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Pediatrics
Assessment and Management of the Critically Ill Child
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Kids are Tattle-Tales
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Goals
• Understand the Role of the Paramedic in Pediatric Emergency Care
• Describe the Developmental Characteristics of different pediatric age groups
• Describe the anatomical and physiological differences between the adult and pediatric patient
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Goals
• Describe assessment techniques for the critically injured and ill child
• Discuss General Management of the Pediatric Patient
• Utilize the Appropriate Assessment Technique to Rapidly Identify Treatment priorities
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Roles of the Paramedic
• Patient advocacy
• Family Advocate
• Professional Education
• Professional Involvement
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Roles of the Paramedic
• Advocacy for the Patient– Patient Needs
• Emergency = Stress = Fear– Separation– Further Injury and Pain– Unknown
• Knowledge = Stress = Fear– Be Honest– Be Understandable– Be Timely
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Roles of the Paramedic
• Advocacy for the Family– Family Needs
• Emergency = Stress = Fear– Guilt - Denial– Anger - Loss of Control– Grief
• Knowledge = Stress = Fear– Be Professional– Be Honest– Be Organized
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Roles of the ParamedicProfessional Education
– Pediatric Advanced Life Support (PALS)
– Advanced Pediatric Life Support (APLS)
– Pediatric Education for Prehospital Providers (PEPP)
– Pediatric Prehospital Care (PPC)
– Prehospital Trauma Life Support (PHTLS)
– Regional and National Conferences
– Life-Long Learning• Journals• Research• Web Resources
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Roles of the Paramedic
• Professional Involvement – Injury Prevention
• Primary, Secondary, and Tertiary• The 4 E’s of Injury Prevention
– Education – (Public Awareness)– Enforcement – (Seatbelt/Helmet law, Zoning
Regs)– Environmental changes – (Free Helmets, gun
locks)– Engineering – (Speed bumps, child-resistant
bottles)
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Roles of the Paramedic
• Professional Involvement – EMS – Children
• Federally Funded Program (1984/1991)• Designed to reduce impact from Illness and
Injury• Address the Special Needs of Pediatrics
– Assessment– Equipment– Education
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Humboldt
Siskiyou Modoc
LassenShastaTrinity
TehamaPlumas
SierraButte
Glenn
Nevada
Placer Colusa
Mendocino
Lake
Sonoma Napa
Yolo
Su
tter
Yub
a
El Dorado
Amador Alpine
Mono
Tuolumne
Sacr
amen
to
SanJoaquin
Solano
ContraCosta
Marin
San Francisco
San Mateo
Santa Cruz
Alameda
SantaClara
Stanislaus
Merced
Mariposa
Madera
SanBenito
Monterey
Fresno
Inyo
KingsTulare
KernSan Luis Obispo
Santa Barbara
VenturaLos Angeles
San Bernardino
Riverside
Orange
San DiegoImperial
EMSC Systems in Placeand not Funded by EMSA (3 Single County Agencies)
EMSC Projects Funded by EMSA(18 Agencies Representing 40 Counties)
No EMSC System in Place(9 Agencies Representing 11 Counties)
Calaveras
DelNorte
Note: Patterned areas indicate EMS regions
4/16/02
EMSC Projects in Early Stage Implementation (funded by EMSA) (2 Agencies Representing 4 Counties)
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Developmental Characteristics
• Greatest Change Occurs in first Few years of Development– Muscle
Coordination– Cognitive Process– Language Skills– Social Skills
• Understanding allows a better and more complete assessment
• Effects the Assessment Findings
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Developmental Characteristics
• Development and Assessment– Knowledge of appropriate developmental
milestones– Information from Parents on child’s norm– Appropriate Communication Skills– Children will REGRESS when STRESSED
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Infants and young children should be allowed to remain
in their parent’s arms.
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The approach to the pediatric patient should
be gentle and slow.
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A small toy may calm a child.
