Peds/OB - EMT Exam 4

respiratory system differences

pediatric airway is smaller in diameter and shorter in length

trachea cartilage not developed

epiglottis larger, tongue normal size

sniffing position

alternative to head tilt chin lift in peds, anatomically neutral position to open airway

prop up head and shoulders (shoulder roll and headrest)

earlobe to sternal notch, parallel to the floor

Belly Breathers

infants and toddlers intercostal muscles are not developed enough to help with breathing, so abdominal muscles rises and fall when they breath

so anything that places pressure on the abdomen of a young child can cause respiratory compromise

NB to 3 months pulse

85-205

3 mo to 2 yrs pulse

100-190

2 to 10 yr pulse

60-140

>10 yr pulse

60-100

Compensation/Decompensation Peds

kids compensate for longer but decompensate faster

peds sign of vasoconstriction

cyanosis, pallor, weak distal pulses in the extremities, delayed capillary refill

head develop peds

proportionally larger heads, throws them more off balance

higher cerebral blood flow, oxygen, and glucose than that of an adult

spinal cord injury are less common

nervous system diff

not well protected

less cushioning for the brain bc of smaller subarachnoid space

brain tissue fragile and prone to bleeding (ex. shaken baby syndrome)

growth plates

end of long bones, allow bones to grow

bones are softer and more flexible, make them prone to stress fracture

bone length discrepancies can occur if injury to growth plate occurs

Fontanelle

gaps in skull plates in infants head, soft spots for front and back of head

can use to check hydration, smooth fontanelle indicates good hydration and over or under inflation indicates problem

Peds thoracic cage

children is highly elastic and pliable because it in primarily composed of cartilaginous connective tissue

ribs and vital organs are less protected by muscles and fat

trauma can cause internal damage with little exterior signs

• likely ribs will not break during compression

Peds Integumentary

thinner less subcutaneous fate

burns more deeply and easily and with less exposure

high ratio of body surfac area to body mass leads to larger fluid and head loss (burns)

hypo and hyperthermia danger

Peds GI

abdominal muscles less dev in peds

less protection from trauma

liver spleen kidneys proportionally larger and more anterior, so prone to bleeding and injury with little sign

newborn

0-2 mo

• crying, inconsolable infant is sign of illness

• risk of hypothermia bc of large head

• cannot tell the diff between parents and strangers

2-6 mo

• can recognize their caregivers

• persistent crying, irritability, lack of eye contact is indicator of smth big

• more active, tracking with eyes

Infants

6-12 months

• mobile, physical danger

• put literally everything in their mouth

• cry if separated with parents

• persistent crying can be a sign

batteries ingestion in children

you have one hour

most battery contents (esp lithium) is a huge danger

stomach acid will break down outer lining

Peds Assessment

observe from distance

built trust with child

if non life threat, assess problem area last

preschool age

school age

6-12

• treat them more like that

• much more reasonable

• don’t give them an option they dont have

adolescents

13-18

• concerned about body image and appearance

• strong feelings about privacy

• time of experimentation and risk-taking

• struggle with independence

• feel indestructible

• allow them agency, don’t give an option if they don’t have an option

female adolescents patient

• may be pregnant

  • may need to partially separate parents

Parental considerations

form of scene control, have a talk with parents if needed

freaking out parent means a freaking out kid

Pediatric Assessment Triangle

Appearance, Work of Breathing, Circulation

all able to do within 30 seconds!! no equipment

Peds Appearence

muscle tone/skin tone - are they weak/floppy

interactiveness

consolability

look/gaze - purposeful eye contact, usually kids are very alert

speech - slow, garbled

Peds Work of Breathing

breath sounds - easier to auscultate

positioning - airway open?

retractions - substernal and clavicular reactions

flaring - nasal flaring and head bobbing

apnea/gasping

Bradypnea Peds

indicates impeding respiratory arrest, kids DO NOT breath slow usually

ventilate immediately (BVM)

OPA insertion technique

tongue depressor required, put in anatomically correct without twisting - national

same as adult - PA

Capillary refill

Pulse

brachial - neonates and infants

exposures peds

hands on XABCs require removal of clothing

take everything off

transport decision peds

if urgent, go to closest facility

pediatric hospital or hospital with peds specialty

Securing peds in ambulance

less than 40 pounds who not require spinal immobilization sould be transported in a car seat

mount car seat to the stretcher

patients younger than 2 years must be transported in a rear facing position

Peds specific question to ask

• events leading up, esp food

minimum systolic BP for ages 1-10

70 + (2 x child age in years)

systolic MINIMUM

mild obstruction

asthma treatment peds

pneumonia

croup

epiglottitis

bronchiolitis

infants/toddlers RR

12-60 breaths/min

blow by oxygen

less effective than face mask or nasal cannula

does not provide high oxygen concentration

non hem hypovolemic shock

most common

1/2-1 day profound vomitting or diarrhea is gonna hit peds harder than in adults

dehydration peds

for older than neonates, ask parents about intake/outtake

skin tenting

meningitis

inflammation of the meninges (that cover the brain and spinal cord)

bulging fontanelles, inconsolable crying

stiff neck that gets worse when trying to move

rash

Neusseria mengitis

bacterial version of meningitis, more deadly version

larger red spots

shock is common

GI emergencies peds

shock

immobilization peds

car seat can be used

spinal immobilization boards for peds can be usefull

use blankets on boards

head injury peds

Level of consciousness

chest injuries peds

ADD

burns

ADD

rule of 9s peds

ADD

Palmar method

using patients hand to estimate cover of burns, 1% ADD

placenta

disk shaped structure attached to the uterine wall that provides nourishment and oxygen to the fetus

