Pediatric

Emergencies
EMS Continuing Education
Technician through Tech AP

Consistent with the

National Occupational Competency Profiles
as developed by
Paramedic Association of Canada
and
“An Alternate Route to Maintenance of Licensure”
as developed by Manitoba Health

Originally Evaluated for content by:

Dr. Michelle Matter

Developed by:
Educational Subcommittee – Paramedic Association
of Manitoba

Revised July 2011

Disclaimer
These documents were developed for improved accessibility to standardized continuing education for all
paramedics in Manitoba.

This training package is consistent with the National Occupational Competency Profiles and the core
competency requirements (both mandatory and optional) as identified in “An Alternative Route to
Maintenance of Licensure” (ARML). It is not the intent that this package be used as a stand-alone teaching
tool. It is understood that the user has prior learning in this subject area, and that this document is strictly
for supplemental continuing medical education. To this end, the Paramedic Association of Manitoba
assumes no responsibility for the completeness of information contained within this package.

It is neither the intent of this package to supersede local or provincial protocols, nor to assume
responsibility for patient care issues pertaining to the information found herein. Always follow local or
provincial guidelines in the care and treatment of any patient.

This package can be used in conjunction with accepted models for education delivery and assessment as
outlined in “An Alternative Route to Maintenance of Licensure”. Any individual paramedics wishing to use
these continuing education packages to augment their ARML program should contact their local EMS
Director.

This document was designed to encompass all licensed training levels in the province (Technician,
Technician – Paramedic, Technician – Advanced Paramedic.). Paramedics are encouraged to read beyond
their training levels. However, it is suggested that the accompanying written test only be administered at
the paramedic’s current level of practice.

This package has been reviewed by the Paramedic Association of Manitoba’s Educational Subcommittee
and is subject to review by physician(s) or expert(s) in the field for content.

As the industry of EMS is as dynamic as individual patient care, the profession is constantly evolving to
deliver enhanced patient care through education and standards. The Paramedic Association of Manitoba
would like to thank those practitioners instrumental in the creation, distribution, and maintenance of these
packages. Through your efforts, our patient care improves.

This document will be amended in as timely a manner as possible to reflect changes to the National
Occupational Competency Profiles, provincial protocols/Emergency Treatment Guidelines, or the
Cognitive Elements outlined in the Alternate Route document.

Any comments, suggestions, errors, omissions, or questions regarding this document may be referred to
info@paramedicsofmanitoba.ca , attention Director of Education and Standards.

1
Table of Contents
Table of Contents ........................................................................................................................................2
Introduction.................................................................................................................................................4
Developmental Stages - A Key to Assessment ...........................................................................................5
Infants - under 6 months old ..................................................................................................................5
Infants-6-12 months old .........................................................................................................................5
Toddlers-1-3 years old ...........................................................................................................................5
Pre-schooler-4-5 years old .....................................................................................................................5
School-age child-6-12 years old ............................................................................................................6
Adolescent-13-18 years old ...................................................................................................................6
Anatomy and Physiology ............................................................................................................................6
Airway ...................................................................................................................................................6
Breathing................................................................................................................................................7
Circulation .............................................................................................................................................9
Musculoskeletal ...................................................................................................................................11
General Approach To Pediatric Assessment ............................................................................................11
History .................................................................................................................................................11
Physical Examination...........................................................................................................................11
Pediatric Vital Signs ............................................................................................................................12
Non-Invasive Monitoring.....................................................................................................................13
Pediatric Trauma Emergencies .................................................................................................................14
Kinematics of Pediatric Trauma ..........................................................................................................14
Head, Face and Neck Injuries ..............................................................................................................14
Chest and Abdomen Injuries ................................................................................................................15
Extremity Injuries ................................................................................................................................16
Burns ....................................................................................................................................................16
Shock ...................................................................................................................................................17
Child Abuse and Neglect ..........................................................................................................................19
The Child Abuser .................................................................................................................................19
Sexual Abuse .......................................................................................................................................19
Pediatric Medical Emergencies.................................................................................................................21
Infections (ear, nose, or throat, and skin rashes etc.) ...........................................................................21
Neurological Emergencies ...................................................................................................................22
Seizures ................................................................................................................................................22
Meningitis ............................................................................................................................................24
Reye’s Syndrome .................................................................................................................................24
Respiratory Emergencies ..........................................................................................................................25
Aspirated Foreign Body .......................................................................................................................26
Croup ...................................................................................................................................................27
Epiglottitis............................................................................................................................................27
Bronchiolitis.........................................................................................................................................28
Asthma .................................................................................................................................................29
Status Asthmaticus ...............................................................................................................................30
Gastrointestinal Emergencies....................................................................................................................31
Nausea and Vomiting ...........................................................................................................................31
Diarrhea ...............................................................................................................................................31
Cardiovascular Emergencies .....................................................................................................................32
Dehydration .........................................................................................................................................32
Sepsis ...................................................................................................................................................33
Dysrhythmias .......................................................................................................................................34
Congenital Heart Disease .....................................................................................................................34
Other Pediatric Emergencies.....................................................................................................................35
Anaphylaxis .........................................................................................................................................35

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 Altered Mental State ............................................................................................................................37
Sudden Infant Death Syndrome (SIDS) ...............................................................................................38
Legal Responsibilities and Implications of Treating Pediatric Patients ....................................................40
Glossary of Terms.....................................................................................................................................45

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Introduction
Dealing with a pediatric emergency is one of the most stressful calls a medic can
encounter. Children are not “little adults”. Their anatomy and physiology deserve
special consideration since it differs from an adult. From an emotional standpoint,
children are also unique. Their reactions and capabilities differ depending on their
developmental stage and life experience.

Conventions Used in this Manual

Black lettering without a border is used to denote information to the EMR Level and
above.

Text with single striped border on the left is information appropriate to EMT Level I
(B)/Primary Care Paramedic and above. The required cognitive elements to be covered
within this module are the same for the EMT I (B), Primary Care Paramedic, EMT II (I),
Advanced Care Paramedic, EMT Level III (P) and Critical Care Paramedic. Therefore
there will only be the 2 conventions used throughout this manual.

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Developmental Stages - A Key to Assessment
Certain general principles apply in dealing with children of any age who are sick and/or
injured. You should:
- be calm, patient and gentle
- be honest. Do not tell the patient it will not hurt if it will hurt
- try not to separate the child from his parents (an exception to this would be where child
abuse is suspected)
However when life-threatening illness or injury occurs in a child of any age, conduct the
primary survey rapidly without taking time for preliminaries, and manage life-threatening
conditions. When illness or injury allows more time for assessment, however, certain
techniques make it easier to work with children.

Infants - under 6 months old

- likely not to mind being totally undressed for assessment

- conduct detailed assessment (secondary) in “toe-to-head” order (most small children do
do not like having their faces touched by strangers)
- attempt to keep infant close to parent
- respond to facial expressions

Infants-6-12 months old

- will tolerate being undressed, however, keep patient very close to parent
- conduct “toe-to-head” assessment
- talk and coo to patient during surveys

Toddlers-1-3 years old

- do not want to talk to strangers or be undressed by them

- very frightened
- prioritize the areas that need immediate assessment and complete them ASAP
- do not shout at patient, remain very calm

Pre-schooler-4-5 years old

- usually cooperative unless extremely frightened

- these children enjoy “helping out” and generally there is no problem with completing
standard head-to-toe survey
- maintain good eye contact and gentle firmness
- able to understand simple directions

5
School-age child-6-12 years old

- likely cooperative
- appreciate being treated with respect and like an explanation of what’s being done

Adolescent-13-18 years old

- unusually concerned about his/her bodily integrity and requires constant reassurance
following completion of each survey segment
- examine the same way as an adult
- quite concerned with having their privacy protected

Anatomy and Physiology

Airway

The pediatric airway is smaller in diameter (narrower) and less rigid than the adult
airway. Small amounts of blood, mucus, or edema have a profound effect on airway
diameter which leads to increased resistance and respiratory distress. Airway obstruction
can come from a variety of sources including croup (airway edema), foreign bodies and
the tongue, which is relatively large compared to an adults.
Opening a pediatric airway is affected by the soft, cartilaginous larynx. Using
hyperextension, as in an adult, to open an airway can cause kinking of the larynx and
subsequent occlusion of the airway. It is difficult to properly position an infant’s airway
due to the large head which naturally, in the supine position, forces the chin into the chest
thereby compromising the airway.

Figure Small changes in the diameter of the Anatomy of a child’s airway differs from that of an adult’s in
infant’s airway can have a great effect on air five principal ways: back of the head is larger in a child, so
flow. head positioning requires more care. The tongue is
proportionally larger and more anterior in the mouth. The
epiglottis is larger. The trachea is smaller in diameter and
more flexible. The airway itself is lower and narrower.
Cricoid cartilage is the narrowest portion of the airway as
versus the larynx in an adult.
6
Unless the child is a victim of trauma, the head tilt chin lift method should be used to
open the airway and the head should be in sniffing position (applies to infants birth to 1
year of age). Oral airways can be used to maintain a patent airway. You must be careful,
however, to choose the appropriate size, since one that is too large (or small) may
displace the tongue back into the pharynx or directly block the airway.

The narrowest portion of the child’s airway is

at the cricoid ring, whereas the adults it is at the
vocal cords.

Suction is often required to achieve airway patency. The suction device is inserted to the
posterior pharynx then suction is applied by occluding the opening of the catheter, while
withdrawing the catheter with a rotating, twisting motion. Suction should not exceed 5-
10 seconds and is preceded and followed by ventilation with 100% oxygen to avoid
hypoxia. Remember, oxygen is removed as well as secretions during suctioning. The
safe amount of suction varies with age:
Premature to Low Birth Weight 60-80 mm Hg
Term Infants 80-100 mm Hg
Children 100-120 mm Hg
Adolescent 110-150 mm Hg

Vagal stimulation, resulting in bradycardia, may occur from catheter stimulation,

therefore heart rate should be monitored.

