant Death Syndrome (SIDS) is more commonly called Cot Death. Death usually occurs when the infant is sleeping. The death comes as a shock because often there has not been any sort of previous illness affecting the child up to that point, however babies are thought to be at an increased risk under the age of 6 months, whether they are from poorer families, parents that smoke and if they have had a sibling lost to SIDS. Other risks may include babies born prematurely and babies of a low birth weight. SIDS has been researched very intensely but it is still unknown what causes it. Some theories believe the child had problems with temperature control or regulation of breathing. So when a situation arose in which a child became too hot or had respiratory problems it may have been too vulnerable to cope so subsequently dies.
When you are called to an unresponsive infant that is not breathing it will not be necessary for you to decide if this is a cot death or not. Your responsibility will be to carry out paediatric resuscitation. Because this type of case is often sudden you may be required to give police a statement of your findings on arrival at scene, what was said by the parents, how was the baby found, were there any unusual marks/bruises on the child, what treatment did you do, etc. All your findings in your statement are to be factual and not your opinion of the job/situation.
Apgar Score
The Apgar score was devised in 1952 by Virginia Apgar as a simple and repeatable method to quickly and summarily assess the health of newborn children immediately after childbirth.
The Apgar score is determined by evaluating the newborn baby on five simple criteria on a scale from zero to two and summing up the five values thus obtained. The resulting Apgar score ranges from zero to 10.
The five criteria of the Apgar score:
| Score 0 | Score 1 | Score 2 | |
|---|---|---|---|
| Heart rate | absent | <100 | >100 |
| Respiration | absent | weak or irregular | strong |
| Muscle tone | none | some flexion | active movement |
| Reflex irritability | no response to stimulation |
grimace/feeble cry when stimulated |
sneeze/cough/pulls away when stimulated |
| Skin color | blue all over | blue at extremities | normal |
The test is generally done at 1 and 5 minutes after birth, and may be repeated later if the score is, and remains, low. Scores below 3 are generally regarded as critically low, with 4 – 7 fairly low and over 7 generally normal.
Management of Paediatric Emergencies
Keep patient with parent/carer unless you need to intervene, Reassurance, High concentrations of O2, Monitoring vital signs. Capillary refill on forehead or sternum as a brachial pulse is not always reliable, Carry out a blood sugar test, Patient temperature, Use a Broselow tape to determine the childs approximate weight, Prepare to carry out assisted ventilations and or chest compressions, Consider paramedic backup
ASHICE (Remember to pass on Broslow tape colour)
Transport to Hospital
Professional Handover