• keeps the circulation of the mother and fetus separated but allow substances to pass

• separates from the uterus during delivery

does come with you to hospital

umbilical cord

2 umbilical arteries - carry deoxygenated blood from the fetus to the placenta

1 vein - carries oxygenated blood from the placenta to the fetus

passage for nutrients, oxygen, and waste product to and from the fetus

22-24 in

amniotic sac

fluid-filled, baglike membrane

contains about 500-1000 mL fluid

helps insulate and protect the fetus

fluid is release in a gush when the sac ruptures

• usually at the beginning of labor

cardiovascular pregnancy changes

• blood volume increases up by 50% by the end of pregnancy

• heart rate increases up by 20%

• cardiac output and RBC count increase

respiratory pregnancy changes

diaphragm gets displaced, RR increases, minute volume decreases

musculoskelatal pregnancy changes

joints become loose or unstable

center of gravity changes increasing the risk of falls

stages of delivery

dilation of the cervix - stage 1

delivery of the fetus - stage 2

delivery of the placenta - stage 3

stage 1

begin with the onset of contractions and ends when the cervix is fully dilated

longest stage, 16 hours

contractions become more regular and last about 30-60 seconds

may experience braxton hicks

stage 2

begins when the fetus begins to encounter the birth canal

ends when the newborn is born

• contractions longer and closer

• perineum will bulge and fetus starts to crown (We get the OB kit and catch the baby!!)

stage 3

The third stage of labor begins with the birth of the newborn and ends with the delivery of the placenta.

During this stage, the placenta must completely separate from the uterine wall.

This may take up to 30 minutes

• afterbirth (placenta)

• delivery

Preparing for delivery

stay on scene

• delivery is imminent will occur

• labor cannot be stopped or slowed down

• get all information needed

bring 2 OB kits

Determining if the delivery is imminent

contraction every 2 minutes lasting about 45 minutes

urge to push or move her bowels

tear away sac and move away face if intact

• how long have you been pregnant

• when are you due?

• is this your first baby?

• are you having contractions?

• how far apart?

• how long do they last?

• have you had spotting or bleeding?

• has your water broken?

• do you feel the need to push/poop?

indication that delivery imminent

contractions evert two minutes lasting about 45 seconds

urge to push or mover her bowels

amniotic sac is still intact

• tear the sac

• move away from face

field delivery

place towels or sheets on the floor around the delivery area

open the OB kit carefully

put on sterile gloves (from the OB kit)

use the sterile

patient position

waist down clothes off, preserve pt privacy as much as possible

legs pulled back, bottom leaned back

delivering the head

check for crowning often

face down, support the head as it rotates up during birth and angle down

delivering the body

head is the largest part of the fetus

support the head and upper body as shoulders deliver

do not pull

vernix caseosa

will be slippery and newborn may be covered with a white cheesy substance

normal delivery steps

Crowning

Support head - Body & head rotate naturally

Check for nuchal cord once head delivers

Upper shoulders - guide head downward

Body delivers Lower shoulders - deliver guide head upward

Place on mother’s abdomen if appropriate w/cord intact

If not - keep at the same level as vagina until cord it cut

Prior to cutting cord – assess for distress

Gurgling / Respiratory distress = SUCTION (Mouth then Nose)

Cut between the clamps ( 3 inches)

post delivery care

Wipe the mouth with a sterile gauze pad as needed.

Clamp and cut the umbilical cord after approximately 60 seconds.

Obtain the 1-minute Apgar score

fundus massage

Record the time of birth in your patient care report.

fundus massage

slows bleeding by massaging the moms abdomen with firm, circular, kneading motion above the fundus

emergencies post delivery

• More than 30 minutes elapse and the placenta has not delivered

• There is more than 500 mL of bleeding before delivery of the placenta.

• There is significant bleeding after the delivery of the placenta

bleeding in postpartum

Bleeding that exceeds approximately 1,000 mL is considered excessive

Continue to massage the fundus.

Check your technique and hand placement if bleeding continues.

Excessive bleeding is usually caused by the uterine muscles not fully contracting

postpartum embolism

Most commonly a pulmonary embolism

Results from a clot that travels through the bloodstream and becomes lodged in the pulmonary circulation

Consider when a woman complains of sudden difficulty breathing or shortness of breath following delivery

gestational diabetes

Diabetes develops during the second half of pregnancy in many women who have not had diabetes previously.

