Module V: Pediatrics

NREMT PRACTICE ANALYSIS TASK ITEMS
•	Assess an infant or child w/ cardiac arrest 
•	Provide care to an infant or child w/ cardiac arrest 
•	Assess an infant or child w/ respiratory distress 
•	Provide care to an infant or child in respiratory distress 
•	Assess an infant or child with shock (hypoperfusion) 
•	Provide care to an infant or child with shock (hypoperfusion) 
•	Assess an infant or child with trauma 
•	Provide care to an infant or child with trauma 

Cognitive Objectives
At the completion of this unit, the paramedic will be able to:
5.1	Describe techniques for successful assessment of infants and children. (C-1) / 6-2.8	
5.2	Describe techniques for successful treatment of infants and children. (C-1) / 6-2.9	
5.3	Discuss the appropriate equipment utilized to obtain pediatric vital signs. (C-1) / 6-2.14	
5.4	Determine appropriate airway adjuncts for infants and children. (C-1) 6-2.15	
5.5	Discuss complications of improper utilization of airway adjuncts with infants and children. (C-1) 6 2.16	
5.6	Discuss appropriate ventilation devices for infants and children. (C-1) 6-2.17	
5.7	Discuss complications of improper utilization of ventilation devices with infants & children. (C-1) 6-2.18	
5.8	Discuss appropriate endotracheal intubation equipment for infants and children. (C-1) / 6-2.19	
5.9	Identify complications of improper endotracheal intubation procedure in infants and children. (C-1) / 6-2.20	
5.10	List the indications and methods for gastric decompression for infants and children. (C-1) / 6-2.21	
5.11	Differentiate between upper airway obstruction and lower airway disease. (C-3) / 6-2.25	
5.12	Describe the general approach to the treatment of children with respiratory distress, failure, or arrest from upper airway obstruction or lower airway disease. (C-3) / 6-2.26	
5.13	Discuss the common causes of hypoperfusion in infants and children. (C-1) / 6-2.27	
5.14	Evaluate the severity of hypoperfusion in infants and children. (C-3) / 6-2.28	
5.15	Identify the major classifications of pediatric cardiac rhythms. (C-1) 6-2.29	
5.16	Discuss the primary etiologies of cardiopulmonary arrest in infants and children. (C-1) / 6-2.30	
5.17	Discuss age appropriate vascular access sites for infants and children. (C-1) 6-2.31	
5.18	Discuss the appropriate equipment for vascular access in infants and children. (C-1) 6-2.32	
5.19	Identify complications of vascular access for infants and children. (C-1) 6-2.33	
5.20	Describe the primary etiologies of altered level of consciousness in infants and children. (C-1) 6-2.34	
5.21	Identify common lethal mechanisms of injury in infants and children. (C-1 ) / 6-2.35	
5.22	Discuss anatomical features of children that predispose or protect them from certain injuries. (C-1) / 6-2.36	
5.23	Describe aspects of infant and children airway management that are affected by potential cervical spine injury. (C-1) / 6-2.37	
5.24	Identify infant and child trauma patients who require spinal immobilization. (C-1) / 6-2.38	
5.25	Discuss fluid management and shock treatment for infant and child trauma patient. (C-1) / 6-2.39	
5.26	Discuss the parent/ caregiver responses to the death of an infant or child. (C-1) / 6-2.44	
5.27	Discuss basic cardiac life support (CPR) guidelines for infants and children. (C-1) / 6-2.47	
5.28	Identify appropriate parameters for performing infant and child CPR. (C-1) / 6-2.48	
5.29	Integrate advanced life support skills with basic cardiac life support for infants and children. (C-3) / 6-2.49	
5.30	Discuss the indications, dosage, route of administration and special considerations for medication administration in infants and children. (C-1) / 6-2.50	
5.31	Discuss appropriate transport guidelines for infants and children. (C-1) / 6-2.51	
5.32	Discuss appropriate receiving facilities for low and high risk infants and children. (C-1) / 6-2.52	
5.33	Describe the epidemiology, including the incidence, morbidity/ mortality, risk factors and prevention strategies for respiratory distress/ failure in infants and children. (C-1) / 6-2.53	
5.34	Discuss the pathophysiology of respiratory distress/ failure in infants and children. (C-1) / 6-2.53	
5.35	Discuss the assessment findings associated with respiratory distress/ failure in infants and children. (C-1) / 6-2.55	
5.36	Discuss the management/ treatment plan for respiratory distress/ failure in infants and children. (C-1) / 6-2.56	
5.37	Describe the epidemiology, including the incidence, morbidity/ mortality, risk factors and prevention strategies for hypoperfusion in infants and children. (C-1) / 6-2.57	
5.38	Discuss the pathophysiology of hypoperfusion in infants and children. (C-1) 6-2.58	
5.39	Discuss the assessment findings associated with hypoperfusion in infants and children. (C-1) / 6-2.59	
5.40	Discuss the management/ treatment plan for hypoperfusion in infants and children. (C-1) / 6-2.60	
5.41	Discuss the assessment findings associated with cardiac dysrhythmias in infants and children. (C-1) / 6-2.63	
5.42	Discuss the management/ treatment plan for cardiac dysrhythmias in infants and children. (C-1) / 6-2.64	
5.43	Describe the epidemiology, including the incidence, morbidity/ mortality, risk factors and prevention strategies for trauma in infants and children. (C-1) / 6-2.69	
5.44	Discuss the pathophysiology of trauma in infants and children. (C-1) / 6-2.70	
5.45	Discuss the assessment findings associated with trauma in infants and children. (C-1) / 6-2.71	
5.46	Discuss the management/ treatment plan for trauma in infants and children. (C-1) / 6-2.72	

PSYCHOMOTOR OBJECTIVES
At the completion of this unit, the paramedic will be able to:
5.47	Demonstrate the appropriate approach for treating infants and children. (P-2) / 6-2.91	
5.48	Demonstrate appropriate intervention techniques with families of acutely ill or injured infants and children. (P-2) / 6-2.92	
5.49	Demonstrate an appropriate assessment for different developmental age groups. (P-2) / 6-2.93	
5.50	Demonstrate an appropriate technique for measuring pediatric vital signs. (P-2) / 6-2.93	