Infants (3-5 months old) are obligate nose breathers. This allows them to feed and
breathe simultaneously. At this young age, infants have not learned to mouth breathe,
therefore blockage of the nasal passages can cause significant respiratory distress.
Vigorous crying or suctioning of the nares, however, can often resolve this problem
providing no serious underlying condition is present.

Breathing

Infants and children have a relatively thin chest wall. This can make auscultation for
decreased or absent breath sounds difficult because sounds are easily transmitted. The
ribs and sternum normally support the lung and help it remain expanded. The intercostal
muscles and diaphragm function to alter intrathoracic pressure and volume resulting in air
exchange. Since a child’s intercostal muscles are poorly developed, they contribute very

7
little to chest wall movement during inspiration. Children, therefore, use their diaphragm
as the major muscle for respiration and require full diaphragmatic excursion to breathe.
Because they rely more on diaphragmatic breathing than adults, anything that restricts
diaphragmatic function such as:
1. pressure from above (pulmonary hyperinflation - asthma) or
2. pressure from below (gastric distention)
can lead to significant respiratory compromise. Distention impedes ventilatory efforts
because the chest wall cannot compensate by expansion. During times of respiratory
distress, the combination of diaphragmatic breathing and pliable ribs allows the chest
wall to move in (retract) during inspiration instead of moving out.

Children have smaller tidal volumes with smaller and fewer alveoli than adults. Too
much volume when ventilating can cause a pneumothorax. However, due to the infants
less compliant lungs, coupled with the tendency of the terminal airways to collapse
during respiratory distress, a slightly increased pressure may be required to achieve
ventilation.

When a pediatric patient is distressed, further compromise occurs due to the increased
oxygen demand required to maintain the increased work of breathing. Hypoxemia in
children may also be aggravated by a high metabolic rate that is about twice that of an
adult. This increased demand, combined with the fact that the infant has fewer alveoli
and less physiologic reserve, can lead to a mismatch between oxygen supply and demand.
When children need to work to breathe, they experience respiratory fatigue more rapidly
than adults. This results in sudden decompensation. Thus supplemental oxygen is
always a priority when a child experiences respiratory distress.

Signs of respiratory distress in children include:

 tachypnea
 increased respiratory effort
 retractions
 nasal flaring
 head bobbing
 grunting
 stridor or wheezing
 weak cry
 depressed level of consciousness
 irritable
 lethargic
 Tracheal tug
 decreased responsiveness (especially to parents)
 Late signs:
 bradycardia
 decreased air movement
 weak muscle tone, flaccid, not struggling
 apnea, gasping, cyanosis

8
Late signs of respiratory distress are indicative of a potential arrest. Initially children can
compensate quite well for illness due to their healthy cardiovascular system. The obvious
signs of serious illnesses, such as changes in mental status and vital signs, are often subtle
in the child and may be complicated by the child’s fear and anxiety. It is imperative to
recognize early signs of distress since once cardiorespiratory arrest occurs, the child’s
physiologic reserves are severely depleted and their prognosis is poor.

Figure 3. Nasal flaring and retractions are signs of significant respiratory distress in pediatrics.

Circulation
Infants and young children have a larger surface area in relation to their height and
weight plus a higher metabolic rate than adults. These factors predispose the child
toward rapid heat loss, greater insensible water losses and hypoglycemia during times of
stress. Central heat regulating centers are not well developed so children develop fevers
or hypothermia easily. Fever and diaphoresis contribute to insensible water losses and if
coupled with sensible fluid losses, such as vomiting and diarrhea, can lead to
dehydration. An infant’s high glucose needs, yet small glycogen stores, can rapidly lead
to hypoglycemia.

Although the infant has a higher per kilogram blood volume than an adult, the absolute
blood volume is less. Therefore, relatively small amounts of blood loss can be significant
in a child. A child can compensate effectively for blood loss, thus there may be no
change in blood pressure until 25% of the blood volume is lost.

Infants have smaller stroke volume (SV) than adults, thus increasing heart rate is the
infant’s primary method of increasing cardiac output (CO = SV x HR). As age increases,
stroke volume increases and heart rates drop. Infants can maintain heart rates higher than
adults without difficulty. However, once heart rate exceeds 180-200 bpm, diastolic
filling time is compromised and cardiac output is decreased. Infants and children
adequately maintain blood pressure by compensating for volume loss through:
 vasoconstriction
 tachycardia
 Hypotension only develops after the cardiovascular reserve is depleted.

9
Bradycardia causes a significant drop in cardiac output because of an infant’s relatively
small stroke volume. Bradycardia is defined as:
 <100 in neonates
 <60-80 in a child

Although tachycardia is an early sign of both shock and respiratory distress, it is not the
most reliable indicator of impending problems because many other factors can cause
tachycardia (fear, anxiety, fever). Bradycardia, however, is a very ominous sign as it
readily leads to hypoxia and hypotension. Indicators of volume depletion, aside from
tachycardia, include:
 strength of peripheral pulses (weak)
 capillary refill (slow)
 lack of tearing
 moistness of mucous membranes (decreased)
 condition of the fontanelle (sunken)
 history of urine output (decreased)
 tenting of skin (ie decreased rebound after retraction)
 sunken eyes (extreme ie. >10% dehydration)
 cool peripheries

Obtaining blood pressures on children is often difficult as they will not remain still or the
proper size cuff is not available. A cuff should cover 2/3 of the upper arm. Keep in mind
that a cuff that is too big will provide a lower reading while too small a cuff will produce
a higher reading.

Table I Modified Glasgow Coma Scale for Infants

Activity Best Response Score
Eye Opening Spontaneous 4
To speech 3
To pain 2
None 1
Verbal Coos, babbles 5
Irritable, cries 4
Cries to pain 3
Moans to pain 2
None 1
Motor Normal spontaneous 6
Withdraws to touch 5
Withdraws to pain 4
Abnormal flexion 3
Abnormal extension 2
None 1

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Musculoskeletal

A child’s bones have not finished growing; they are more flexible and elastic than those
in an adult’s skeleton. Fat is distributed in a child in a somewhat different way than in an
adult, so vital organs in the abdomen and the chest of a child are less well insulated.
Therefore, a child may experience significant injuries to internal organs but have little or
no evidence of external trauma. This is especially true of chest injuries. Because a
child’s ribs are softer and more flexible than those of an adult, they may compress the
underlying lungs and heart, causing life-threatening conditions without obvious external
damage.

General Approach To Pediatric Assessment

Priorities in management of the pediatric patient, as with all

patients are established on a threat-to-life basis. However, if life-
threatening problems are not present, the following general
approach is recommended.

History

Questions for the child should be specific and direct. Keep in mind the developmental
stages described previously. You should focus on the observed behavior, as well as on
what the child or parent says. Visual assessment is very important. Approach the child
slowly and gently to encourage cooperation and to gain confidence. The approach should
be kind, yet firm. The child should not be separated from the parent unnecessarily. Get
down to the same visual level as the child. Remember, if the child violates a parental
rule, he or she may distort the facts. In addition, children may imagine fantasy as reality
and reality as fantasy. Always be honest with the patient. Never tell the child that it
“won’t hurt” if you know it will. Instead say “ This might hurt a little bit, and you can
cry if you want to.” Children respond to calm reassurance. Converse with the patient in
a soft voice, using simple words.

Physical Examination

After the pertinent patient history has been obtained, attention should be turned toward
the physical examination. Avoid touching any injured or painful areas until the child’s
confidence has been gained. Begin your examination without instruments. If possible,
allow the child to determine the order of the examination.

The physical examination of the child should be systematic and should follow the same
format used for adults. In the infant, special attention should be paid to the anterior
fontanelle. The fontanelles are areas of the skull that have not yet fused. They allow for
compression of the head during childbirth and for rapid growth of the brain during early
life. The posterior fontanelle is generally closed by 4 months of age. The anterior

11
fontanelle diminishes after 6 months of age and is generally closed by 9 -18 months of
age.

The anterior fontanelle should be inspected in all infants. Normally, it should be level
with the surface of the skull, or slightly sunken, and it may pulsate. With increased
intracranial pressure, such as occurs with meningitis or head trauma, the fontanelle may
become tight and bulging. Pulsations may diminish or disappear. With dehydration, the
anterior fontanelle may often fall below the level of the skull and appear sunken.

Gastrointestinal disturbances are common in children and can occur with virtually any
disorder. When confronted with a child who has been vomiting, it is important to
determine how many times the child has vomited, the color of the vomitus, and other
associated symptoms. The same procedure holds true for diarrhea.

Pediatric Vital Signs

Poorly-taken vital signs in the pediatric patient are of less value than no vital signs at all.
The following general guidelines will help you obtain accurate pediatric vital signs.

 Take vital signs with the patient in as close to a resting state as possible. If necessary,
allow the child to calm down before attempting vital signs. Vital signs in the field
should include pulse, respirations, blood pressure, and, if equipment available,
temperature.
 Obtain blood pressure with an appropriate-sized cuff. The cuff should be two-thirds
the width of the upper arm.
 Determine the pulse at the brachial artery, carotid artery, or wrist, depending upon the
size of the child. There is often a significant variation in the pulse rate in children due
to respirations. Therefore, it is important to monitor the pulse for at least 30 seconds,
a full minute if possible.
 It is generally not possible to weigh the child. However, if medications are required,
make a good estimate of the child’s weight. Often the parents can provide a fairly
reliable weight from a recent visit to the doctor.

12
 Normal Pediatric Vital Signs by Age

 Observe respiratory rate before beginning the examination. After the examination is
started, the child will often begin to cry. It will then be impossible to determine
respiratory rate. For an estimate of upper limit of respiratory rate, subtract the child’s
age from 40. It is also important to identify respiratory pattern, as well as retractions,
nasal flaring, or paradoxical chest motion.
 Observe the child for level of consciousness. There may be a wide variability in
levels of consciousness and activity.

