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Slide 1-

1 Traumatic Emergencies Lesson 6
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2 In this lesson, the focus will first be on the following: Common mechanisms of injury in children Patterns of injury that result from these mechanisms Assessment techniques that help EMTs determine the severity of traumatic injury Appropriate interventions for traumatic injuries in children
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3 Also included in this lesson are sections on child abuse burns near-drowning
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4 Mechanisms and Patterns of Injury in Children In children, most serious injuries involve blunt trauma to the head. Head injuries are likely to result in problems affecting the airway and breathing due to loss of or decreased consciousness.
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5 Blunt vs. Penetrating Trauma Blunt injury accounts for about 85% of all trauma. Penetrating injury occurs in only about 10% of all trauma. In blunt trauma, external signs may be few and the RFI may be non-urgent despite the presence of serious injuries.
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6 High-Risk Mechanisms of Injury Motor vehicle crashes unrestrained passenger pedestrian Moderate (5-15 ft) and high falls (15 ft+) Diving injuries Bicycle crashes while not wearing a helmet.
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7 Lower-Risk Mechanisms of Injury Motor vehicle crashes properly restrained passenger Low falls (age dependent 2-4 feet) Bicycle crashes while wearing a helmet.
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8 Immediate Concerns -Urgent Trauma Patient Respiratory failure due to airway obstruction by tongue or secretions Hypoperfusion from severe internal injuries to their organs even when there is little external evidence.
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9 Treatment Priorities-Urgent Trauma Patient The most critical interventions in the majority of pediatric trauma patients are: Airway management Cervical spine precautions Supplemental high-concentration oxygen Assisted ventilation when needed
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10 Cervical Spine Precautions EMTs should perform cervical spine precautions for a pediatric trauma patient if: The child has a high-risk mechanism for head or neck injury. The child’s mental status is anything other than alert, or There is evidence of head or neck injury on examination.
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11 Cervical Spine Precautions A cervical collar must be applied before moving patient. Prior to applying collar, hold bi-manual stabilization. Check the back of the neck for crepitus (crunchiness) tenderness muscle spasm
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12
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13 Rapid First Impression Quickly assess: Mental status Muscle tone and body position Visible breathing movement Breathing effort Skin color Obvious severe injuries
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14 Urgent First Impression-Trauma For a child with obvious, severe injury: Immediately provide needed interventions such as bleeding control, splinting, etc. Perform cervical spine precautions. Begin transport and initial assessment. This child’s condition is urgent.
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15 Urgent First Impression-Trauma EMTs who arrive to find a child who does not seem alert: Immediately take spinal precautions Provide high concentration oxygen Begin transport and initial assessment This child’s condition is urgent even though there are no obvious injuries
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16 Urgent First Impression-Trauma For a child with signs of hypoperfusion but no obvious external bleeding: Presume that child to have additional injuries causing internal bleeding. Continue to assess and reassess. Maintain airway and support breathing. Transport as soon as possible.
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17 Urgent First Impression Trauma A child showing signs of hypoperfusion, but whose only obvious injury is head trauma can be presumed to have other injuries. Head trauma alone does not cause hypoperfusion in children, except for very young infants. Even then, it is a rare event.
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18 Non-urgent First Impression-Trauma Alert Possibly sitting up Good muscle tone Equal movement of the arms and legs Normal breathing Good skin color. EMTs must find out whether there was a high-risk mechanism of injury (MOI).
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19 High Risk Mechanism of Injury A well-appearing patient who has experienced a high-risk MOI is treated as potentially unstable due to the likelihood of serious internal injuries. Begin initial assessment quickly. Repeat assessment steps frequently. Be ready if child’s condition worsens.
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20 Low Risk Mechanism of Injury Non-urgent rapid first impression: Complete the initial assessment. Obtain a focused history. Conduct a detailed physical exam on the scene.
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21 Extrication Issues Past teaching: Leave child in safety seat, pad and tape prn, transport. Drawbacks Ineffective immobilization Extended scene time Compromises EMTs’ ability to assess and manage airway and breathing.
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22 Extrication Issues Current teaching: Remove from the safety seat because: easily able to achieve neutral alignment full, unimpeded ability to assess and manage airway and breathing more efficient on-scene time
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23 Extrication Issues EMTs need to remove the patient from the car before they can truly assess and manage the airway and breathing.
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24 Initial Assessment-Airway AIRWAY Maintain cervical spine stabilization. Assess the airway. Responsive child Talking or crying is good evidence that the airway is open.
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25 Unresponsive child Maintain cervical spine stabilization. Look, listen, feel for air movement. If there is no air movement Open the airway using a modified jaw thrust while stabilizing C spine. Check for foreign bodies and other matter in the mouth and nose, including teeth, secretions, vomit, blood, and fluid.
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26 Remove foreign bodies that can be clearly seen and provide gentle suctioning if necessary. Give high-concentration oxygen before and after suctioning. As soon as airway is cleared, recheck for air movement.
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27 Look, listen, and feel for air movement and gently reposition the airway if necessary while maintaining spinal stabilization.
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28 If there is no air movement, begin assisted ventilation and initiate transport.
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29 If there is air movement, assess breathing.
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30 Interventions During Breathing Assessment After airway opening, provide assisted ventilation using a bag-valve-mask device with supplemental high-concentration oxygen if there is no air movement. Use the two-handed E-C Clamp to maintain spinal stabilization.
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31 Interventions During Breathing Assessment To keep the airway open without moving the neck, lift the jaw into the mask rather than pushing the mask down on the face. Use the “squeeze . . . release . . . release” technique to approximate proper ventilatory rates.
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32
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33 Initial Assessment-Breathing Maintain cervical spine stabilization. Assess: Respiratory effort Breath sounds Breathing rate, pattern, and depth Chest wall for life threatening injuries Skin color at the lips and tongue
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34
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35 Interventions During Breathing Assessment Administer high-concentration oxygen to using a non rebreather mask if: The child shows signs of respiratory distress. Breathing is normal but the mechanism of injury was significant.
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36 Interventions During Breathing Assessment Assist ventilations with a bag-valve-mask and high-concentration oxygen if the child shows signs of respiratory failure.
Slide 37-