5.51	Demonstrate the use of a length-based resuscitation device for determining equipment sizes, drug doses and other pertinent information for a pediatric patient. (P-2) / 6-2.95	
5.52	Demonstrate the appropriate approach for treating infants and children with respiratory distress, failure, and arrest. (P-2) / 6-2.96	
5.53	Demonstrate proper technique for administering blow-by oxygen to infants and children. (P-2) / 6-2.97	
5.54	Demonstrate the proper utilization of a pediatric non-rebreather oxygen mask. (P-2) / 6-2.98	
5.55	Demonstrate proper technique for suctioning of infants and children. (P-2) / 6-2.99	
5.56	Demonstrate appropriate use of airway adjuncts with infants and children. (P-2) / 6-2.100	
5.57	Demonstrate appropriate use of ventilation devices for infants and children. (P-2) 6-2.101	
5.58	Demonstrate endotracheal intubation procedures in infants and children. (P-2) / 6-2.102	
5.59	Demonstrate appropriate treatment/ management of intubation complications for infants and children. (P-2) / 6-2.103	
5.60	Demonstrate appropriate needle cricothyroidotomy in infants and children. (P-2) / 6-2.104	
5.61	Demonstrate proper placement of a gastric tube in infants and children. (P-2) / 6-2.105	
5.62	Demonstrate an appropriate technique for insertion of peripheral intravenous catheters for infants and children. (P-2) / 6-2.106	
5.63	Demonstrate an appropriate technique for administration of intramuscular, inhalation, subcutaneous, rectal, endotracheal and oral medication for infants and children. (P-2) / 6-2.106	
5.64	Demonstrate an appropriate technique for insertion of an intraosseous line for infants and children. (P-2) / 6-2.108	
5.65	Demonstrate appropriate interventions for infants and children with a partially obstructed airway. (P-2) / 6-2.109	
5.66	Demonstrate age appropriate basic airway clearing maneuvers for infants and children with a completely obstructed airway. (P-2) / 6-2.110	
5.67	Demonstrate proper technique for direct laryngoscopy and foreign body retrieval in infants and children with a completely obstructed airway. (P-2) / 6-2.111	
5.68	Demonstrate appropriate airway and breathing control maneuvers for infant and child trauma patients. (P-2) / 	
5.69	Demonstrate appropriate treatment of infants and children requiring advanced airway and breathing control. (P-2) / 6-2.113	
5.70	Demonstrate appropriate immobilization techniques for infant and child trauma patients. (P-2) / 6-2.114	
5.71	Demonstrate treatment of infants and children with head injuries. (P-2) / 6-2.115	
5.72	Demonstrate appropriate treatment of infants and children with chest injuries. (P-2) / 6-2.116	
5.73	Demonstrate appropriate treatment of infants and children with abdominal injuries. (P-2) / 6-2.117	
5.74	Demonstrate appropriate treatment of infants and children with extremity injuries. (P-2) / 6-2.118	
5.75	Demonstrate appropriate treatment of infants and children with burns. (P-2) / 6.2.119	
5.76	Demonstrate appropriate parent/ caregiver interviewing techniques for infant and child death situations.(P-2) / 6-2.120	
5.77	Demonstrate proper infant CPR. (P-2) / 6-2.121	
5.78	Demonstrate proper child CPR. (P-2) / 6-2.122	
5.79	Demonstrate proper techniques for performing infant and child defibrillation and synchronized cardioversion.(P-2) / 6-2.123	

DECLARATIVE
I.	Assessment 
A.	General considerations 
1.	Many components of the initial patient evaluation can be done by observing the patient. Utilize the parent/ guardian to assist in making the infant or child more comfortable as appropriate. 
2.	Interacting with parents and family 
a.	Normal responses to acute illness and injury 
b.	Parent/ guardian and child interaction 
c.	Intervention techniques 
B.	Physical exam 
1.	Scene survey 
a.	Observe the scene for hazards or potential hazards 
b.	Observe the scene for mechanism of injury/ illness 
i.	Ingestion 
a.	ills, medicine bottles, household chemicals, etc. 
ii.	Child abuse 
a.	Injury and history do not coincide, bruises not where they should be for mechanism of injury, etc. 
iii.	Position patient found 
c.	Observe the parent/ guardian/ caregiver interaction with the child 
i.	Do they act appropriately 
ii.	Is parent/ guardian/ caregiver concerned 
iii.	Is parent/ guardian/ caregiver angry 
iv.	Is parent/ guardian/ caregiver indifferent 
2.	Initial assessment 
a.	General impression 
i.	General impression of environment 
ii.	General impression of parent/ guardian and child interaction 
iii.	General impression of the patient/ Pediatric Assessment Triangle 
a.	A structure for assessing the pediatric patient 
b.	Focuses on the most valuable information for pediatric patients 
c.	Used to ascertain if any life-threatening condition exists 
d.	Components 
i.	Appearance 
ii.	Work of breathing 
iii.	Circulation 
iv.	Initial triage decisions 
a.	Urgent - proceed with rapid ABC assessment, treatment and transport 
b.	Non urgent - proceed with focused history, detailed physical exam after initial assessment 
b.	Vital functions 
i.	Determine level of consciousness 
a.	AVPU scale 
i.	Alert 
ii.	Responds to verbal stimuli 
iii.	Responds to painful stimuli 
iv.	Unresponsive 
b.	Modified Glasgow Coma Scale 
c.	Signs of inadequate oxygenation 
ii.	Airway 
a.	Determine patency 
iii.	Breathing 
a.	Adequate chest rise and fall 
b.	Use of accessory muscles 
c.	Nasal flaring 
d.	Tachypnea 
e.	Bradypnea 
f.	Irregular breathing pattern 
g.	Head bobbing 
h.	Grunting 
i.	Absent breath sounds 
j.	Abnormal sounds 
iv.	Circulation 
a.	Pulse 
i.	Central 
ii.	Peripheral 
iii.	Quality of pulse 
b.	Blood pressure 
i.	Measuring blood pressure is not necessary in children < 3 years of age 
c.	Skin color 
d.	Active hemorrhage 
v.	Vital signs 
a.	Infant 
b.	Toddler 
c.	Preschool 
d.	School aged 
e.	Adolescent 
3.	Transition phase - Utilized to allow the infant or child to become familiar with you and your equipment 
a.	Use of transition phase depends on the seriousness of the patient's condition 
b.	For the conscious, non-acutely ill child 
c.	For the unconscious, acutely ill child do not perform the transition phase but proceed directly to the treatment and transport 
4.	Focused history 