Non-Invasive Monitoring

Electronic monitoring devices are becoming commonplace in modern pre-hospital care.

Pulse oximeters, ECG monitors, and automated blood pressure devices all have
application in pediatric emergency care.

Pulse oximetry is particularly useful in pediatric care as many pediatric emergencies are
due to respiratory problems. The pulse oximeter gives you immediate information
regarding peripheral oxygen saturation. In addition, it allows you to follow trends in the
patient’s pulse rate and oxygenation status.

Any critically ill or injured child should receive continuous ECG monitoring. This will
provide essential information regarding the patient’s heart rate. It will also help you to
monitor the effects of any mediations administered.

13
Monitoring devices may frighten the child. Before applying any monitoring device,
explain to the child what you are going to do. Show him or her the display or lights. If
the monitoring device makes noise, allow the child to hear the noise before you apply it.
Reassure the child that the device will not hurt him or her.

Pediatric Trauma Emergencies

Trauma is the leading cause of death in children. The most common mechanism of injury
is motor vehicle accidents, followed by burns, drowning, falls, and firearms. Most
pediatric injuries result from blunt trauma. However, if you serve in an urban area, you
can expect to see an increasing incidence of penetrating trauma in children. The most
common body area injured in pediatric multiple trauma victims are the head, trunk, and
extremities. Your approach to pediatric trauma is much the same as for adult trauma
victims. You should first complete the A-B-C-D-E steps of initial assessment (primary).
These include:

 Airway with cervical spine stabilization

 Breathing
 Circulation
 Disability (neurological examination)
 Exposure

Any immediate threats to life detected during the initial assessment (primary) should be
corrected when found. Following this, you should proceed to the detailed assessment
(secondary), unless the child’s condition requires immediate transport. Particular
emphasis in the detailed assessment (secondary) should be on detection of the injuries,
described in the following discussion.

Kinematics of Pediatric Trauma

The size of a child produces a smaller target to which linear forces from fenders,
bumpers, and falls are applied. Due to decreased fat, increased elasticity of connective
tissue and close proximity of multiple organs, these forces do not dissipate well as in the
adult and disperse more energy to multiple organs. The skeleton of a child is
incompletely calcified and contains multiple active growth centers, which make it more
resilient. However, it is less able to absorb the kinetic forces applied during a traumatic
event and may allow significant internal injury with little or no external injury.

Head, Face and Neck Injuries

The majority of children who sustain multiple trauma will suffer an associated head
injury. Head injuries are the most common cause of death in pediatric patients. Children

14
are particularly prone to head injuries because their heads are proportionally larger and
heavier in comparison to the rest of their body. The mechanism of injury resulting in
head trauma varies based upon the age of the child. Infants and small children usually
sustain head injuries during a fall. School-age children tend to sustain head injuries from
bicycle accidents, falls from trees, or auto-pedestrian accidents. Older children most
commonly sustain head injuries in association with sporting events. Remember, child
abuse is a frequent cause of head injury. Always be alert for the signs and symptoms of
child abuse. Common head injuries seen in children include skin lacerations, skull
fractures, contusions, concussions, and intracranial hemorrhage.

Children also frequently injure their faces. The most common facial injuries are
lacerations, secondary to falls. Young children are very clumsy as they first start
walking. A fall onto a sharp object, such as the corner of a coffee table, can result in a
laceration. Older children sustain dental injuries in falls from bicycles, skateboard
accidents, fights, and sports activities.

Spinal injuries in children are not as common as in adults. However, because of a child’s
proportionally larger and heavier head, the cervical spine is vulnerable to injury. Any
time a child sustains a head injury, always assume that a neck injury may also be present.

Chest and Abdomen Injuries

Chest injuries are the second most common cause of pediatric trauma deaths. Most
thoracic injuries result from blunt trauma. Pneumothorax and hemothorax can occur in
the pediatric patient, especially if the mechanism of injury was a motor vehicle accident.
Tension pneumothorax can also occur in childhood. Pediatric tension pneumothorax
results in diminished breath sounds over the affected lung, shift of the trachea to the
opposite side, and a progressive decrease in ventilatory compliance. The ribs are soft and
pliable, and do not provide protection, so internal organs are more prone to injury.

Significant blunt trauma to the abdomen can result in injury to the spleen or liver. In fact,
the spleen is the most commonly injured organ in children. Signs and symptoms of a
splenic injury include tenderness in the left upper quadrant of the abdomen, abrasions on
the abdomen, and occasionally, ecchymosis over the affected area. The liver is also
frequently injured in blunt abdominal trauma. Symptoms of liver injury include right
upper quadrant abdominal pain and/or right lower chest pain. Both splenic and hepatic
injuries can cause life-threatening internal hemorrhage.

Because of the high mortality associated with blunt trauma, children with significant
blunt abdominal or chest trauma should be transported immediately to a pediatric trauma
center with appropriate care provided en route. Treat for shock with positioning, fluids,
and maintenance of body temperature.

15
Extremity Injuries

Extremity injuries in children are typically limited to fractures and lacerations. Children
rarely sustain amputations and other serious extremity injuries. An exception includes
farm children who may become entangled in agricultural equipment thus causing severe
injuries to the extremities.

The most common injuries are fractures, usually resulting from falls. Because children
have more flexible bones than adults, they tend to have incomplete fractures such as
bend fractures, buckle fractures, and greenstick fractures. In younger children, the
bone growth plates have not yet closed. Some types of growth plate fractures can lead to
permanent disability if not managed correctly.

 bend fractures - fractures seen in children characterized by angulation and deformity

in the bone without obvious break.
 buckle fractures - fractures seen in children characterized by a raised or bulging
projection at the fracture site.
 greenstick fractures - fractures seen in children characterized by an incomplete
break in the bone

Burns

Burns are the second leading cause of death in children. Scald burns are the most
common type of burn injury encountered. Children can burn themselves by pulling hot
liquids off tables or stoves. Immersion in hot water can also cause a significant scald
injury. Chemical burns, flame burns, and electrical burns also occur in children. The
common problem following burns in children is infection. Skin injured by burns cannot
protect against infection as effectively as normal skin can.

Estimation of the burn surface area is slightly different for children, as a general guide,
the area of the patient’s palm is approximately one per cent (1%) of the patient’s body
surface area. This can be used as a tool to estimate the total area burned. The following
(Lund and Bowder Chart) can also be used in estimation of burn size in children.

16
Area 0 years 1 year 5 years 10 years 15 years
* ½ of head 9.5% 8.5% 6.5% 5.5% 4.5%
* ½ of one 2.75% 3.25% 4% 4.25% 4.5%
thigh
*½ of one 2.5% 2.5% 2.75% 3% 3.25%
leg
 whereas ½ refers to anterior portion or posterior portion (i.e. front of head)

Body surface area distribution in a young child or infant differs considerably from the
body surface area distribution for an adult. The infant or young child’s head represents a
larger portion of the surface area, and the lower extremities a lesser proportion, when
compared to an adult. The percentage of total body surface of the infant’s head is twice
that of a normal adult.

Shock

Shock is a condition that develops when the circulatory system is unable to deliver a
sufficient amount of blood to the organs of the body. This results in organ failure and
eventually cardiopulmonary arrest. In children, shock is rarely due to a primary cardiac
event, such as a heart attack. Shock may be due to many things; the most common
causes include the following:
 Traumatic injury with blood loss (especially abdominal)
 Dehydration from diarrhea and vomiting
 Severe infection
 Neurologic injury such as severe head trauma
 A severe allergic reaction to an insect bite or allergy (anaphylaxis)
 Diseases of the heart
 A collapsed lung (pneumothorax)
 Blood or fluid around the heart (cardiac tamponade or pericarditis)

Infants and children have less blood circulating in their bodies than adults do, so the loss
of even a small volume of fluid or blood may lead to shock. Pediatric patients also
respond differently than adults to fluid loss. They may respond by increasing their heart
rate so that it is 160 to 220 beats/min; they may also breathe quickly and/or appear pale
or blue. You must be able to recognize the signs of shock in infants and children.

Assessments

Begin by assessing the ABCD, intervening immediately as required; do not wait until you
have completed a detailed assessment (secondary) to take action. Children in shock often
have increased respirations but do not demonstrate a fall in blood pressure until shock is
severe.
In assessing circulation, you should pay particular attention to the following:

17
Pulse: Assess both the rate and the quality of the pulse. A weak, “thready” pulse is a
sign that there is a problem. The appropriate rate depends on age; anything over 160
beats/min suggests shock

Skin signs: Assess the temperature and moisture on the hands and feet. How does this
compare with the temperature of the skin on the trunk of the body? Is the skin dry and
warm, or cold and clammy?

Capillary refill: Squeeze a finger or toe for several seconds until the skin blanches, then
release it. The time it takes for the blood to return to the area is the capillary refill time.
Does the fingertip return to its normal color within 2 seconds, or is it delayed?

Color: Assess the patient’s skin color. Is it pink, pale, ashen, or blue?

Changes in pulse rate, color, skin signs, and capillary refill are all important clues
suggesting shock.
Blood pressure is the most difficult vital sign to take in pediatric patients. The cuff must
be the proper size: two thirds the length of the upper arm. Cuffs that are too large will
give pressures that are lower than actual; cuffs that are too small will give pressures that
are higher than actual. The value for normal blood pressure is also age-specific.
Remember that blood pressure may be normal; this is called compensated shock. If the
blood pressure is low, this is a sign of decompensated shock, a serious condition that
requires care an ALS team can provide.
Part of your assessment should also include talking with the caregivers to determine
when the signs and symptoms first appeared and whether any of the following has
occurred:
 Decrease in urine output (with infants, are there fewer than 6 to 10 wet diapers/day?)
 Absence of tears, even when the child is crying
 Changes in level of consciousness and behavior

Management

Shock is a serious condition; therefore you should limit your care to the following
interventions:

1. Immobilize the entire spine if you suspect trauma.

2. Position the patient with the head lower than the feet by elevating the feet with
blankets.
3. Ensure that the airway is open, and give supplemental oxygen by mask or nasal
cannula as tolerated/required
4. Be prepared to provide artificial ventilation if necessary.
5. Control bleeding if present.
6. Keep the patient warm with blankets and by raising the rescue vehicle temperature.
7. Provide immediate transport to the nearest appropriate facility.