37 Interventions During Breathing Assessment For Open Pneumothorax Any puncture wound to the chest that makes a gurgling sound when the child breathes should be covered with sterile dressings that prevent air from being sucked into the chest through the wound.
Slide 38-

38 Tape the dressings on three sides to prevent air from being trapped under pressure beneath.
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39 Tension Pneumothorax If the child shows signs of respiratory failure and has no breath sounds on one side of the chest, there may be a tension pneumothorax (air trapped under pressure in the chest, compressing one lung).
Slide 40-

40 Tension Pneumothorax To release pressure, a needle must be placed between the ribs and the air pocket. This procedure requires ALS assistance.
Slide 41-

41 Initial Assessment-Circulation Look for active bleeding and apply sterile compresses using direct pressure over bleeding sites. Check for the presence of central and peripheral pulses and compare their strength. Check skin color and temperature as well as capillary refill time.
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42 Circulation Assessment- Trauma Patient Repeat initial assessment frequently. Be aware of changes in mental state, skin color, breathing effort and rate. Compare trunk to extremities skin color temperature
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43 Interventions During Circulation Assessment If there are signs of hypoperfusion: fast heart rate poor skin perfusion
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44 Interventions During Circulation Assessment Maintain Cervical Spine immobilization. Continue oxygen administration. Initiate transport. Elevate the foot end of the spine board. Preserve body heat.
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45
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46 Initial Assessment -Mental Status AVPU Alert status already known. Differentiate between V-P-U V Child responds to a voice Child does not have to speak. Can respond through movement, eye contact,etc.
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47 Initial Assessment -Mental Status AVPU Pain Squeeze fingernail if child does not respond to voice. Unresponsive if child does not respond to either voice or pain.
Slide 48-

48 Interventions in Mental Status Assessment A or V Status - Provide high concentration oxygen by non-rebreather mask P or U Status - Provide assisted ventilations with BVM and oxygen reservoir.
Slide 49-