a.	Approach 
i.	For infant, toddler, and preschool age patient, obtain from parent/guardian 
ii.	For school age and adolescent patient, most information may be obtained from the patient 
iii.	For older adolescent patient question the patient in private regarding sexual activity, pregnancy, illicit drug and alcohol use 
b.	Content 
i.	Chief complaint 
a.	Nature of illness/injury 
b.	How long has the patient been sick/injured 
c.	Presence of fever 
d.	Effects on behavior 
e.	Bowel/ urine habits 
f.	Vomiting/ diarrhea 
g.	Frequency of urination 
ii.	Past medical history 
a.	Infant or child under the care of a physician 
b.	Chronic illnesses 
c.	Medications 
d.	Allergies 
5.	Detailed physical exam 
a.	Examine all body regions 
i.	Head-to-toe in older child 
ii.	Toe-to-head in younger child 
b.	Some or all of the following may be appropriate, depending on the situation 
i.	Pupils 
ii.	Capillary refill 
a.	Normal - two seconds or less 
b.	Valuable to assess on patients less than six years of age 
c.	Less reliable in cold environment 
d.	Blanch nailbed, base of the thumb, sole of the feet 
iii.	Hydration 
a.	Skin turgor 
b.	Sunken or flat fontanelle in an infant 
c.	Presence of tears and saliva 
iv.	Pulse oximetry 
a.	Should be utilized on any moderately injured or ill infant or child 
b.	Hypothermia and shock can alter reading 
v.	Cardiac monitor 
6.	On-going exam - continually monitor the following 
a.	Respiratory effort 
b.	Color 
c.	Mental status 
d.	Pulse oximetry 
e.	Vital signs 
f.	Patient temperature 
C.	General management 
1.	Airway management in pediatric patients 
a.	Basic airway management 
i.	Manual positioning 
a.	Allow medical patients to assume position of comfort 
b.	Support under the torso for trauma patients less than 3 year old 
a.	Occipital elevation for supine medical patients 3 years of age or older 
i.	Foreign body airway obstruction - basic clearing methods 
a.	Infants 
i.	Back blows 
ii.	Chest thrusts 
b.	Children 
i.	Abdominal thrusts 
ii.	Suction 
a.	Avoid hypoxia 
b.	Avoid upper airway stimulation 
c.	Decrease suction negative pressure (100 mm/Hg) in infants 
iii.	Oxygenation 
a.	Non-rebreather mask 
b.	Blow-by oxygen if mask is not tolerated 
i.	Utilize the parent or guardian to deliver oxygen if (patient condition warrants 
c.	Maintain proper head position 
iv.	Oropharyngeal airway 
a.	Sizing 
b.	Preferred method of insertion uses the tongue blade to depress the tongue and jaw 
v.	Nasopharyngeal airway 
a.	Sizing 
b.	No major differences in sizing or use compared to adults 
vi.	Ventilation 
a.	Bag size 
b.	Proper mask fit 
c.	Proper mask position and seal (E-C clamp) 
d.	Ventilate at age appropriate rate (squeeze-release-release) 
e.	Obtain chest rise with each breath 
f.	Allow adequate time for exhalation 
g.	Assess BVM ventilation 
h.	Apply cricoid pressure to minimize gastric inflation and passive regurgitation 
a.	Advanced airway management 
i.	Foreign body airway obstruction - advanced clearing methods 
a.	Direct laryngoscopy with Magill forceps 
b.	Attempt intubation around foreign body 
c.	Consider needle cricothyroidotomy per medical direction only as a last resort if complete upper airway obstruction is present 
ii.	Endotracheal intubation in pediatric patients 
a.	Laryngoscope and appropriate size blade 
i.	Length based resuscitation tape to determine size 
ii.	Straight blade is preferred 
b.	Appropriate size endotracheal tube and stylet 
i.	Sizing methods 
a.	Length based resuscitation tape 
ii.	Stylet placement 
c.	Technique for pediatric intubation 
d.	Depth of insertion 
e.	Endotracheal tube securing device 
iii.	Needle cricothyroidotomy in pediatric patients 
1.	Circulation 
a.	Vascular access 
i.	Intraosseous access in children < 6 years of age in cardiac arrest or if intravenous access fails 
b.	Fluid resuscitation 
i.	20 ml/kg of lactated ringer’s or normal saline bolus as needed 
2.	Pharmacological 
a.	Rapid sequence intubation per medical direction 

3.	Non-pharmacological 
a.	C-spine immobilization for traumatic cause 
4.	Transport considerations 
a.	Appropriate mode 
i.	Transport should not be delayed to perform procedures that can be done en route 
ii.	Proper BLS care must be performed prior to any ALS interventions 
b.	Appropriate facility 
i.	The availability of a receiving hospital with expertise in pediatric care may improve the patient’s outcome 
5.	Psychological support/ communication strategies 
a.	Utilize the parent/ guardian to assist in making the infant or child more comfortable 
b.	Encourage parents to help calm the child during painful procedures 
c.	Infants, toddlers, preschool and school aged patients do not like to be separated from parent/ guardian 
d.	Infants and children have a natural fear of strangers; for stable patients, allow them to become accustomed to you before your hands-on assessment 
e.	Give some control of what is going to happen to the patient (which arm to have their IV) 
f.	When possible and practical, physically position your face at the same level as the patient’s face to facilitate communication and minimize fear 
g.	Use age-appropriate vocabulary 
h.	Keep patient warm 
i.	Allow child to take their favorite toy/ blanket if possible 
j.	Permit the child to express their feelings (e.g., fear, pain, crying,) 
k.	Let the child know that certain physical actions (e.g., hitting, biting, spitting) are not permitted 
II.	Specific pathophysiology, assessment and management 
A.	Respiratory compromise 
1.	Introduction 
a.	Epidemiology 
i.	Incidence 
ii.	Morbidity/ mortality 
iii.	Risk factors 
iv.	Prevention strategies 
b.	Categories of respiratory compromise 
i.	Upper airway obstruction 
ii.	Lower airway disease 
2.	Pathophysiology 
a.	Respiratory illnesses cause respiratory compromise in airway/ lung 
i.	Severity of respiratory compromise depends on extent of respiratory illness 
ii.	Approach to treatment depends on severity of respiratory compromise 
b.	Severity 
i.	Respiratory distress 
a.	Increased work of breathing 
b.	Carbon dioxide tension in the blood initially decreases, then increases as condition deteriorates 