18
8. Continue monitoring vital signs en route to the hospital.
9. Start an IV (if protocols allow)
10. Contact ALS backup if available.
11. Whenever possible, allow a caregiver to accompany the child.

Limit your management to these simple interventions. Time should not be wasted in
field procedures. Immediate transport is of utmost importance.

Child Abuse and Neglect

Child abuse should always be suspected, especially if injuries are not consistent with the
history. There are several characteristics common to abused children. Often, the child is
seen as “special” and different from others. Premature infants or a twin stand a higher
risk of abuse than other children. Many abused children are less than 5 years of age.
Handicapped children, as well as those with special needs, are also at greater risk. So are
uncommunicative (i.e. autistic) children. Boys are more often abused than girls. A child
who is not what the parents wanted (e.g. the wrong sex) is at increased risk for abuse too.

The Child Abuser

The child abuser can come from any geographic, religious, ethnic, occupational,
educational, or socio-economic group. However, people who abuse children tend to
share certain characteristics. The abuser is usually a parent or someone in the role of a
parent. When the mother spends most time with the child, she is the parent most
frequently identified as the abuser. Most child abusers were abused themselves as
children. Three conditions can alert you to the potential for abuse. They include:

 A parent or adult capable of abuse

 A child in one of the high-risk categories
 The presence of a crisis

Common crises that may precipitate abuse include financial stress, marital or relationship
stress, and physical illness in a parent or child.

There are four major types of abuse found in children. They include physical abuse,
sexual abuse, emotional / psychological abuse, and neglect.

Sexual Abuse

Sexual abuse can occur at any age. The sexual abuser is almost always someone in the
family, someone known to the family, or someone the child trust. Stepchildren or
adopted children face a greater risk for sexual abuse by a parent than biological children.
If you suspect the child has been sexually abused, examine the genitalia externally for
serious injury. Avoid touching the child or disturbing the clothing. Police may need to

19
examine the child and the clothes for evidence. Your best approach to sexually abused
children is one of caring support. If your region has a sexual assault team or program
ensure that they are contacted.

Assessment of the Potentially Abused Child

Signs of child abuse can be startling. As a guide, the following findings should trigger a
high index of suspicion.

 Any obvious or suspected fractures in a child under 2 years of age.

 Injuries in various stages of healing, especially burns and bruises.
 More injuries than usually seen in children of the same age.
 Injuries scattered on many areas of the body.
 Bruises or burns in patterns that suggest intentional infliction (ex. cigarette burns,
hand marks, bruises found on the buttocks, genitals, thighs, ears and face)
 Increased intracranial pressure in infants.
 Suspected intra-abdominal trauma in a young child.
 Any injury that does not fit with the description of the cause given.

Information in the medical history may also raise the index of suspicion. Examples
include:

 A child who does not turn to the parent for comfort.

 A history that does not match the nature or severity of the injury.
 Vague parental accounts or accounts that change during the interview.
 Accusations that the child injured himself or herself intentionally.
 Delay in seeking help.
 Child dressed inappropriately for the situation.
 A child who seems apathetic and does not cry despite his/her injuries.

Suspect child neglect if you spot any of the following conditions.

 Extreme malnutrition
 Multiple insect bites
 Longstanding skin infections
 Extreme lack of cleanliness

Management of the Potentially Abused Child

In cases of child abuse or neglect, the goals of management include: appropriate

treatment of injuries, protection of the child from further abuse, and notification of proper
authorities. You should obtain as much information as possible, in a non-judgmental
manner. Document all findings or statements in the patient care report. Don’t “cross-

20
examine” the parents; this job belongs to the police. Try to be supportive and non-
judgmental toward the parents. However, you should make sure the child is transported
to the hospital by the ambulance.
Upon arrival at the emergency department, report your suspicions to the
emergency department personnel and the proper authorities. Complete the patient care
report and all available documentation at this time, since delay may inhibit the accurate
recall of data. Child abuse and neglect are particularly stressful aspects of emergency
medical services. You must recognize and deal with your feelings, perhaps taking them
up at a Critical Incident Stress Debriefing.

Pediatric Medical Emergencies

Infections (ear, nose, or throat, and skin rashes etc.)

Most childhood medical emergencies involve the respiratory system. However, any body
system can be involved. Infections are common during this period in life. Infectious
diseases are those illnesses caused by the infection or infestation of the body by an
infectious agent such as a virus, bacteria, fungus or parasite. Childhood is a time of
frequent infectious illness due to the relative immaturity of the immune system. Most
children will have 5-6 upper respiratory infections per year. Most infections are minor
and self-limited. Children with infection may have a variety of signs and symptoms,
depending on the source and extent of infection and the length of time since the patient
was exposed. The following is a list of the possible signs and symptoms of infection in
pediatric patients:
 Fever
 Hypothermia (neonates)
 Chills
 Tachycardia
 Cough
 Sore throat
 Nasal congestion
 Malaise
 Tachypnea
 Cool or clammy skin
 Respiratory distress
 Poor feeding
 Vomiting or diarrhea (or both)
 Dehydration
 Hypoperfusion
 Seizure
 Severe headache
 Irritability
 Lethargy
 Stiff neck

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 Bulging fontanelle (infants)

Often the parent or caregiver provides a history of recent illness (e.g., fever, upper
respiratory tract infection, skin rash, ear, nose or throat infections, pain, or drainage).

Most children with infection need only supportive care while being transported for
evaluation by a physician. There are, however, several infections that can be life-
threatening. These include meningitis, pneumonia, and bacterial septicemia.
In severe cases the patient may require airway, ventilatory, and circulatory support. If
signs of decompensated shock are present, IV therapy may be warranted (per medical
direction/access to protocol). Active seizure activity may require the administration of
anticonvulsant agents (again if certified in protocol). When possible, children in stable
condition should be transported in their position of comfort in the company of the parent
or caregiver.

Neurological Emergencies

Neurological emergencies in childhood are fairly uncommon. These include seizure,

febrile seizures, Reye’s syndrome, and meningitis, among others. Children can have
intracranial bleeding significant enough to cause shock. Children suffer increased risk of
apneic periods with head injuries.

Seizures

Seizures can and do occur in children and are also are a frequent reason for summoning
EMS. Several factors have been identified as causing seizures. These include:

 Fever
 Hypoxia
 Infections (such as meningitis)
 Idiopathic epilepsy
 Electrolyte disturbances
 Head trauma
 Hypoglycemia (and other metabolic disorders)
 Toxic ingestions or exposure
 Tumor
 CNS malformations

Often, however, the etiology is not known. Status epilepticus can also occur in
children. Status epilepticus is a prolonged seizure or multiple seizures with no regaining
of consciousness between them. This is a serious medical emergency. Most pediatric
seizures that involve EMS personnel are febrile seizures.

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 Febrile seizures are seizures that occur as a result of a sudden increase in body
temperature. They occur most commonly between the ages of 6 months and 6 years.
Febrile seizures seem related to the rate at which the body temperature increases, not to
the degree of fever. Febrile seizures are difficult to diagnose in the field. Often, the
parents will report the recent onset of fever or cold symptoms. All pediatric patients
suffering a seizure must be transported to the hospital so that all etiologies can be
excluded.

Assessment

The history is a major factor in determining seizure type. Febrile seizure should be
suspected if the temperature is above 1030F (39.20C) and you are advised of a rapid
onset. The history of a previous seizure may suggest idiopathic epilepsy or other CNS
problem. However, there is a tendency for recurrence of febrile seizures in children who
are predisposed.
When confronted with a seizing child, determine whether there is a history of
seizures or seizures with fever. Has the child had a recent illness? Also, determine how
many seizures occurred during the incident. If the child is not seizing upon arrival, elicit
a description of seizure activity. Note the condition and position of the child when found.
Question parents or bystanders about the possibility of a head injury. A history of
irritability or lethargy prior to the seizure may indicate CNS infection. If possible, find
out whether the child suffers from diabetes or has recently complained of a headache or a
stiff neck. Note any current medications, as well as possible ingestions.
The physical examination should be systematic. Pay particular attention to the
adequacy of respirations, the level of consciousness, neurological evaluation, and signs of
injury. Also inspect the child for signs of dehydration. Dehydration may be evidenced
by the absence of tears or, in an infant by the presence of a sunken fontanelle.

Management

Management of the pediatric seizure is essentially the same as for the seizing adult. Place
the patient on the floor or on the bed. Be sure to lay the child on his or her side, away
form the furniture. Do not restrain the child, but take steps to protect him or her from
injury. Maintain the airway, but do not force anything, such as a bite stick, between the
teeth. Consider the use of an NPA to maintain the airway. Administer supplemental
oxygen. Then take and record all vital signs. If the child is febrile, remove excess layers
of clothing. If status epilepticus is present, transport without delay. Management of
these emergencies may also include (where service protocols permit) starting an IV and
administering diazepam for controlling seizures and acetaminophen to lower fever if
child is febrile. Reassure and support parents; this is a very stressful and frightening
situation for them.

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Meningitis

Meningitis is an infection of the meninges, the lining of the brain and spinal cord.
Meningitis can result from both bacteria and viruses. Viral meningitis is frequently
called aseptic meningitis, since an organism can not be routinely cultured from CSF fluid.
Aseptic meningitis is generally less severe than bacterial meningitis and self-limited.
Bacterial meningitis most commonly results from Streptococcus pneumoniae,
Haemophilus influenza, and Neisseria meningitides. These infections can be rapidly fatal
if not promptly recognized and treated appropriately. Meningitis can cause permanent
damage to the brain and nervous system, and is sometimes the cause of deafness.