49 Pediatric CUPS Assessment Category Assessment Actions
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50 Critical Assessment Absent: Airway Breathing Circulation Actions Perform rapid initial interventions and transport simultaneously Example: Severe traumatic injury with respiratory arrest or cardiac arrest
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51 Unstable Assessment Compromised: Airway Breathing Circulation with altered mental status Actions Perform rapid initial interventions and transport simultaneously Example: Significant injury with respiratory distress, active bleeding, shock; near-drowning; unresponsiveness
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52 Potentially Unstable Assessment Normal: Airway Breathing Circulation + MS BUT significant mechanism of injury or illness Actions Perform initial assessment with interventions; transport promptly; do focused history and physical exam during transport if time allows Example: Minor fractures; pedestrian struck by car but with good appearance and normal initial assessment; infant younger than three months with fever
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53 Stable Assessment Normal: Airway Breathing Circulation + MSno significant mechanism of injury or illness Actions Perform initial assessment with interventions; do focused history and detailed physical exam; routine transport Example: Small lacerations, abrasions, or ecchymoses; infant older than three months with fever
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54 Reassess . . . Reassess . . . Children with life-threatening injuries may initially present with a fairly healthy appearance. Therefore, the ABCs and CUPS status should both be continually reassessed throughout transport.
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55 . . . Reassess . . . Reassess . . Treatment decisions may need to be adjusted accordingly. ALS backup and delivery to a pediatric trauma center should be considered for any patient whose condition worsens.
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56 Focused History-Urgent Try to determine what happened without delaying immediate interventions and transport: Most important: Mechanism of Injury Time frame Changes in mental status
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57 Focused History-Urgent Any head injury severe enough to cause loss of consciousness must be evaluated in the hospital, as serious brain injuries may not become apparent for six to twelve hours.
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58 Focused History-Non Urgent Obtain as much detail as possible about mechanism of injury. Consider patient’s condition in contrast to the mechanism of injury. May indicate potentially unstable patient.
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59 Detailed Physical Exam Performed on the scene if the patient is stable and non-urgent. For a potentially unstable or unstable patient: Initiate transport Support ABCs Detailed physical exam is done enroute to hospital, if time allows.
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60 Detailed Physical Exam Examine all parts of the body for: deformities ecchymoses (bruising) lacerations and abrasions punctures and penetrating wounds tenderness swelling
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61 Detailed Physical Exam-Head Check for signs of severe head injury: Deep lacerations to the scalp or face Blood or watery fluid draining from the nose or ears Bruising of the bony area behind the ear Bruising around the eyes Skull fractures or leaking brain matter
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62 Detailed Physical Exam-Head A patient with any of these signs should be considered urgent. Transport to a trauma center should already be underway. Reassess mental status frequently. Changes in mental status may indicate the need for more airway or breathing intervention.
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63 Detailed Physical Exam-Head If not already done, perform spinal immobilization and initiate transport. Monitor airway and breathing Provide high-concentration oxygen. Be prepared to assist ventilations with a BVM.
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64 Detailed Physical Exam-Neck Check front of neck Position of trachea Midline is normal Shifted position indicates life threat Reassess breathing and circulation
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65 SCIWORA Spinal Cord Injury Without Radiographic Abnormality Owing to the less rigid anatomy of the pediatric spinal column, the neck bones move easily across each other. With sudden, forceful neck flexion and extension, there is a potential for spinal cord injury.
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66 SCIWORA The vertebrae can slide across each other and pinch or bruise the spinal nerves without any bones breaking. Signs of this condition, including numbness or tingling and an inability to move the extremities, may take time to develop.
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67 Detailed Physical Exam-Chest Fractures are uncommon in small children: Soft, pliable bones Allows forces to freely pass through chest wall to internal organs Severe internal injuries occur with little or no external signs.
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68 Detailed Physical Exam-Chest Stabilize impaled objects in place with bulky dressings. Gently feel for tender areas Listen for equal breath sounds. Reassess respiratory rate and effort every few minutes.
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69 Detailed Physical Exam-Abdomen Check for: distention ecchymoses (bruises) abrasions penetrating injuries vomiting (Note if blood or bile)
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70 Detailed Physical Exam-Abdomen Gently feel for tender areas Note guarding where child tenses the abdominal muscles over a painful area may be a sign of serious internal injuries. A child with guarding is treated as potentially unstable, even when he appears stable.
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71 Detailed Physical Exam-Abdomen The liver and spleen are poorly protected by the abdominal wall. Blunt force to a child's abdominal area makes damage to internal organs likely. Internal bleeding with little or no outward sign.
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72 Detailed Physical Exam-Abdomen Hypoperfusion findings may include guarding in the abdominal area, or altered mental status with an enlarged appearance to the abdominal area. There may be no abdominal signs.
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73 Detailed Physical Exam-Abdomen Cover stab or puncture wounds with sterile dressings. Moisten the dressing with sterile saline if internal organs are showing. Stabilize an impaled object with a soft, bulky dressing and do not attempt to remove it.
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74 Stomach Decompression When a child's stomach is swollen with air, it can press on the lungs and diaphragm, preventing good ventilation. The excess pressure can also cause the heart rate to slow down.
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75 Release this air when all of these findings are present: The upper abdomen is swollen and firm. Assisted ventilation requires high pressure. There is poor chest rise The pulse rate is slower than normal for the child's age.
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76 Stomach Decompression Two ways to address this problem: Pass a tube through the nose or mouth into the stomach, or Decompress the stomach by pushing on the abdomen.
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77 Pushing on the abdomen carries a serious risk of vomiting and aspiration loss of airway lung damage Therefore, this procedure should only be attempted when passing a tube is not possible.