c.	If uncorrected, respiratory distress leads to respiratory failure 

ii.	Respiratory failure 
a.	Inadequate ventilation or oxygenation 
i.	Respiratory and circulatory systems are unable to exchange enough oxygen and carbon dioxide 
b.	Carbon dioxide tension in the blood increases, leading to respiratory acidosis 
c.	Very ominous condition; patient is on the verge of respiratory arrest 
iii.	Respiratory arrest 
a.	Cessation of breathing 
b.	Failure to intervene will result in cardiopulmonary arrest 
c.	Good outcomes can be expected with early intervention that prevents cardiopulmonary arrest 
c.	Assessment 
i.	Chief Complaint 
ii.	History 
iii.	Physical findings 
a.	Signs and symptoms of respiratory distress 
i.	Normal mental status => irritability or anxiety 
ii.	Tachypnea 
iii.	Retractions 
iv.	Nasal flaring 
v.	Good muscle tone 
vi.	Tachycardia 
vii.	Head bobbing 
viii.	Grunting 
ix.	Cyanosis which improves with supplemental oxygen 
b.	Signs and symptoms of respiratory failure 
i.	Irritability or anxiety ==> lethargy 
ii.	Marked tachypnea ==> bradypnea 
iii.	Marked retractions ==> agonal respirations 
iv.	Poor muscle tone 
v.	Marked tachycardia ==> bradycardia 
vi.	Central cyanosis 
c.	Signs and symptoms of respiratory arrest 
i.	Obtunded ==> coma 
ii.	Bradypnea ==> apnea 
iii.	Absent chest wall motion 
iv.	Limp muscle tone 
v.	Bradycardia ==> asystole 
vi.	Profound cyanosis 
iv.	On-going assessment - improvement indicated by 
a.	Improvement in color 
b.	Improvement in oxygen saturation 
c.	Increased pulse rate 
d.	Increased level of consciousness 
d.	Management 
i.	Graded approach to treatment 
ii.	Consider separating parent and child 
iii.	Airway 
a.	Manage upper airway obstructions as needed 
b.	Insert airway adjunct if needed 
iv.	Ventilation and oxygenation 
a.	Respiratory distress/ early respiratory failure 
i.	Administer high flow oxygen 
b.	Late respiratory failure/ respiratory arrest 
i.	BVM - ventilate patient with 100% oxygen via age- appropriate sized bag 
ii.	ETT - intubate patient if positive pressure ventilation does not rapidly improve patient condition 
iii.	Consider gastric decompression if abdominal distention is impeding ventilation 
iv.	Consider needle decompression per medical direction if tension pneumothorax is present 
v.	Consider cricothyroidotomy per medical direction only as a last resort if complete upper airway obstruction is present 
v.	Circulation 
vi.	Supportive care 
vii.	Transport considerations 
a.	Appropriate mode 
b.	Appropriate facility 
viii.	Psychological support/ communication strategies 
3.	Upper airway obstruction 
a.	Croup 
i.	Epidemiology 
a.	Incidence 
i.	Very common in infants and children (6 months to 4 years of age) 
b.	Risk factors 
c.	Prevention strategies 
ii.	Pathophysiology 
a.	An inflammatory process of the upper respiratory tract involving the subglottic region 
b.	Main cause is viral infection of the upper airway 
c.	Another form is spasmodic croup 
i.	Occurs mostly in the middle of the night 
ii.	Usually without prior upper respiratory infection 
iii.	Assessment 
a.	Signs and symptoms of respiratory distress or failure, depending on severity, plus 
i.	Appears sick 
ii.	Stridor 
iii.	Barking (seal or dog-like) or brassy cough 
iv.	Hoarseness 
v.	Fever (+/-) 
b.	History 
i.	Usually with history of upper respiratory infection in classic croup (1-2 days) 
ii.	Rarely progresses to respiratory failure 
iv.	Management 
a.	Airway and ventilation 
i.	Humidified or nebulized oxygen 
ii.	Cool mist oxygen at 4-6 L/min 
b.	Circulation 
c.	Pharmacological 
d.	Non-pharmacological 
i.	Keep child in position of comfort 
e.	Transport considerations 
f.	Psychological support/ communication strategies 
i.	Do not agitate the patient (no IVs, blood pressure, etc.) 
ii.	Keep the parent/ guardian/ caregiver with the infant or child if appropriate 
b.	Foreign body aspiration 
i.	Epidemiology 
a.	Incidence 
i.	Usually occurs in toddlers and pre-schoolers (1 to 4 years of age, but can occur at any age) 
ii.	Common 
b.	Risk factors 
c.	Prevention strategies 
ii.	Pathophysiology 
a.	Partial or complete blockage of the upper airway by a foreign body 
b.	Objects are usually food (hard candy, nuts, seeds, hot dog) or small objects (coins, balloons) 
c.	If no interventions or if interventions are unsuccessful, respiratory arrest followed by cardiopulmonary arrest will ensue 
iii.	Assessment 
a.	Partial obstruction 
i.	Signs and symptoms of respiratory distress or failure, depending on severity, plus 
ii.	History - Usually a history of choking if observed by adult 
b.	Complete obstruction 
i.	Signs and symptoms of respiratory failure or arrest, depending on severity, plus 
ii.	History 
iv.	Management 
a.	Airway and ventilation 
i.	Partial obstruction 
ii.	Complete obstruction 
b.	Circulation 
c.	Pharmacological 
d.	Transport considerations 
i.	Notify hospital of patient status 
ii.	Transport expeditiously 
e.	Psychological support/ communication strategies 
i.	Do not agitate patient 
ii.	Keep caregiver with child, if appropriate 
c.	Bacterial tracheitis 
i.	Epidemiology 
a.	Incidence 
i.	Usually occurs in infants and toddlers (1-5 years old), but can occur in older children 
ii.	Very uncommon 
b.	Risk factors 
c.	Prevention strategies 

ii.	Pathophysiology 
a.	Bacterial infection of the upper airway, subglottic trachea, usually following viral croup 
iii.	Assessment 
a.	Signs and symptoms - respiratory distress or failure depending on severity, plus 
i.	Appears agitated, sick 
ii.	High-grade fever 
iii.	Inspiratory and expiratory stridor 
iv.	Coughing up pus/ mucous 
v.	Hoarse voice 
vi.	Pain in throat 
b.	History 
i.	Usually a history of croup in the preceding few days 
c.	May progress to respiratory failure or arrest 
iv.	Management 
a.	Assure airway and ventilation 
b.	Administer oxygen by non-rebreather or blow-by 
c.	Complete obstruction or respiratory failure/ arrest 
i.	BVM ventilation 
ii.	May require high pressure to adequately ventilate 
iii.	Intubate patient 
iv.	Suction endotracheal tube to reduce pus or mucous 
d.	Circulation 
e.	Pharmacological 
f.	Transport considerations 