Assessment

Meningitis is more common in children than in adults. Findings in the history that may
suggest meningitis include: a child who has been ill for one day to several days, recent
ear or respiratory tract infection, high fever, lethargy or irritability, a severe headache, or
a stiff neck, may complain of sensitivity to light and in bacterial meningitis the child may
also have a rash. The child with meningitis may present in various ways. Infants
generally do not develop a stiff neck. They will generally become lethargic and will not
feed well. Some babies may simply develop a fever. Documented fever in a child less
than 3 months of age is considered meningitis until proven otherwise.
On physical examination, the child with meningitis will appear very ill. With an
infant, the fontanelle may be bulging or full unless accompanied by dehydration.
Extreme discomfort with movement, due to irritability of the meninges, may be present.

Management

Recommended precautions for EMS personnel include wearing gloves, safety glasses and
a mask. Pre-hospital care of the infant or child with meningitis is supportive. Rapidly
complete the primary survey and detailed assessment (secondary). Then transport the
infant to the emergency department. If shock is present treat the child with oxygen and
intravenous fluids if local protocol permits.

Reye’s Syndrome

Reye’s syndrome is an acute, potentially fatal disease of childhood, characterized by

severe edema of the brain and increased intracranial pressure, hypoglycemia, and fatty
infiltration and dysfunction of the liver.
Reye’s syndrome is a disease that was undescribed until 1963. The etiology of Reye’s
syndrome has not been clearly established. Reye’s syndrome affects all ages, with peak
incidence between ages 5-15 years. It tends to occur more frequently in younger
children. The frequency is higher in fall and winter. After 1 year of age, there is a higher
incidence in the suburban and rural populations.

24
 Although no single etiological factor has been identified, several possible toxic
and metabolic causes have been postulated. Outbreaks tend to cluster during epidemics
of Influenza B. Occasionally, it has been associated with the chicken pox (varicella)
virus. Infants often will have a recent history of gastroenteritis. There has also been a
correlation between the use of aspirin and the disease, particularly after the flu.
Reye’s syndrome typically presents itself in a healthy child who develops severe
nausea and vomiting during an unremarkable viral illness. Within hours, the patient may
begin to display hyperactive or combative behavior. In addition, there may be personality
change, irrational behavior, progressive stupor, restlessness, convulsions, and coma. The
sudden onset of vomiting often marks the early stages of the disease. In approximately
10-20 percent of cases, there is a recent history of chicken pox. Other children may have
had a recent upper-respiratory infection. Infants may have recently had gastroenteritis.

Assessment

On physical examination, there may be rapid, deep respirations, which may be irregular.
The pupils can be dilated and react sluggishly. There also may be signs of increased
intracranial pressure, such as deviations in gaze. Unfortunately, Reye’s syndrome cannot
be diagnosed in the field. The diagnosis is difficult enough to make in the hospital.
Complications that can occur with Reye’s syndrome include respiratory failure,
cardiac arrhythmias, and acute pancreatitis. Death usually results from CNS
complications such as herniation of the brainstem.

Management

Management is general and supportive. Complete the initial assessment (primary survey)
with particular attention on the respiratory status. Support ventilations, if necessary, and
administer supplemental oxygen. Transport should be rapid. The prognosis depends on
early diagnosis and control of the increased intracranial pressure.

Respiratory Emergencies

Respiratory problems are common in childhood. Children are susceptible to many of the
respiratory problems that occur in adults. In addition, there are several problems that are
unique to children. Respiratory problems should be identified in the initial assessment
(primary) and treated appropriately. First, assess the airway. If it is obstructed, clear the
airway using BLS techniques, if possible. Second, assess breathing. If the child is not
breathing, you should initiate artificial ventilations.
Pediatric respiratory emergencies that deserve special attention include
bronchiolitis, croup, epiglottitis, asthma, and aspiration of foreign bodies. Children with

25
any of these disorders can suffer respiratory arrest. This is most often due to airway
obstruction or exhaustion.

Aspirated Foreign Body

Children especially 1 to 3 year olds, are always putting objects into their mouths. These
children are at increased risk of aspirating the object, especially when they are running or
falling. In addition, many children choke on, or aspirate, food given to them by their
parents or other well-meaning adults. Young children have not yet developed
coordinated chewing motions in the mouth and pharynx and cannot adequately chew
food. Common foods associated with aspiration and airway obstruction in children
include chewing gum, hot dogs, grapes, peanuts, and sausages.

Assessment

The children with a suspected aspirated foreign body may present in one of two ways. If
the obstruction is complete, the child will not be breathing. If it is partial, the child may
exhibit labored breathing, retractions, chest expansion, and cyanosis. A foreign body
aspirated into the respiratory tree will often drop until it lodges. Large objects will lodge
in the trachea or the mainstem bronchi. Smaller objects may drop to the bronchioles.
Often, the food particle will act as a one-way valve, allowing the entry of air, while
restricting its exit. This results in hyperexpansion of the affected lung. If severe, tracheal
deviation, away from the involved lung, may be noted.

Management

When confronted with a child suspected of aspirating a foreign body, immediately

complete the primary survey. If complete obstruction is noted, clear the airway with
accepted basic life support techniques.

If unsuccessful visualize the airway with a laryngoscope, (if trained to do so). If the
foreign body is seen, and readily accessible, try to remove it with Magill forceps.
If the obstruction is partial, make the child comfortable and administer humidified
oxygen. Be prepared to initiate BLS procedures as complete airway obstruction can

26
occur. The child should be transported to a hospital, where the foreign body can be
removed by fiberoptic bronchoscopy.

Croup

Croup, medically referred to as laryngotracheobronchitis, is a viral infection of the upper

airway. It most often occurs in children 3 months to 3 years of age and is most prevalent
in the fall and winter. The infection causes edema to develop beneath the larynx and
glottis, narrowing the lumen of the airway. Severe cases of croup may result incomplete
airway obstruction.

Assessment

The history for croup is fairly classic. Often, the child will have a mild cold or other
infection and be doing fairly well until dark. After dark, however, a harsh, barking cough
develops. The attack may subside in a few hours, but can persist for several nights.
The physical exam will often reveal inspiratory stridor. There may be associated
nasal flaring, tracheal tugging, or retraction. You SHOULD NEVER examine the
oropharynx. Often, in the pre-hospital setting, it is difficult to distinguish croup from
epiglottitis. (See table below.) If epiglottitis is present, examination of the oropharynx
may result in laryngospasm and complete airway obstruction. If the attack of croup is
severe and progressive the child may develop restlessness, tachycardia, and cyanosis.
Croup can result in complete airway obstruction and respiratory arrest.

When responding to possible croup or epiglottitis patients, the recommended precautions

for EMS personnel include wearing gloves, safety glasses and a mask or face shield. An
oxygen mask may be placed on the child if tolerated when epiglottitis is suspected.

Management

Management of croup should consist of appropriate airway maintenance. Place the child
in a position of comfort and administer humidified oxygen by face mask. Then prepare
the child for transport to the hospital. The process of transporting the child from the
house to the ambulance will often allow him or her to breathe the cool air. Because this
cool air causes a decrease in subglottic edema, the child may be clinically improved by
the time he or she reaches the ambulance. If the attack of croup is severe, Salbutamol via
nebulizer may be considered. Some physicians advocate the use of steroids in croup,
because they feel these drugs shorten the course of the illness.

Epiglottitis

Epiglottitis is an acute infection and inflammation of the epiglottis and is potentially life-
threatening. The epiglottis is a flap of cartilage that protects the airway during
swallowing. Epiglottitis, unlike croup, is caused by a bacterial infection, usually

27
Haemophilus influenza. Most commonly seen in children from the ages of 2 and 7, but
may occur at any age. It is characterized by a swollen, cherry red epiglottis.

Assessment

The child with epiglottitis is acutely ill. The presentation is similar to croup. Often, the
child will go to bed feeling relatively well, usually with what the parents consider to be a
mild infection of upper respiratory tract. Later, the child awakens with a high fever and a
brassy cough. The progression of symptoms can be dramatic. There is often pain upon
swallowing, sore throat, high fever, shallow breathing, dyspnea, inspiratory stridor, and
drooling. Remember that most often it is a sudden onset, and rapid progression!
On physical examination, the child appears toxic. Most often, the child will be
sitting with head forward, neck extended and mouth open, reluctant to speak. YOU
SHOULD NEVER attempt to visualize the airway. Often, however when the child is
crying, the tip of the epiglottis can be seen posterior to the base of the tongue. In
epiglottitis, it is red and swollen. As airway obstruction develops, the child will exhibit
retractions, nasal flaring, and pulmonary hyperexpansion.

Management

Management of epiglottitis should consist of appropriate airway maintenance. Place the

child in a position of comfort and administer humidified oxygen by face mask. Be
prepared to intervene should complete airway obstruction occur. In cases of epiglottitis,
transport the child to the hospital as quickly as possible. If total obstruction develops,
attempts should be made to ventilate the patient with a BVM attached to supplemental
oxygen.

Symptoms of Croup and Epiglottitis

Croup Epiglottitis
Slow onset Sudden onset, rapid progression
Generally wants to sit up Prefers to sit up
Barking cough No barking cough
No drooling Drooling; painful to swallow
Fever approx. 100-1010 F Fever approx. 102-1040 F
Occasional stridor

Bronchiolitis

Wheezing in a child less than one year of age is frequently due to bronchiolitis.
Bronchiolitis is a respiratory infection of the medium sized airways-the bronchioles-that
occurs in early childhood, most commonly between the ages of 6 and 18 months. It
should not be confused with bronchitis, which is an infection of the larger bronchi.
Bronchiolitis is caused by a viral infection, most commonly respiratory syncytial virus
(RSV), which affects the lining of the bronchioles. Characterized by prominent
expiratory wheezing, it clinically resembles asthma.