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78 Passing a tube is the preferred technique if regional protocols permit. This procedure should only be attempted by personnel who have been trained to perform it.
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79 To decompress the stomach: First, turn child onto the left side Gently squeeze the upper abdomen Have a large-bore suction device ready as vomiting is most likely to ensue.
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80 Detailed Physical Exam-Back Assess the back for tenderness ecchymoses bony crepitus. Do this before immobilizing on a spine board.
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81 Detailed Physical Exam-Pelvis Check the pelvis for fractures: Place a hand on each hip bone Squeeze them gently toward each other. Next, push downward, first on one hip, then the other. Finally, place one hand on the pubic bone and press gently.
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82 If the EMTs detect: movement of the bony structures grating sensations pain Suspect a break in the ring of bone that forms the pelvis. Immobilize the pelvis and legs to a spine board.
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83 Detailed Physical Exam-Extremities Look and feel for deformed, swollen, bruised, or painful areas. Check capillary refill in the extremities and feel for peripheral pulses. If an injured arm or leg has: poor capillary refill no pulse or sensations This patient’s condition is unstable.
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84 Femur fractures and Hypoperfusion In children, a single isolated femur fracture will not cause enough bleeding to result in hypoperfusion. If EMTs find that a child with a fractured femur shows signs of hypoperfusion, they should look for other injuries that may be causing additional bleeding.
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85 Extremity Trauma Treatment Immobilize deformed or swollen areas using appropriately sized equipment. If the area is severely bent, try to straighten it by applying gentle traction, but stop if there is any resistance. A traction splint may be used for a possible fracture of the femur.
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86 Trauma and Child Abuse It is always the responsibility of the EMTs to assure that the child receive appropriate care and transportation to a hospital. It is never the responsibility of the EMTs to confront or accuse anyone.
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87 Trauma and Child Abuse Environment
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88 Trauma and Child AbuseFirst Impression
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89 Trauma and Child Abuse - Initial Assessment
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90 Trauma and Child AbuseCUPS Assessment Category Assessment Actions
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91 Critical Assessment Absent: Airway Breathing Circulation Action Perform rapid initial interventions and transport simultaneously Example: Severe traumatic injury with respiratory arrest or cardiac arrest
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92 Unstable Assessment Compromised: Airway Breathing Circulation with altered mental status Action Perform rapid initial interventions and transport simultaneously Significant injury with respiratory distress, active bleeding, shock; near-drowning; unresponsiveness
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93 Potentially Unstable Assessment Normal: Airway Breathing Circulation + MSBUT significant mechanism of injury or illness Action Perform initial assessment with interventions; transport promptly; do focused history and physical exam during transport if time allows Example: minor fractures with good appearance and normal initial assessment
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94 Stable Assessment Normal: Airway Breathing Circulation + MSno significant mechanism of injury or illness Action Perform initial assessment with interventions; do focused history and detailed physical exam; routine transport Example: Small lacerations, abrasions, or ecchymoses
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95 Trauma and Child AbuseFocused History
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96 Trauma and Child AbuseFocused History
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97 Trauma and Child AbuseFocused History
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98 Trauma and Child AbuseFocused History
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99 Trauma and Child AbuseDetailed Physical Exam
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100 Trauma and Child AbuseDetailed Physical Exam
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101 Trauma and Child AbuseDetailed Physical Exam
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102 Shaken Baby Syndrome Most common in infants and children younger than two years. There may be no external evidence of trauma, yet severe head injuries can occur. Altered mental status may be the only sign that the injury has occurred.
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103 Transport Considerations The most effective prehospital treatment for child abuse is transportation of the child to a hospital where legal and social services are available.
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104 Documentation of Child Abuse Record observations as clearly and accurately as possible. Include factual documentation about the child’s environment that is otherwise unavailable to hospital personnel. Avoid stating personal feelings, opinions, or interpretations.
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105 Documentation of Child Abuse Record any statements that parents or witnesses make in quotation marks. Documentation should include the history of the injury or illness. Be precise in describing findings from the detailed physical examination.
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106 Reporting At the Hospital Personally inform a hospital staff member about your suspicions preferably the physician in charge Document the name of the person who received their report.
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107 Pediatric Burns Second leading cause of injury-related death in children from 1-14 years old. Leading cause of death in the home. Most common in those less than 3 yrs. 80% of childhood burns result from preventable household injuries. Many of the rest are due to child abuse.
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108 Impact of Burn Injuries Skin serves as a barrier and protector for the body. It is the largest organ of both adults and children. For children, it is proportionately larger than for adults. Burns breach the integrity of the skin so that the barrier and protection it provides is adversely affected:
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109 Burns cause greater stress on the child's body systems than any other type of injury. The following are frequent short-term complications: Dehydration Low body temperature Infection Damage to internal organs
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110 Long-term effects include:severe physical and emotional scarring. Burn survivors frequently require long hospital stays as well as extensive, painful rehabilitation.
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111 Burn Causes and Types There are six major categories of pediatric burn injuries: Scalds are caused by hot liquids. About 85 percent of severe burns Most involve toddlers Hot tap water is the most common cause. Hot drinks and cooking liquids are secondary causes.
Slide 112-