i.	Place patient in sitting position 
ii.	Notify hospital of patient status as early as possible 
iii.	Transport quickly 
g.	Psychological support/ communication strategies 
i.	DO NOT AGITATE THE PATIENT - no IVs, no BP, do not look in patient’s mouth 
ii.	Keep caregiver with child if appropriate 
d.	Epiglottitis 
i.	Epidemiology 
a.	Incidence 
i.	Usually occurs in pre-school and school-age children (3-7 years of age) but can occur at any age 
ii.	Extremely uncommon due to the H. flu vaccine 
b.	Risk factors 
c.	Prevention strategies 
ii.	Pathophysiology 
a.	Rapidly forming cellulitis of the epiglottis and its surrounding structures 
b.	Bacterial infection, usually Hemophilus influenza type B 
c.	Can be a true life-threatening emergency 
iii.	Assessment 
a.	Signs and symptoms of respiratory distress or failure depending on severity, plus 
i.	Appears agitated, sick 
ii.	Stridor 
iii.	Muffled voice 
iv.	Drooling 
v.	Sore throat 
vi.	Pain on swallowing 
vii.	High fever 
b.	History 
i.	Usually no previous history but a rapid onset of symptoms (6-8 hours) 
c.	Can quickly progress to respiratory arrest 
iv.	Management 
a.	Airway and ventilation 
i.	NEVER ATTEMPT TO VISUALIZE THE AIRWAY IF THE PATIENT IS AWAKE 
ii.	Allow the parent to administer oxygen 
iii.	If airway becomes obstructed, two rescuer ventilation with BVM is almost always effective 
iv.	If BVM is not effective, attempt intubation with stylet in place 
v.	Intubation should not be attempted in settings with short transport times 
vi.	Performing chest compression upon glottic visualization during intubation may produce a bubble at the tracheal opening 
vii.	Consider needle cricothyroidotomy per medical direction as a last resort if complete upper airway obstruction is present 
b.	Circulation 
c.	Pharmacological 
d.	Transport considerations 
i.	Allow patient to assume position of comfort 
ii.	Notify hospital of patient status early 
iii.	Transport to the hospital without delay, keeping child warm 
e.	Psychological support/ communication strategies 
i.	DO NOT AGITATE THE PATIENT - no IVs, BP, do not look in patient’s mouth 
ii.	Keep the caregiver with the child if appropriate 
4.	Lower airway disease 
a.	Asthma 
i.	Epidemiology 
a.	Incidence 
i.	Usually occurs in children older than 2 years of age 
ii.	Very common 
b.	Risk factors 
i.	Typically in child with known history of asthma 
ii.	Triggered by upper respiratory infections, allergies, changes in temperature, physical exercise and emotional response 
iii.	Children that experience prolonged asthma attacks tire easily; watch for signs of respiratory failure 
c.	Prevention strategies 
ii.	Pathophysiology 
a.	Bronchospasm 
b.	Excessive mucous production 
c.	Inflammation of the small airways 
iii.	Assessment 
a.	Signs and symptoms - respiratory distress or failure depending on severity, plus 
i.	Appears anxious 
ii.	Wheezes 
iii.	Prolonged expiratory phase 
iv.	A silent chest means danger 
b.	History 
i.	Usually follows exposure to known trigger 
c.	Bronchiolitis and asthma may present very similarly 
iv.	Management 
a.	Airway and ventilation 
i.	Administer oxygen by tolerated method 
ii.	BVM ventilations for respiratory failure/ arrest (progressive lethargy, poor muscle tone, shallow respiratory effort) 
iii.	Endotracheal intubation for respiratory failure/ arrest with prolonged BVM ventilations, or inadequate response to BVM ventilations 
b.	Circulation 
c.	Pharmacological 
i.	Albuterol nebulizer 
ii.	Subcutaneous epinephrine 1:1000 - only with severe respiratory distress or failure 
iii.	Medications can be repeated if no effect 
d.	Transport considerations 
i.	Allow patient to assume position of comfort 
e.	Psychological support/ communication strategies 
i.	Keep caregiver with child if appropriate 
b.	Bronchiolitis 
i.	Epidemiology 
a.	Incidence 
i.	Usually occurs in children less than 2 years of age 
ii.	Very common 
b.	Risk factors 
i.	Usually occurs in winter months 
c.	Prevention strategies 
ii.	Pathophysiology 
a.	An inflammatory process of the lower respiratory tract including the terminal airways 
b.	Main cause is respiratory syncytial virus infection of the lower airway 
iii.	Assessment 
a.	Signs and symptoms - respiratory distress or failure depending on severity, plus 
i.	Appears anxious 
ii.	Wheezing 
iii.	Rales (diffuse) 
b.	History 
i.	Usually a history of upper respiratory infection symptoms 
c.	Bronchiolitis and asthma may present very similarly 
iv.	Management 
a.	Airway and ventilation 
i.	Administer oxygen by tolerated method 
ii.	BVM ventilations for respiratory failure/ arrest (progressive lethargy, poor muscle tone, shallow respiratory effort) 
iii.	Endotracheal intubation for respiratory failure/ arrest with prolonged BVM ventilations, or inadequate response to BVM ventilations 
b.	Circulation 
c.	Pharmacological 
i.	Albuterol nebulizer 
d.	Transport considerations 
i.	Allow patient to assume position of comfort 
e.	Psychological support/ communication strategies 
i.	Keep caregiver with child if appropriate 
c.	Pneumonia 
i.	Epidemiology 
a.	Incidence 
i.	Usually occurs in infants, toddlers and pre-schoolers (1-5 years of age), but can occur at any age 
ii.	Common 
b.	Risk factors 
c.	Prevention strategies 
ii.	Pathophysiology 
a.	Infection of the lower airway and lung 
b.	May be caused by bacteria or virus 
iii.	Assessment 
a.	Signs and symptoms - respiratory distress or failure depending on the severity, plus 
i.	Appears anxious 
ii.	Decreased breath sounds 
iii.	Rales 
iv.	Rhonchi (localized or diffuse) 
v.	Pain in the chest 
vi.	Fever 
b.	History 
i.	Usually a history of lower respiratory infectious symptoms 
iv.	Management 
a.	Airway and ventilation 
i.	Administer oxygen by tolerated method 
ii.	BVM ventilations for respiratory failure/ arrest (progressive lethargy, poor muscle tone, shallow respiratory effort) 
iii.	Endotracheal intubation for respiratory failure, prolonged BVM ventilations, or inadequate response to BVM ventilations 
b.	Circulation 
c.	Pharmacological 
d.	Transport considerations 
i.	Allow patient to assume position of comfort 