28
Assessment

A history is necessary to distinguish bronchiolitis from asthma. Often, with bronchiolitis,

there is a family history of asthma or allergies, although neither is yet present in the child.
In addition, there often is a low-grade fever. A major distinguishing factor is age.
Asthma rarely occurs before the age of one year, whereas bronchiolitis is more frequent
in this age group. There is often a history of a cold; often the child has a runny nose.
The physical examination should be systematic. Pay particular attention to the
presence of rales or wheezes. Also, note any evidence of infection or respiratory distress,
including tachypnea and hypoxia.

Management

Pre-hospital management of suspected bronchiolitis is much the same as with asthma.

Place the child in a semi-sitting position, if old enough, and administer humidified
oxygen by mask. Ventilations should be supported as necessary. If wheezing is present,
and local protocols permit both the Tech and Tech-P mayadminister Salbutamol via small
volume nebulizer. The cardiac rhythm should be constantly monitored. Pulse oximetry,
if available, should be used continuously.

Asthma

Asthma is a common respiratory disease. It is the most common chronic illness in

children. It occurs usually before the age 10 in approximately 50 percent of the cases,
and before age 30 in an additional 33 percent of cases. The disease tends to run in
families. It is also commonly associated with atopic conditions, such as eczema and
allergies. Although deaths from other respiratory conditions have been steadily
declining, asthmatic deaths have increased significantly in the last decade.
Hospitalization of children for treatment of asthma has increased by 200 percent or more
during the same interval. Because children can die from asthma, prompt pre-hospital
recognition and treatment are essential.

Pathophysiology

Asthma is a chronic inflammatory disorder of the airways. In susceptible children, this

inflammation causes widespread, but variable, airflow obstruction. In addition to airflow
obstruction, the airways become hyperresponsive.
Asthma may be induced by one of many different factors, commonly called
“triggers”. The triggers vary from one child to the next. Common triggers include
environmental allergens, cold air, exercise, foods, irritants, and certain medications.

29
 Within minutes of exposure to the trigger, a two-phase reaction occurs. The first
phase of the reaction is characterized by the release of chemical mediators such as
histamine. These cause bronchoconstriction and bronchial edema that effectively
decrease expiratory airflow, causing the classic “asthma attack”. If treated early, asthma
may respond to inhaled bronchodilators. If the attack is not aborted, or does not resolve
spontaneously, a second phase may occur. The second phase is characterized by
inflammation of the bronchioles as cells of the immune system invade the respiratory
tract. This causes additional edema and further decreases expiratory airflow. The second
phase will typically not respond to inhaled bronchodilators. Instead, anti-inflammatory
agents, such as corticosteroids are often required.
As the attack continues, and swelling of the mucous membranes lining the
bronchioles worsens, there may be plugging of the bronchi by thick mucus. This further
obstructs airflow. As a result, there is an increase in sputum production. In addition, the
lungs become progressively hyperinflated since airflow is more restricted on exhalation.
This effectively reduces vital capacity and results in decreased gas exchange at the
alveoli, resulting in hypoxemia. If allowed to progress untreated, hypoxemia will
worsen, and unconsciousness and death may ensue.

Assessment

Asthma can often be differentiated from other pediatric respiratory illnesses by the
history. In many cases, there is a prior history of asthma or reactive airway disease. The
child’s medications may also be an indicator. Children with asthma often have an inhaler
or take a theophylline or oral beta agonist preparation.
On physical examination, the child is usually sitting up, leaning forward, and
tachypneic. Often, there is an associated unproductive cough. Accessory respiratory
muscle usage is usually evident. Wheezing may be heard. However, in a severe attack,
the patient may not wheeze at all-this is an ominous finding. Generally, there is an
associated tachycardia, and this should be monitored, since virtually all medications used
to treat asthma increase the heart rate.

Management

The primary therapeutic goal in the asthmatic is to correct hypoxia, reverse

bronchospasm, and decrease inflammation. First, it is imperative that you establish an
airway. Next, administer supplemental, humidified oxygen as necessary. Tech, Tech-P
and Tech-AP may also administer a nebulized bronchodilator medications (Salbutamol)as
per protocols..

Status Asthmaticus

Status asthmaticus is defined as a severe, prolonged asthma attack that cannot be broken
by repeated doses of epinephrine. This is a serious medical emergency and prompt
recognition, treatment, and transport are required. Often, the child suffering status
asthmaticus will have a greatly distended chest from continued air trapping. Breath
sounds, and often wheezing, may be absent. The patient is usually exhausted, severely

30
acidotic, and often dehydrated. The management of status asthmaticus is basically the
same as asthma. However, you should recognize that respiratory arrest is imminent and
remain prepared for advanced airway management. Transport should be immediate, with
aggressive treatment continued en route.

Gastrointestinal Emergencies

Childhood gastrointestinal problems almost always present with nausea and vomiting as a
chief complaint. As a child gets older, gastrointestinal system emergencies, such as
appendicitis, become more common.

Nausea and Vomiting

Nausea and vomiting are symptoms of other disease processes. Virtually any medical
problem can cause nausea and vomiting in a child. Fever, ear infections, and respiratory
infections are common causes of nausea and vomiting. In addition, many viruses, and
certain bacteria, can infect the gastrointestinal system. These infections, collectively
called gastroenteritis, readily cause vomiting, diarrhea, or both.
The biggest risks associated with nausea and vomiting in children are dehydration
and electrolyte abnormalities. Infants and toddlers can quickly become dehydrated from
bouts of vomiting. If diarrhea or fever is also present, fluid loss is further accelerated,
worsening the situation. Dehydration in infants and toddlers is more difficult to detect
compared to older children.
Treatment of pediatric nausea and vomiting is primarily supportive. If the child is
dehydrated, and unable to keep oral fluids down, intravenous fluid therapy (where
protocols allow) may be indicated. Severe dehydration, is evidenced by prolonged
capillary refill time of more than 2 seconds.

Diarrhea

Diarrhea is a common occurrence in childhood. Often, what parents call diarrhea is

actually loose bowel movements. Generally, 10 or more loose stools per day is
considered diarrhea. As with nausea and vomiting, the main concern associated with
diarrhea is dehydration. Most diarrhea is due to viral infections of the gastrointestinal
system or secondary to infections elsewhere in the body. However, certain bacterial
infections can cause significant, even life-threatening, diarrhea.
Treatment of the child suffering diarrhea is primarily supportive as mentioned
above for nausea and vomiting.

Signs and Symptoms of Dehydration

Signs/Symptoms Mild Moderate Severe

Vital Signs
Pulse normal increased markedly increased
Respirations normal increased tachypneic

31
 Blood Pressure normal normal hypotensive
Capillary Refill normal 2-3 seconds >2 seconds
Mental Status alert irritable lethargic
Skin normal dry and ashen dry, cool, mottled
Mucous Membranes dry very dry very dry/no tears

Cardiovascular Emergencies

Cardiovascular emergencies in children most commonly result from volume depletion

due to severe dehydration, hemorrhage, or severe infection. With the exception of
congenital heart disease, cardiac emergencies in children are extremely rare. Cardiac
arrest in children usually follows respiratory arrest. The criteria for using an AED on a
child is a minimum age of 1 year old. Pediatric pads are preferred for children 1 to 8
years of age but are not essential. Management for children in cardiac arrest consists of
performing BLS procedures as outlined by the Heart and Stroke Foundation and use of an
AED if the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Lethal
dysrhythmias, such as ventricular fibrillation, ventricular tachycardia, or high-grade heart
blocks rarely occur in children.

Dehydration

Dehydration is defined as the lack of adequate body fluids for the body to carry on
normal functions at an optimal level; by loss, inadequate intake, or both.
The child is very vulnerable to dehydration. Among the causes are diarrhea, vomiting,
poor fluid intake, fever, and burns. Children have a high body-surface-area-to-weight
ratio. Therefore, they are very vulnerable to heat loss, and along with it, dehydration.
They also have a higher percentage of water to body tissues than adults. Fluid losses up
to 5% are considered mild; up to 10% are considered moderate; and up to 15% are
considered severe.

Assessment

When confronted with a dehydrated child, question the parents about recent infection,
diarrhea, vomiting and fever. Also, ask them about decreased urination. Many parents
will notice that their children are wetting fewer diapers than usual.
Physical examination may show decreased skin turgor, weight loss, and absent
tears. Urine may be quite concentrated. The eyes may be dull and sunken-looking.
Infants may exhibit a depressed anterior fontanelle. The child may have altered mental
status or poor pain response. The table on the previous page will help you determine the
severity of dehydration.

32
Management

The management of dehydration should first include the initial assessment (primary):
airway, breathing, and circulation. The vital signs should be determined and monitored.
If the child is in shock, and age/protocol permits; start an IV of normal saline. Do not
delay transport however if there is difficulty in starting an IV. Severe dehydration can
result in cardiovascular collapse and death if not treated quickly.

Sepsis

Sepsis is a bacterial infection of the bloodstream. It usually occurs as a complication of

an infection at another site such as pneumonia, an ear infection, or a urinary tract
infection. Meningitis is frequently associated with sepsis. The etiology can be varied, as
can the presenting signs and symptoms. Occasionally, the focus of infection cannot be
initially determined. Newborns and small infants are at increased risk of developing
sepsis as their immune systems are still relatively immature.
The septic child is critically ill. Septic shock may develop due to the release of
deadly toxins by the bacteria causing the infection. These toxins cause peripheral
vasodilation, leading to drop in blood pressure and decreased tissue perfusion. Sepsis can
be rapidly fatal if not promptly identified and treated.