112 The Ten Degree Difference Tap water set at 130 degrees can quickly scald a child, causing a third-degree burn in just thirty seconds. Tap water set at 120 degrees takes ten minutes to cause this serious an injury.
Slide 113-

113 Burn Causes and Types Flame burns involve actual contact with flames. Traumatic injuries and airway damage often accompany flame burns. A. M. S., low blood oxygen levels, and hypoperfusion due to fluid loss are also common problems with this type of burn.
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114 Burn Causes and Types Contact burns occur when touching a hot object such as a stove or iron. Radiation burns in children are almost always caused by overexposure to sun. Sunburns are usually first-degree burns involving skin redness, but occasionally second-degree burns with blisters may result.
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115 Low Voltage Electrical Burns Electrical burns are caused by contact with electricity in any form. Most pediatric electrical burns involve household current, which has a comparatively low voltage: A toddler who chews on an electrical cord A child who puts an object into an electrical outlet
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116 High Voltage Electrical Burns High-voltage injuries result from lightning strikes or contact with live power lines: Involve older children Associated with serious problems Airway damage, seizures, injury to deep muscles, fractures due to severe muscle spasms, and disturbances in heart function.
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117 Chemical Burns Chemical burns occur when a child handles or swallows a caustic substance. Usually involve household products: drain cleaner automotive battery acid
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118 Pediatric Burns Four key differences between children and adults: 1. Children have thinner skin that is more easily damaged by burns. 2. Young children are more likely to die from burns than adults.
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119 Pediatric Burns 3. Children can be burned accidentally or intentionally. 4. Child’s body proportions change over time so that estimating burn area differs: Use different Rules of Nines for infants, young children, and adolescents.
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120 Rules of Nines for Infant, Child, Adolescent
Slide 121-

121 Assessment and Management The first priority is to assure everyone’s safety. Check the scene for potential dangers from the source of the exposure including: fire hazardous chemicals live electric wire
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122 Assessment and Management Stop burning process Remove the child from the burn source. Stop the burn process before starting assessment Smother or douse flames from clothing Remove any smoldering clothing that is not stuck to the child's skin.
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123 Assessment and Management Assess for risk of inhalation injury: found in a smoke-filled, enclosed space soot around the mouth and nose signs of respiratory distress continual cough stridor Provide high concentration oxygen.
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124 Assessment and Management If the child shows signs of respiratory failure, immediately begin assisted ventilation with BVM and supplemental oxygen. Any child who does not require assisted ventilation should receive high concentration oxygen by non-rebreather face mask.
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125 Burn Assessment Findings Factors that affect burn management and CUPS status: depth and extent of the burn burn location special circumstances burn center criteria
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126 Burn Severity and Risk Four elements together determine the severity of the burn and the risk to the patient:
Slide 127-