e.	Psychological support/ communication strategies 
i.	Keep caregiver with child if appropriate 
d.	Foreign body lower airway obstruction 
i.	Epidemiology 
a.	Incidence 
i.	Usually occurs in toddlers and preschool age children (1-4 years of age), but can occur at any age 
ii.	Uncommon 
b.	Risk factors 
c.	Prevention strategies 
ii.	Pathophysiology 
a.	Foreign body in the lower airway or lung 
b.	Objects are usually food (nuts, seeds, etc.) or small objects 
iii.	Assessment 
a.	Signs and symptoms - respiratory distress of failure depending on the severity, plus 
i.	Appears anxious 
ii.	Decreased breath sounds 
iii.	Rales 
iv.	Rhonchi (localized or diffuse) 
v.	Pain in the chest 
b.	History 
i.	May be a history of choking if witnessed by an adult 
iv.	Management 
a.	Airway and ventilation 
i.	Administer oxygen by tolerated method 
ii.	BVM ventilations for respiratory failure/ arrest (progressive lethargy, poor muscle tone, shallow respiratory effort) 
iii.	Endotracheal intubation for respiratory failure/ arrest with prolonged BVM ventilations, or inadequate response to BVM ventilations 
iv.	Do not attempt to retrieve foreign body as it is beyond the reach of Magill forceps 
b.	Circulation 
c.	Transport considerations 
i.	Allow patient to assume position of comfort 
d.	Psychological support/ communication strategies 
i.	Keep caregiver with child if appropriate 
B.	Shock 
1.	Introduction 
a.	Epidemiology 
i.	Incidence 
ii.	Morbidity/ mortality 
iii.	Risk factors 
iv.	Prevention strategies 
b.	Categories of shock 
i.	Non-cardiogenic 
ii.	Cardiogenic 
2.	Pathophysiology 
a.	An abnormal condition characterized by inadequate delivery of oxygen and metabolic substrates to meet the metabolic demands of tissues 
b.	Severity 
i.	Compensated (early) 
a.	Patient’s blood pressure is normal although signs of inadequate tissue perfusion are present 
b.	Reversible 
ii.	Decompensated (late) 
a.	Hypotension and signs of inadequate organ perfusion are present 
b.	Often irreversible 
c.	Assessment 
i.	Chief complaint 
ii.	History 
iii.	Physical findings 
a.	Signs and symptoms of compensated shock 
i.	Irritability or anxiety 
ii.	Tachycardia 
iii.	Tachypnea 
iv.	Weak peripheral pulses, full central pulses 
v.	Delayed capillary refill 
vi.	Cool, pale extremities 
vii.	Systolic blood pressure within normal limits 
viii.	Decreased urinary output 
b.	Signs and symptoms of decompensated shock 
i.	Lethargy or coma 
ii.	Marked tachycardia or bradycardia 
iii.	Marked tachypnea or bradypnea 
iv.	Absent peripheral pulses, weak central pulses 
v.	Markedly delayed capillary refill 
vi.	Cool, pale, dusky, mottled extremities 
vii.	Hypotension 
viii.	Markedly decreased urinary output 
d.	Management 
i.	Graded approach to treatment 
ii.	Consider separating parent and child 
iii.	Airway 
a.	Trauma - immobilize c-spine 
iv.	Ventilation and oxygenation 
a.	Compensated shock 
i.	Oxygen 
b.	Decompensated shock 
i.	BVM - consider ventilating patient with 100% oxygen via appropriate-sized bag 
ii.	ETT - consider intubating patient if positive pressure ventilation does not rapidly improve patient’s condition 
v.	Circulation 
a.	Compensated shock 
i.	Oxygen 
b.	Decompensated shock 
i.	Non-cardiogenic 
ii.	Cardiogenic 
vi.	Supportive care 
vii.	Transport considerations 
a.	Appropriate mode 
b.	Appropriate facility 
viii.	Psychological support/ communication strategies 
3.	Noncardiogenic 
a.	Hypovolemia 
i.	Epidemiology 
a.	Common 
ii.	Pathophysiology 
a.	Intravascular volume depletion 
i.	Severe dehydration 
ii.	Blood loss 
iii.	Assessment 
a.	Signs and symptoms of compensated or decompensated shock depending on severity, plus 
i.	Blood loss 
ii.	Dehydration 
b.	History 
iv.	Management 
a.	Airway and ventilation 
i.	Oxygen 
ii.	Trauma - immobilize c-spine 
b.	Circulation 
i.	Compensated shock 
ii.	Decompensated shock 
c.	Supportive care 
d.	Transport considerations 
e.	Psychological support/ communication strategies 
b.	Distributive 
i.	Epidemiology 
a.	Uncommon 
ii.	Etiology 
a.	Septic 
b.	Neurogenic 
c.	Anaphylactic 
iii.	Pathophysiology 
a.	Peripheral pooling due to loss of vasomotor tone 
iv.	Assessment 
a.	Signs and symptoms of compensated or decompensated shock depending on severity, plus 
i.	Septic 
ii.	Neurogenic 
iii.	Anaphylactic 
b.	History 
v.	Management 
a.	Airway and ventilation 
i.	Oxygen 
ii.	Trauma - immobilize c-spine 
b.	Circulation 
i.	Compensated shock 
ii.	Decompensated shock 
c.	Supportive care 
d.	Transport considerations 
e.	Psychological support/ communication strategies 

4.	Cardiogenic 
a.	Cardiomyopathy 
i.	Epidemiology 
a.	Infection 
b.	Congenital abnormalities 
ii.	Pathophysiology 
a.	Mechanical pump failure 
b.	Usually biventricular 
iii.	Assessment 
a.	Signs and symptoms of compensated or decompensated shock, depending on severity, plus 
i.	Rales 
ii.	Jugular venous distention 
iii.	Hepatomegaly 
iv.	Peripheral edema 
b.	History 
iv.	Management 
a.	Airway and ventilation 
i.	Oxygen 
b.	Circulation 
i.	Compensated shock 
ii.	Decompensated shock 
c.	Supportive care 
d.	Transport considerations 
e.	Psychological support/ communication strategies 
b.	Dysrhythmias 
i.	Epidemiology 
a.	Bradydysrhythmias - common 
b.	Supraventricular tachydysrhythmias - uncommon 
c.	Ventricular tachydysrhythmias - very uncommon 
ii.	Pathophysiology 
a.	Electrical pump failure 
i.	Results in cardiogenic shock or cardiopulmonary arrest depending on type 
iii.	Assessment 
a.	Signs and symptoms of cardiogenic shock (compensated or decompensated) or cardiopulmonary arrest, depending on type 
b.	History 
iv.	Management 
a.	Specific to each type 
C.	Dysrhythmias 
1.	Tachydysrhythmias 
a.	Supraventricular tachycardia 
i.	Epidemiology 
a.	Incidence 
i.	Usually in infants with no prior history 
b.	Risk factors 
c.	Prevention strategies 
ii.	Pathophysiology 
a.	Stable (compensated shock) - patient will usually remain stable during transport with oxygen 
b.	Unstable (decompensated shock) - PATIENT REQUIRES IMMEDIATE TREATMENT 
c.	Children may be able to sustain increased rates for a while, but after several hours, they will decompensate 
iii.	Assessment 