Gestational diabetes, resolves in most women after delivery.

The treatment is the same as for any other patient with diabetes

hypertensive emergencies

Gestational hypertension is the presence of high blood pressure in the absence of other systemic effects.

Defined as a systolic blood pressure higher than 140 mm Hg and a diastolic blood pressure higher than 90 mm Hg.

Considered severe when the systolic blood pressure is higher than 160 mm Hg and/or the diastolic pressure is higher than 110 mm Hg

preeclampsia

Preeclampsia is pregnancy-induced hypertension.

Can develop after the 20th week of gestation

Signs and symptoms include severe hypertension, severe or persistent headache, visual abnormalities, swelling in the hands and feet, and anxiety

preeclampsia

Severe hypertension

Severe or persistent headache

Visual abnormalities such as seeing spots, blurred vision, or sensitivity to light

Swelling in the hands and feet (edema)

Upper abdominal or epigastric pain.

Dyspnea and/or retrosternal chest pain

Anxiety

Altered mental status

eclampsia

Eclampsia is characterized by seizures that occur as a result of hypertension.

To treat seizures:

Lay the patient on her left side.

Maintain her airway.

Administer supplemental oxygen if necessary.

If vomiting occurs, suction the airway.

Provide rapid transport.

Call for an ALS intercept, if available

supine hypotension syndrome

caused by compression of the descending aorta and the inferior vena cava by the pregnancy uterus when the pt is supine

transport pt on LEFT side

bleeding in pregnancy (up to 20 weeks)

bleeding prior to 20 weeks

• hemorrhage from the vagina that occurs before labor begins may be very serious

• may be a sign of spontaneous abortion or ectopic pregancy

• shock is a concern

bleeding in pregnancy (after 20 weeks)

• placenta previa

• abruptio placenta

• uterine rupture

• uterine inversion

fetal alcohol syndrome

infants born to women who have abused alcohol

ectopic pregnancy

embryo implants outside of uterus

unilateral pain, sudden sharp tearing pain, below belly button - 1st trimester vaginal bleeding

signs of shock if ruptured

at risk : PID, tubal ligation, previous

suspect if sudden onset of severe abdominal pain and vaginal bleeding in 1st trimester, missed her period

spontaneous/induced abortion

prior to 20 weeks

miscarriage or elective

bleeding, infection, treat for shock, bring any tissues that passes to the hospital, no pulling or packing the vagina

placenta previa

dev over the cervix, cervix dilates, may have heavy vaginal bleeding

heavy bleeding, no pain

treat as such and place on left side, sterile pad

abruptio placenta signs

the placenta separates prematurely from the wall of the uterus, most commonly caused by hypertension or trauma

• severe tearing pain, acute

• bleeding not always visible

• signs of shock

treat as such and place on left side, sterile pad

uterine rupture

• Rare

• Occurs during vaginal delivery

• Uterus tears

• Baby slips into the abdomen, if Baby is being delivered, it gets sucked back in

uterine rupture signs

Excessive vaginal bleeding

Sudden pain between contractions

Contractions slow down

Contractions become less intense

Baby’s head recedes back into birth canal

uterine rupture causes

Labors lasting more than 24 hrs

Weakened uterus

Placenta embedded to deeply into the uterine wall

Placenta implants in the fundal portion (very top) of the uterus

Pulling on the umbilical cord to speed delivery of the placenta

Women at risk:

Previous cesarean deliveries

Uterine surgeries

Risk increases with every c-section

uterine inversion

Uterus inverts (flips inside out)

Rare

Caused by pulling on the umbilical cord or baby

Signs

Abdominal pain

Excessive bleeding

Signs of shock, like very low blood pressure

In a complete inversion, the uterus will be visible in the vagina

unruptured amniotic sac

If the amniotic sac does not rupture by the time the head is crowning, it will appear as a fluid-filled sac emerging from the vagina.

It will suffocate the fetus if not removed.

You may puncture the sac with a clamp or tear it by twisting it between your fingers.

Clear the newborn’s mouth and nose immediately

nuchal cord

Umbilical cord around the neck

As soon as the head is delivered, use one finger to feel whether the umbilical cord is wrapped around the neck (nuchal cord).

Usually, you can slip the cord gently over the delivered head.

If not, you must cut it, on cut, put your fingers under the cord and cut over your fingers so you do not cut baby

breech delivery

Prolapsed cords are more common

Preparation - same as a normal delivery

Allow the buttocks & legs to deliver spontaneously

Support them to avoid rapid expulsion

legs to dangle on either side of your arm

Support the trunk & chest

The head is almost always face down

Allow to deliver spontaneously

Keep the walls of the vagina off the newborn’s face

Make a “V” with your gloved fingers

position them in the vagina

Keep walls of vagina off the fetus’s airway