127 Burn Severity and Risk the depth through the skin layers the extent of the burn (percentage) on the child's total body surface area the location of the burn special circumstances that indicate the need for a burn center
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128 Undress the child, as needed: Cover exposed areas as soon as possible to maintain body temperature Remove all clothing unless it sticks to a burned area. Remove jewelry. If the child is not alert, remove glasses or contact lenses.
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129 Low Body Temperature Risk Pediatric burn patients lose body heat faster than adults causing them to be at greater risk for low body temperature: Large body surface area Thinner skin Make sure that they are covered and not in the direct path of a breeze.
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130 Burn Depth First Degree = Superficial Skin is reddened, painful. Second Degree = Partial Thickness Skin reddened, blistered, painful
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131 Burn Depth Third Degree = Full Thickness Skin white, waxy, or blackened Not painful due to nerve damage (Adjacent second degree burns are painful).
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132 First or Second Degree? A first-degree sunburn covering 40 percent or more of the total body surface area in an infant or toddler should be treated as potentially serious burn. Scald burns that initially appear only red may later blister, showing that they are second-degree burns.
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133 Assessing Burn Location Second or third degree burns should be considered serious due to their location: face genitals and rectal area
Slide 134-

134 Assessing Burn Location Hands, feet or any major joint (elbows, knees, wrists, ankles, shoulder, hips) Burns that completely encircle an arm or leg or the chest Transport to a burn center if possible
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135 Special Circumstances High-voltage burns are deceiving: A small area of visibly burned skin can cover and hide a large, severely burned area of skin, muscle, or bone. Immobilize C-Spine and observe closely for hypoperfusion. Transport to a Burn Center if available
Slide 136-

136 Special Circumstances Chemical burns involving swallowed caustic substances causing internal burns with possible respiratory compromise Respiratory failure and arrest can occur suddenly
Slide 137-

137 Burn Center Criteria The American Burn Association recommends that a patient who has any of the following problems should be treated in a burn center if possible: 2nd or 3rd degree burns covering more than 10 % of the body surface area in patients aged younger than ten years
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138 Burn Center Criteria 2nd or 3rd degree burns covering more than 20 percent of the body surface area in all patients aged ten years or older 3rd degree burns covering more than 5 percent of the body surface area
Slide 139-

139 Burn Center Criteria 2nd or 3rd degree burns that pose a serious danger for loss of function or permanent changes in appearance, including any burn involving the face, genitals, rectal area, hands, feet, or major joints. Any electrical burn
Slide 140-

140 Burn Center Criteria Chemical burns also pose a serious danger for loss of function or permanent changes in appearance (especially swallowed caustics and burns involving the eyes or face) Burns in combination with inhalation injury
Slide 141-

141 Burn Center Criteria 2nd or 3rd degree burns that entirely encircle an extremity or the chest Burns with associated trauma in which the burn is the greatest risk to life
Slide 142-

142 Burn Center Criteria In some cases, it may be more practical to transport the patient to the nearest emergency department for stabilization before transferring care to a burn center. EMTs should proceed according to regional protocols.
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143 CUPS Assessment ofPediatric Burns Category Assessment Actions
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144 Critical Assessment Absent: Airway Breathing Circulation; AVPU=P or U Action Perform initial interventions and transport simultaneously; call ALS backup; request routing to a burn center if possible
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145 Unstable Assessment Compromised: Airway Breathing Circulation; AVPU=V or P Action Perform rapid initial assessment and interventions; call for ALS backup if available; transport promptly to a burn center if possible
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146 Potentially Unstable Assessment Normal: Airway Breathing Circulation AVPU=A meets burn center criteria, has risk of inhalation injury, or is possible victim of child abuse Action Initial assessment and preliminary CUPS ; assess and manage burns; transport promptly; begin focused history and physical exam during transport if time allows; consider requesting burn center routing and ALS backup if available
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147 Stable Assessment Normal: Airway Breathing Circulation AVPU=A does not meet burn center criteria; no risk of inhalation injury; no suspicion of child abuse Action Perform initial assessment and preliminary CUPS assess and manage burns; complete focused history and detailed physical examination; transport promptly
Slide 148-