Assessment

Suspect sepsis in any child who becomes ill or who has been ill for several days,
especially if accompanied by fever, lethargy, irritability, or shock. Initial management of
the septic child includes the initial assessment (primary) and detailed assessment
(secondary). Signs and symptoms of sepsis include:

 Ill appearance
 Irritability or altered mental status
 Fever
 Vomiting and diarrhea
 Cyanosis, pallor, or mottled skin
 Nonspecific respiratory distress
 Poor feeding

Signs and symptoms of septic shock include:

 Very ill appearance

 Altered mental status
 Tachycardia
 Capillary refill time greater than 2 seconds
 Hyperventilation, leading to respiratory failure
 Cool and clammy skin

33
 Inability of child to recognize parents

Management

The initial assessment (primary)) should be completed. Secure and maintain the airway
and assist ventilation as required. Administer supplemental oxygen at a high
concentration. If protocol allows, establish IV access and begin infusion of normal
saline. Shock can develop and should be anticipated and treated appropriately. Sepsis is
a very serious condition than can deteriorate quickly. It must be promptly recognized and
treated appropriately. The goal is to prevent the development of septic shock.

Dysrhythmias

Dysrhythmias in children are uncommon and usually due to non-cardiac problems. The
most common pediatric dysrhythmia is bradycardia. It usually results from hypoxia,
hypotension, or acidosis. Supraventricular tachycardia can also occur in children.
Although a rare disorder, supraventricular tachycardia can cause sustained heart rates of
200 beats per minute or greater. Heart rates in excess of 200 beats per minute do not
allow for adequate ventricular filling. Because of this, cardiac output may fall, resulting
in decreased tissue perfusion. Asystole is usually a terminal event, following prolonged,
untreated bradycardia. Ventricular fibrillation in children is rare and usually results from
serious electrolyte imbalances.
Treatment of pediatric dysrhythmias is much the same as for adults. However,
algorithms have been developed for the treatment of pediatric bradycardia and pediatric
asystole.

Congenital Heart Disease

Congenital heart disease is an abnormality or defect in the heart present at birth. It is the
primary cause of heart disease in children. Most congenital heart problems are detected
at birth. Some, however, are not discovered until later in childhood. The most common
emergency due to congenital heart disease is cyanosis. This occurs when blood going to
the lungs for oxygenation mixes with blood bound for other parts of the body. This may
result from holes in the internal walls of the heart or abnormalities of the great vessels.
The child with congenital heart disease may develop respiratory distress,
congestive heart failure, or a “cyanotic spell”. Cyanotic spells occur when oxygen
demand exceeds that provided by the blood. It begins as irritability, inconsolable crying,
or altered mental status. Severe dyspnea may develop, including progressive cyanosis.
In severe and prolonged cases, seizures, coma, or cardiac arrest may result. Non-cyanotic
problems associated with congenital heart disease include respiratory distress,
tachycardia, decreased end-organ perfusion, drowsiness, fatigue, and pallor.
Treatment includes the standard initial assessment (primary). Administer oxygen
at a high concentration. If necessary, provide ventilatory support. If the child is having a

34
cyanotic spell, place him or her in the knee-chest position facing downward. This will
help decrease the cardiac workload. Apply the ECG monitor, and start an intravenous
line at a TKO rate (if local protocol allows). Transport immediately.

Other Pediatric Emergencies

Anaphylaxis
Anaphylaxis is an allergic reaction in the most severe form. It is an acute, generalized
reaction that may be rapidly fatal even with prompt and appropriate medical care. An
antigen is a foreign substance to which the body mounts an immune response. Examples
of potent antigens include antibiotics (penicillins, sulfas), insect stings (bees, wasps),
foods (peanuts, strawberries), or other substances (perfumes, cleaning agents). Antigens
such as these are often referred to as “allergens” because of the allergic response
produced.
Anaphylaxis may develop in seconds to minutes after the ingestion, injection, inhalation,
or absorption of the antigenic substance. Anaphylaxis is an emergency that requires
prompt recognition of the condition and appropriate treatment by EMS personnel. This
initial treatment may be life saving.

General (Signs and Symptoms, Assessment and Management)

 Personal protective equipment should be utilized and safety precautions in place

(swarms of bees/wasps)
 Routine Practices (BSI) techniques and equipment should be utilized as appropriate
 Initial assessment (primary))
 Administer high concentration oxygen
 Assess the patient for symptoms or signs that may indicate a moderate or severe
anaphylactic reaction
 abdominal cramps, nausea, vomiting
 altered level of consciousness
 vital signs
 tachycardia or bradycardia (late finding)
 tachypnea
 elevated blood pressure or decreased blood pressure (if reaction is
severe)
 respiratory system
 swelling of the face, mouth, throat
 wheezing, stridor, difficulty with secretions
 partial or complete airway obstruction
 cardiovascular system
 chest tightening or pain
 skin
 local warmth and swelling, urticaria (hives), rash

35
  swelling of extremities
 Obtain a focused history
 time of onset of symptoms
 possible source of exposure to allergen(s)
 known sensitivities and allergies
 medical identification, such as Medic Alert bracelet, anklet or neck chain
 medications the patient takes
 routinely to prevent reactions
 in emergency situations for anaphylaxis
 whether patient has self-administered any emergency medications
 name of medication(s)
 dose of medication(s)
 time(s) of administration
 number of doses
 results of medication(s)

Administration of Epinephrine

 EMS personnel trained and certified to treat anaphylaxis using epinephrine may do so
as outlined in the Anaphylaxis Protocol
 EMS personnel should administer epinephrine to the patient as early as
possible
 refer to Anaphylaxis Treatment Protocols
 Initiate transport
 on scene times should be kept to a minimum
 treat other life-threatening conditions en route
 Transport the patient to the nearest appropriate health care facility
 notify the receiving health care facility of the patient’s status as soon as
possible
 monitor and treat the patient en route
 high concentration of oxygen should be delivered to the patient
 be prepared to support respiratory and circulatory functions
 additional surveys and treatments should be conducted en route
 Report all findings to the receiving facility staff, and document on the patient care
report

Special Consideration

 Anaphylaxis is a true medical emergency-time to initial treatment and definite care

are critical
 rapid assessments, appropriate interventions, and early load and go can impact
on the patient’s outcome

36
 Respiratory compromise in the setting of anaphylaxis is an indication for immediate
transport
 A “hoarse” voice in a patient having an allergic reaction is a danger signal of an
impending airway obstruction
 If an insect stinger is imbedded in the skin, remove by scrapping with a fingernail or
scissors
 do not grasp the stinger to remove it
 do not delay load and go to remove stinger
 If time permits, remove jewelry from the affected area
 once the area is swollen, it may be difficult to remove and may cause distal
neurovascular compromise
 If the anaphylactic reaction is possibly due to a substance injected into an extremity,
refer to the injected Poison section of the Poisoning Treatment Guideline

Note

 Patients typically have a past medical history of allergies or anaphylaxis due to

specific known allergens
 patients may have an anaphylactic reaction the first time they come into
contact with a substance
 In many cases, the patient will have their own epinephrine and delivery device
 while the patient may self-administer their own medication, EMS personnel
should use the epinephrine and delivery device carried by EMS
 this ensures the epinephrine is not expired, is delivered with aseptic
techniques, and negates the need for the patient to exert him/herself in
the delivery process
 this also ensures consistency in drug delivery in all patients

Altered Mental State

People who are aware of themselves and their surroundings are said to be conscious.
Nonverbal infants may demonstrate consciousness by following a person’s face or an
object (tracking) by babbling and cooing, or by crying. Infants and children may exhibit
an altered mental state (also called altered level of consciousness) in many ways,
including lack of response to vocal commands and pain, combative behavior, confusion,
thrashing about, drifting into and out of an alert state, or a change in the pitch and nature
of their cry. Be aware of the many terms that are used to describe an altered mental state,
including coma, delirium, and stupor. However, you should avoid using all of these
terms, as none are accurate.
Common causes of altered mental state or altered level of consciousness in a pediatric
patient include the following:

 Head trauma

37
 Shock
 Meningitis
 Seizures
 Brain tumor
 Intracranial bleeding
 Metabolic disease such as diabetes
 Low blood glucose
 Severe dehydration
 Lack of oxygen to the brain
 Stroke

Your first step in caring for a patient with an altered level of consciousness is to assess
ABCD and provide appropriate care as necessary. As you determine responsiveness,
remember to use the AVPU scale. Then obtain a brief history from the patient’s
caregivers, focusing on the following points:
 Does the patient have any illnesses?
 Does the patient take any medications? When was the last dose?
 Did the patient ingest any substances (eg. poisons, drugs, or plant material)?
 Has the patient been ill?
 Has the patient had any behavior problems?

Next, observe the child’s pupils: Are they dilated or pinpoint? Do they react to a light by
constricting? Are the eyes turned to the right, left, up or down? Is the child staring
without moving his/her eyes? Is the child posturing?
Once you have completed your initial assessment (primary), immediately secure the
airway. If respirations are inadequate, provide assisted ventilation with a BVM device.
If you suspect trauma, log roll the child onto a backboard, and apply a cervical collar. If
a collar is not available, tape the child’s head to the backboard with towel rolls on both
sides of the neck to prevent movement. Give supplemental oxygen by mask or nasal
cannula.
If the child is actively seizing, follow the care described in the Treatment Guidelines for
Seizures. No matter what the cause, you should support for the patient’s vital functions
and provide prompt transport.

Sudden Infant Death Syndrome (SIDS)

In addition to the pediatric emergencies previously discussed, you should be

familiar with Sudden Infant Death Syndrome (SIDS). SIDS is a sad and difficult
situation for both parents and pre-hospital personnel. An understanding of SIDS is
essential in order to enable you to deal effectively with this heart-breaking emergency.