a.	Signs and symptoms - compensated or decompensated shock, depending on severity, plus 
i.	Narrow complex tachycardia with rates of greater than 220 beats per minute (too fast to count) 
ii.	Poor feeding 
iii.	Hypotension 
b.	History 
iv.	Management 
a.	Stable - supportive care 
b.	Unstable 
i.	Airway and ventilation 
ii.	Circulation 
iii.	Pharmacological 
iv.	Non-pharmacological 
v.	Transport considerations 
vi.	Psychological support/ communication strategies 
b.	Ventricular tachycardia with a pulse 
i.	Epidemiology 
a.	Incidence 
b.	Risk factors 
c.	Prevention strategies 
ii.	Pathophysiology 
a.	Stable (compensated shock) - patient will usually not tolerate for long periods of time 
b.	Unstable (decompensated shock) - PATIENT REQUIRES IMMEDIATE TREATMENT 
c.	Most VT with a pulse is secondary to structural heart disease and responds poorly to lidocaine 
iii.	Assessment 
a.	Signs and symptoms - signs of compensated or decompensated shock, depending on severity, plus 
i.	Rapid, wide complex tachycardia 
ii.	Poor feeding 
iii.	Hypotension 
b.	History 
iv.	Management 
a.	Stable - supportive care 
b.	Unstable 
i.	Airway and ventilation 
ii.	Circulation 
iii.	Pharmacological 
iv.	Non-pharmacological 
v.	Transport considerations 
vi.	Psychological support/ communication strategies 
2.	Bradydysrhythmias 
a.	Epidemiology 
i.	Incidence - most common dysrhythmia in children 
ii.	Risk factors 
iii.	Prevention strategies 
b.	Pathophysiology 
i.	Usually develops as a result of hypoxia 
ii.	May develop due to vagal stimulation (rare) 
c.	Assessment 
i.	Signs and symptoms - compensated or decompensated shock, depending on severity, plus 
a.	Bradycardia 
b.	Slow, narrow complex heart rhythm, QRS duration may be normal or prolonged 
ii.	History 
d.	Management 
i.	Stable - supportive care 
ii.	Unstable 
a.	Airway and ventilation 
i.	Ventilate patient with 100% oxygen via BVM 
ii.	Intubate patient if poor response to BVM ventilations 
b.	Circulation 
i.	Perform chest compressions if oxygen does not increase heart rate 
c.	Pharmacological 
i.	Medications can be given down the endotracheal tube 
ii.	Administer epinephrine 
iii.	Administer atropine for vaguely induced bradycardia 
d.	Non-pharmacological 
e.	Transport considerations 
f.	Psychological support/ communication strategies 
3.	Absent rhythm 
a.	Asystole 
i.	Epidemiology 
a.	Incidence - may be the initial cardiac arrest rhythm 
b.	Risk factors 
c.	Prevention strategies 
ii.	Pathophysiology 
a.	Bradycardias may degenerate into asystole 
b.	High mortality rate 
iii.	Assessment 
a.	Signs and symptoms 
i.	Pulseless 
ii.	Apneic 
iii.	Cardiac monitor indicating no electrical activity 
b.	History 
iv.	Management 
a.	Confirm in two leads 
b.	Airway and ventilation 
i.	Ventilate the patient with 100% oxygen via BVM 
ii.	Intubate patient if poor response to BVM ventilations 
c.	Circulation 
i.	Perform chest compressions 
d.	Pharmacological 
i.	Medications can be given down the endotracheal tube 
ii.	Administer epinephrine 
e.	Non-pharmacological 
f.	Transport considerations 
g.	Psychological support/ communication strategies 
b.	Ventricular fibrillation/ pulseless ventricular tachycardia 
i.	Epidemiology 
a.	Incidence - rare 
b.	Risk factors 
c.	Prevention strategies 
ii.	Pathophysiology 
a.	Possibly due to electrocution and drug overdoses 
b.	High mortality rate 
iii.	Assessment 
a.	Signs and symptoms 
i.	Pulseless 
ii.	Apneic 
iii.	Cardiac monitor indicating no organized electrical activity or rapid wide complex tachycardia 
b.	History 
iv.	Management 
a.	Unmonitored - perform basic life support 
b.	Monitored - defibrillate up to three consecutive shocks 
c.	Airway and ventilation 
i.	Ventilate the patient with 100% oxygen via BVM 
ii.	Intubate patient if poor response to BVM ventilations 
d.	Circulation 
i.	Perform chest compressions 
e.	Pharmacological 
i.	Medications can be given down the endotracheal tube 
ii.	Administer epinephrine 
iii.	Administer lidocaine 
iv.	Administer bretylium 
v.	After administration of a medication, allow it to circulate for one minute before repeat defibrillation 
f.	Non-pharmacological 
g.	Transport considerations 
h.	Psychological support/ communication strategies 
c.	Pulseless electrical activity 
i.	Epidemiology 
a.	Incidence - look for a treatable cause 
b.	Risk factors 
c.	Prevention strategies 
ii.	Pathophysiology 
a.	Pneumothorax 
b.	Cardiac tamponade 
c.	Hypovolemia 
d.	Hypoxia 
e.	Acidosis 
f.	Hypothermia 
g.	Hypoglycemia 

iii.	Assessment 
a.	Signs and symptoms 
i.	Pulseless 
ii.	Apneic 
iii.	Cardiac monitor indicating organized electrical activity 
b.	History 
iv.	Management 
a.	Resuscitation should be directed toward relieving cause 
b.	Airway and ventilation 
i.	Ventilate the patient with 100% oxygen 
ii.	Intubate patient 
c.	Circulation 
i.	Perform chest compressions 
d.	Pharmacological 
i.	Medications can be given down the endotracheal tube 
ii.	Administer epinephrine 
e.	Non-pharmacological 
f.	Transport considerations 
g.	Psychological support/ communication strategies 
III.	Pediatric trauma 
A.	Pathophysiology 
1.	Blunt 
a.	Thinner body wall allows forces to be readily transmitted to body contents 
b.	Predominant cause of injury in children 
2.	Penetrating 
a.	Becoming an increasing problem in adolescents 
b.	Higher incidence in the inner city (mostly intentional), but significant incidence in other areas (mostly unintentional) 
B.	Mechanism of injury 
1.	Fall 
a.	Single most common cause of injury in children 
b.	Serious injury or death resulting from truly accidental falls is relatively uncommon unless from a significant height 
c.	Prevention strategies 
2.	Motor vehicle crash 
a.	Leading cause of permanent brain injury and new cases of epilepsy 
b.	Leading cause of death and serious injury in children 
c.	Prevention strategies 
3.	Pedestrian vehicle crash 
a.	Particularly lethal form of trauma in children 
b.	Initial injury due to impact with vehicle (extremity/ trunk) 
c.	Child is thrown from force of impact causing additional injury (head/ spine) upon impact with other objects (ground, another vehicle, light standard, etc.) 