148 Child Abuse and Burns Be alert for signs that suggest abuse: Contact burns caused by cigarettes and other manufactured items a distinctive appearance found in unusual locations ( back, inner thighs, genitals, or backs of the hands).
Slide 149-

149 Child Abuse and Burns Scalds arising from child abuse often have a characteristic appearance, such as the “glove” or “stocking” burn from dipping the child’s hand or foot in scalding water.
Slide 150-

150 Near Drowning The sequence of events in near drowning are: The vocal cords close causing an upper airway obstruction prevents air from entering the lungs rapidly leads to low blood oxygen levels
Slide 151-

151 Near Drowning Low blood oxygen causes: altered mental status poor muscle tone a slow pulse rate respiratory arrest cardiopulmonary arrest
Slide 152-

152 Water Rescue Remove child from water, if safety and training allow, but first: Cervical spine precautions including: Logroll, if prone, onto spineboard
Slide 153-

153 Water Rescue Immobilize all children who have: a diving injury another mechanism of injury that could damage the neck or spine AMS with no clear mechanism of injury.
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154 Water Rescue Establish an open airway: Open airway with modified jaw thrust Ventilate via pocket mask or BVM Proceed with removal from water.
Slide 155-

155 Assessment Reassess the airway and breathing: Check for signs of respiratory distress or failure, in responsive patient. Continue assisted ventilation of unresponsive patient. Add oxygen source as soon as possible. Begin transport as soon as possible.
Slide 156-

156 Assessment Assess circulation: EMTs may find it difficult to feel a pulse in children suffering near-drowning. Blood vessels constrict Heart pumps weakly Pulses may not be palpable Initiate chest compressions if no central pulse pulse rate less than 60/min
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157 Cold Water Near Drowning Slow pulse rates are very common in cold water pediatric near-drowning incidents If the child has a very low body temperature, pulses may be so weak and slow that they are nearly impossible to detect, in which case the child will appear dead.
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158 Cold Water Near Drowning When the body is very cold: Brain cells need less oxygen and energy Survival is possible, even after long submersion. Initiate and continue resuscitation efforts throughout transport.
Slide 159-

159 Prevent Further Heat Loss As soon as possible after removing from the water: Place the child in a warm environment, heated ambulance Remove the child's wet clothing Dry the child Provide heat lamps or warm blankets.
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160 Secondary Drowning Child appears well after submersion incident with: Trouble resurfacing Protracted coughing spell after being assisted to surface Aspiration of water or stomach contents may have occurred
Slide 161-

161 Secondary Drowning Symptoms of acute respiratory distress may take hours to develop. Always transport these children to a pediatric 911 center.
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162 CUPS ASSESSMENT OFPEDIATRIC NEAR DROWNING CATEGORY ASSESSMENT ACTION
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163 Critical Assessment Absent: Airway Breathing Circulation; AVPU=P or U Action Perform initial interventions and transport simultaneously; call for ALS backup if available
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164 Unstable Assessment Compromised: Airway Breathing Circulation; AVPU=V Action Perform initial assessment and interventions; transport promptly; call for ALS backup
Slide 165-

165 Potentially Unstable Assessment Normal: Airway Breathing Circulation + AVPU=A, BUT child required assisted ventilation, or was underwater and needed help getting out, or experienced choking and coughing after removal from water Action Perform initial assessment and interventions; transport promptly; begin focused history and physical exam during transport if time allows
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166 Stable Assessment Normal: Airway Breathing Circulation; AVPU=A Action Perform initial assessment and interventions; complete focused history and detailed physical examination; transport
Slide 167-

167 EMTs must transport every child who has any problem following a submersion no matter where it occurred.
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168 Focused History Time spent submerged MOI -struck object while diving Alcohol and/or drugs involved Medical history that may have contributed to the incident.
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169 Focused History Water temperature Clean or polluted Salt or fresh Notify hospital while en route.