Sudden Infant Death Syndrome (SIDS) is defined as the sudden death of an infant
during the first year of life from an illness of unknown etiology. The incidence of SIDS
in Canada is approximately 1 death per 1,000 births. SIDS is the leading cause of death
between 1 week and 1 year of age in Canada. It is responsible for a significant number of

38
deaths between 1 month and 6 months of age, with peak incidences occurring at 2-4
months.
Death usually occurs during sleep. The incidence seems to be greater during
winter and is more common in males than in females. It is more prevalent in families
with younger mothers and in those from low socioeconomic groups. A higher incidence
is also reported in infants with low birth weight. Occasionally, a mild upper respiratory
infection will be reported prior to the death. SIDS is not caused by external suffocation
from blankets or pillows. Neither is it related to child abuse, regurgitation and aspiration
of stomach contents, or allergies to cow’s milk. It is not hereditary, but does tend to recur
in families.
Current theories vary about the etiology. Some authorities feel it may result from
an immature respiratory center in the brain that leads the child to simply stop breathing.
Others feel there may be an airway obstruction in the posterior pharynx, as a result of
pharyngeal relaxation during sleep, a hyper-mobile mandible, or an enlarged tongue.
There are many other theories and investigation continues.

Other potential risk factors include:

- sleeping on the stomach - crowded living conditions

- tobacco use in the home - drug use during pregnancy
- adolescent mothers - multiple births
- lack of prenatal care - African American & Native American ethnicity

Assessment

Infants suffering SIDS have similar physical findings. From an external standpoint, there
is a normal state of nutrition and hydration. The skin may be mottled. There are often
frothy, occasionally blood-tinged, fluids in and around the mouth and nostrils. Vomitus
may be present. Occasionally, the infant may be in an unusual position, due to muscle
spasm at the time of death. Common findings noted at autopsy include intrathoracic
petechia (small hemorrhages) in 90 percent of cases. There is often associated pulmonary
congestion and edema. Sometimes, stomach contents are found in the trachea.
Microscopic examination of the trachea often reveals the presence of inflammatory
changes.

Management

The immediate needs of the family with a SIDS baby are many. Undertake active and
aggressive care of the infant to assure the parents that everything possible is being done.
If death of the baby is obvious, it may be important to the family that the child is
Baptized immediately. Regardless of your religion, you may facilitate this wish if you
feel comfortable. Otherwise you can make arrangements to call the family’s minister or
priest. To perform the baptism, sprinkle a few drops of water on the baby’s head, and
repeat the exact words, “I baptize you in the name of the Father, and of the Son, and of
the Holy Spirit”.. One medic should be assigned to assist the parents and to explain the
procedures. After arrival at the hospital, direct management and care for the parents,

39
since often nothing can be done for the child. If the infant is dead, allow the family to see
the child. Expect a normal grief reaction from the parents. Initially, there may be shock,
disbelief, and denial. Other times, the parents may express anger, rage, hostility, blame
or guilt. Often, there is a feeling of inadequacy as a parent, as well as helplessness,
confusion, and fear. The grief process may last as long as 1-2 years. SIDS has a major
long-term effect on family relationships.

Legal Responsibilities and Implications of Treating Pediatric

Patients
The following are excerpts from the Child Protection Act.

PART III: CHILD PROTECTION

Child in Need of Protection

17(1) For purposes of this Act, a child is in need of protection where the life, health or
emotional well-being of the child is endangered by the act or omission of a
person.

S.M. 1986-87, s.8; SM. 1989-90, c. 3,s.3.

Illustrations of Child in Need

17(2) Without restricting the generality of subsection (1), a child is in need of

protection where the child:

(a) is without adequate care, supervision or control;

(b) is in the care, custody, control or charge of a person
(i) who is unable or unwilling to provide adequate care,
supervision or control of the child, or
(ii) whose conduct endangers or might endanger the life,
health or emotional well-being of the child, or
(iii) who neglects or refuses to provide or obtain proper
medical or other remedial care or treatment necessary
for the health or well-being of the child or who refuses
to permit such care or treatment to be provided to the
child when the care or treatment is recommended by a
duly qualified medical practitioner;
(c) is abused or is in danger of being abused
(d) is beyond the control of a person who has the care, custody, control
or charge of the child;
(e) is likely to suffer harm or injury due to the behavior, condition,
domestic environment or associations of the child or of a person
having care, custody, control or charge of the child;
(f) is subjected to aggression or sexual harassment that endangers the
life, health or emotional well-being of the child;
(g) being under the age of 12 years, is left unattended and without

40
 reasonable provision being made for the supervision and safety of
the child, or
(h) is the subject, or is about to become the subject, of an unlawful
adoption under section 63 or of an unlawful sale under section 84.

S.M. 1986-87, c. 19, ~.8; S.M. 1989-90, c. 3, ~.3.

41
Reporting a Child in Need of Protection

18(1) Subject to subsection (1.1), where a person has information that leads the
person reasonably to believe that a child is or might be in need of protection as
provided in section 17, the person shall forthwith report the information to an
agency or to a parent or guardian of the child.
S.M. 1989-90, c. 3, s.4.

Reporting to Agency Only

18(1.1) Where a person under subsection (1):

(a) does not know the identity of the parent or guardian of the child;
(b) has information that leads the person reasonably to believe that the
parent or guardian
(i) is responsible for causing the child to be in need of
protection, or
(ii) is unable or unwilling to provide adequate protection to the
child in the circumstances; or
(c) has information that leads the person reasonably to believe that the
child is or might be suffering abuse; subsection (1) does not apply
and the person shall forthwith report the information to an agency.

S.M. 1989-90, c. 3, s.4.

Duty to Report

18(2) Notwithstanding the provisions of any other Act, subsection (1) applies even
where the person has acquired the information through the discharge of
professional duties or within a confidential relationship, but nothing in this
subsection abrogates any privilege that may exist because of the relationship
between a solicitor and the solicitor's client.

Protection of Informant

18.1(1) No action lies against a person for providing information in good faith and in
compliance with section 18.

S.M. 1989-90, c. 3,s. 5.

Identity of Informant

18.1(2) No person shall, except as required in the course of a judicial proceeding,

disclose to the family of a child reported in need of protection the identity of
the informant under section 18 without the written consent of the informant.

42
 S.M. 1989-90, c. 3, s.5.
Manitoba Emergency Services College 2
Part Ill: Child Protection
Child and Family Services

No Interference or Harassment

18.1(3) No person shall interfere with or harass an informant under section 18.

S.M. 1989-90, c. 3, S. 5.

Director Reports to Professional Organizations

18.2(1) Where the director has reasonable grounds to believe that a person has caused a
child to be in need of protection as provided in section 17 or has failed to report
information in
accordance with section 18, the director may report the person to the
professional society or association or regulatory organization of which the
person is a member or that governs the professional status of the person.

S.M. 1898-90, C. 3, s.5.

43
Glossary of Terms

anaphylaxis: an acute, generalized, and violent antigen-antibody reaction that can be

rapidly fatal.

bend fracture: fracture seen in children characterized by angulation and deformity in

the bone without obvious break.

bronchiolitis: viral infection of the medium-sized airways, occurring most frequently

during the first year of life.

buckle fracture: fracture seen in children characterized by a raised or bulging projection

at the fracture site.

child abuse: any improper or excessive action that injures or otherwise harms a child or
infant.

congenital: present at birth

croup: laryngotracheobronchitis, a common viral infection of young children, resulting

in edema of the sub-glottic tissues. Characterized by barking cough and inspiratory
stridor.

dehydration: an abnormal decrease in total body water.

epiglottitis: bacterial infection of the epiglottis, usually occurring in children older than
age 4. A serious medical emergency.

epinephrine: major hormone secreted by the adrenal medulla in response to sympathetic

stimulation; a major mediator of the sympathetic response.

febrile: denoting or relating to fever.

fontanelles: areas in the infant skull where bones have not yet fused. Posterior and
anterior fontanelles are present at birth.

glottis: the slit-like opening between the vocal cords.

greenstick fracture: fracture seen in children characterized by an incomplete break in

the bone.

meningitis: infection and inflammation of the meninges, the covering of the brain and
spinal cord.

neonate: an infant from the time of birth to one month of age.

44
Glossary of Terms

Reye’s syndrome: illness of uncertain etiology that results in alteration of mental

function in children. Often associated with viral infections and the use of aspirin.

sepsis: the presence of an infectious agent, usually bacteria, in the blood stream.

septic shock: type of shock which accompanies a bacterial infection, often due to release
of endotoxins by the bacteria.

status epilepticus: the term used to describe a continuous seizure or multiple seizures
without return to consciousness for 30 minutes.

stridor: a high-pitched “crowing” sound, caused by restriction of the upper airway.

sudden infant death syndrome (SIDS): illness of unknown etiology that occurs during
the first year of life.

wheezing: whistling type breath sound associated with narrowing or spasm of the
smaller airways.

45
References

“An Alternative Route to Maintenance of Licensure”, Manitoba Health Emergency

Services, Revised March 14, 2001

National Occupational Competency Profiles and Curriculum Blueprints, June 29, 2001,
Paramedic Association of Canada

First Responder: A Skills Approach, 5th Edition, Keith J. Karren, Brent Q. Hafen, Daniel
Limmer, Prentice Hall, Upper Saddle River, New Jersey, 07458, 1998.

EMT: Pre-hospital Care, 1st Edition, Henry, Mark C., Stapelton, Edward R., W.B.
Saunders Company, The Curtis Center, Independence Square West, Philadelphia, 19106,
1992.

AAOS Emergency Care and Transportation of the Sick and Injured, 7th Edition, Browner
Bruce, Lenworth Jacobs, Jones and Bartlett Publishers, Toronto, Ontario M5S 1X1, 1999

Paramedic Emergency Care, Third Edition, Brady, Prentice Hall Inc., 1997

Paramedic Textbook, Revised Second Edition, Mike J. Sanders, Mosby, Inc. 11830
Westline Industrial Drive, St. Louis, Missouri 63146, 2001

“Management of Medical Emergencies, Neonatal Care, Pediatric Emergencies”, City of

Winnipeg Fire Paramedic Service Primary Care Paramedic Bridging Program, 2002

46