d.	Prevention strategies 
4.	Near-drowning 
a.	Third leading cause of injury or death in children between birth and 4 years of age 
b.	Causes approximately 2000 deaths annually 
c.	Severe, permanent brain damage occurs in 5-20% of hospitalized children for near drowning 
d.	Prevention strategies 
5.	Penetrating injuries 
a.	Risk of death from firearm injuries increase with age 
b.	Stab wounds and firearm injuries account for approximately 10-15% of all pediatric trauma admissions 
c.	Visual inspection of external injuries can not evaluate the extent of internal involvement 
d.	Prevention strategies 
6.	Burns 
a.	The leading cause of accidental death in the home for children under the age of 14 years 
b.	Burn survival is a function of burn size and concomitant injuries 
i.	Modified "rule of nines" is utilized to determine percentage of surface area involved 
c.	Prevention strategies 
7.	Physical abuse 
a.	Has been classified into four categories - physical abuse, sexual abuse, emotional abuse and child neglect 
b.	Social phenomena such as increased poverty, domestic disturbance, younger aged parents, substance abuse, and community violence have been attributed to increase of abuse 
c.	Document all pertinent findings, treatments and interventions 
d.	Prevention strategies 
C.	Special considerations 
1.	Airway control 
a.	Maintain in-line stabilization in neutral, not sniffing position 
b.	Administer 100% oxygen to all trauma patients 
c.	Patent airway must be maintained via suctioning and jaw thrust 
d.	Be prepared to assist ineffective respirations 
e.	Intubation should be performed when the airway remains inadequate 
f.	Gastric tube should be placed after intubation 
g.	Needle cricothyroidotomy is rarely indicated for traumatic upper airway obstruction 
2.	Immobilization 
a.	Indications for stabilization and immobilization of cervical spine 
b.	Utilize appropriate sized pediatric immobilization equipment 
i.	Rigid cervical collar 
ii.	Towel/ blanket roll 
iii.	Child safety seat 
iv.	Pediatric immobilization device 
v.	Vest-type/ short wooden backboard 
vi.	Long backboard 
vii.	Straps, cravats 
viii.	Tape 
ix.	Padding 
c.	Maintain supine neutral in-line position for infants, toddlers, and pre-schoolers by placing padding from the shoulders to the hips 
3.	Fluid management 
a.	Management of the airway and breathing take priority over management of circulation because circulatory compromise is less common in children than adults 
b.	Vascular access 
i.	Large-bore intravenous catheter should be inserted into a large peripheral vein 
ii.	Do not delay transport to gain access 
iii.	Intraosseous access in children < 6 years of age if intravenous access fails 
iv.	Initial fluid bolus of 20 ml/kg of an lactated ringers or NS 
v.	Reassess vital signs and rebolus with 20 ml/kg if no improvement 
vi.	If improvement does not occur after the second bolus, there is likely to be significant blood loss and the need for rapid surgical intervention 
4.	Traumatic brain injury 
a.	Early recognition and aggressive management can reduce mortality and morbidity 
b.	Severity 
i.	Mild - GCS is 13 to 15 
ii.	Moderate - GCS is 9 to 12 
iii.	Severe - GCS is less than or equal to 8 
c.	Signs of increased intracranial pressure 
i.	Elevated blood pressure 
ii.	Bradycardia 
a.	Rapid deep respirations (Kussmaul) progressing to slow, deep respirations alternating with rapid deep respirations (Cheyne-Stokes) 
iii.	Bulging fontanelle (infant) 
d.	Signs of herniation 
i.	Asymmetrical pupils 
ii.	Posturing 
e.	Specific management 
i.	Administer high concentration of oxygen for mild to moderate head injuries (GCS 9-15) 
ii.	Intubate and ventilate at normal breathing rate with 100% oxygen for severe head injuries (GCS 3-8) 
a.	Use of lidocaine may blunt rise in ICP (controversial) 
b.	Consider RSI per medical direction 
iii.	Indications for hyperventilation 
a.	Asymmetric pupils 
b.	Active seizures 
c.	Neurologic posturing 
D.	Specific injuries 
1.	Head and neck injury 
a.	Larger relative mass of the head and lack of neck muscle strength provides increased momentum in acceleration-deceleration injuries and a greater stress to the cervical spine region 
b.	Fulcrum of cervical mobility in the younger child is at the C2-C3 level 
c.	60% to 70% of pediatric fractures occur in C1 or C2 
d.	Head injury is the most common cause of death in pediatric trauma victim 
e.	Diffuse injuries are common in children, focal injuries are rare 
f.	Soft tissues, skull and brain are more compliant in children than in adults 
i.	Due to open fontanelles and sutures, infants up to an average age of 16 months may be more tolerant to an increase of intracranial pressure and can have delayed signs 
g.	Subdural bleeds in a infant can produce hypotension (extremely rare) 
h.	Significant blood loss can occur through scalp lacerations and should be controlled immediately 
i.	The Modified Glasgow Coma scale should be utilized for infants and young children 

2.	Chest injury 
a.	Chest injuries in children under 14 years of age are usually the result of blunt trauma 
b.	Due to the compliance of the chest wall, severe intrathoracic injury can be present without signs of external injury 
c.	Tension pneumothorax is poorly tolerated and is an immediate threat to life 
d.	Flail segment is an uncommon injury in children; when noted without a significant mechanism of injury, suspect child abuse 
e.	Many children with cardiac tamponade will have no physical signs of tamponade other then hypotension 
3.	Abdominal injury 
a.	Musculature is minimal and poorly protects the viscera 
b.	Organs most commonly injured are liver, kidney and spleen 
c.	Onset of symptoms may be rapid or gradual 
d.	Due to the small size of the abdomen, be certain to palpate only one quadrant at a time 
i.	Any child who is hemodynamically unstable without evidence of obvious source of blood loss should be considered as having an abdominal injury until proven otherwise 
4.	Extremity 
a.	Relatively more common in children than adults 
b.	Growth plate injuries are common 
c.	Compartment syndrome is an emergency in children 
d.	Any sites of active bleeding must be controlled 
e.	Splinting should be performed to prevent further injury and blood loss 
f.	PASG may be useful in unstable pelvic fractures with hypotension 
5.	Burns 
a.	Thermal burns in children 
b.	Chemical burns in children 
c.	Electrical burns in children 
d.	Management priorities 
i.	Prompt management of the airway is required as swelling can develop rapidly 
ii.	If intubation is required, an endotracheal tube up to two sizes smaller than what would normally be used may be required 
iii.	Thermally burned children are very susceptible to hypothermia; maintain normal body temperature