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Anatomy and Physiology of Kids
• Head• Airway• Chest and Lungs• Abdomen• Extremities• Skin and BSA
• Respiratory • Cardiovascular• Nervous• Metabolic
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Anatomy
Head• Proportionally Larger
– Occipital region • Small Face/Flat Nose• Fontanelles
– Posterior closes @ 4 months
– Anterior Closes @ 9-18 months
Airway• Smaller Airways• Obligate Nose
Breather (<6 months)• Large Tongues• Large/Floppy
Epiglottis• Softer Trachea• Trachea Narrows
– Cricoid ring
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Head and Airway
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Anatomy
Chest and Lungs• Ribs – Softer and
more Flexible• Muscles – Fatigue
Early• Belly Breathers• Thin Chest wall –
Transmitted Sounds
• Prone to Gastric Distention
• Higher Energy Transfer from Blunt Trauma
• Increased risk of Pneumo and Tension
• Maxed out on Tidal Volume
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Anatomy
Abdomen
• Belly Breathers
• Large Organs in Small Space– Liver and Spleen
• Gastric Distention will Impede Tidal Volume
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Anatomy
Extremities• Still Growing
– Epiphyseal Plate
• Soft and Flexible– Sprains, Strains,
Fractures
Skin – BSA• Thinner• Less
Subcutaneous Fat• Greater
BSA:Weight • All increase risk
– Heat Loss– Burn Severity
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Physiology
Respiratory• Increased Oxygen
Demand• Decrease Oxygen
Supply (Reserve)• Vm = TV x RR
– Minimal Change in TV
Cardiovascular• Skin Perfusion is
Best Assessment Tool
• CO = SV x HR• BP = (SV x HR) x SVR• Minimal Change in SV• Significant Shock W/O
Hypotension
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Physiology
Nervous• Still Developing• Prone to Increased
Injury• Vagus Nerve
– Direct Stimulation– Passive Control
Metabolic• Increase Rate for
Compentsation• Limited Glygogen
and Glucose stores
• Newborns/neonate – don’t shiver
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Assessment Techniques
• Scene Size - Up
• General Impression
• Initial Assessment
• Treatment/Transport Priority
• Focused History And Physical
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Assessment Techniques
• Scene Size - Up
• General Impression
• Initial Assessment
• Treatment/Transport Priority
• Focused History And Physical
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Assessment Techniques
• Pediatric Assessment Triangle– Appearance– Work of Breathing– Circulation
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Assessment Techniques
• Rapid Cardiopulmonary Assessment– AHA – PALS– What you:
• See • Hear• Feel
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The Pediatric Assessment Triangle• Observational assessment
• Formalizes the “general impression”
• Establishes severity of illness or injury
• Determines urgency of intervention
• Identifies general category of physiologic abnormality
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Pediatric Assessment Triangle
Appearance Work of Breathing
Circulation
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The Pediatric Assessment Triangle
• Appearance
– Alertness
– Distractibility/ consolability
– Eye contact
– Speech or cry
– Motor activity
– Color
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Appearance
– Alertness
– Distractibility/ consolability
– Eye contact
– Speech or cry
– Motor activity
– Color
The Pediatric Assessment Triangle
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Appearance
– Alertness
– Distractibility/ consolability
– Eye contact
– Speech or cry
– Motor activity
– Color
The Pediatric Assessment Triangle
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Appearance
– Alertness
– Distractibility/ consolability
– Eye contact
– Speech or cry
– Motor activity
– Color
The Pediatric Assessment Triangle
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Appearance
– Alertness
– Distractibility/ consolability
– Eye contact
– Speech or cry
– Motor activity
– Color
The Pediatric Assessment Triangle
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Appearance
– Alertness
– Distractibility/ consolability
– Eye contact
– Speech or cry
– Motor activity
– Color
The Pediatric Assessment Triangle
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Appearance
– Alertness
– Distractibility/ consolability
– Eye contact
– Speech or cry
– Motor activity
– Color
The Pediatric Assessment Triangle
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How do we recognize respiratory distress or respiratory failure by just looking at a child?
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Pediatric Assessment Triangle
Work of BreathingAbnormal breath sounds
Retractions
Nasal flaring
Appearance
Circulation
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Respiratory Distress
Normal Work of Breathing
Appearance Retractions
Normal Circulation
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Respiratory Failure
Abnormal Work of Breathing
Appearance
Circulation Normal or Poor
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Appearance Work of Breathing
Circulation
Without the use of instruments, how can we rapidly assess the adequacy of circulation?
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Skin Circulation
• Skin temperature
• Pulse strength
• Capillary refill time
• Color
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Shock
Abnormal Normal Work of
Appearance Breathing
Poor Circulation
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Brain Dysfunction
Abnormal Normal Work of
Appearance Breathing
Normal Circulation
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PAT: Respiratory Distress
Circulation to SkinNormal
Work of BreathingIncreased
AppearanceNormal
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PAT: Respiratory Failure
Circulation to SkinNormal or abnormal
Work of BreathingIncreased or decreased
AppearanceAbnormal
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PAT: Shock
Circulation to SkinAbnormal
Work of BreathingNormal
AppearanceAbnormal
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PAT: (CNS) Dysfunction or Metabolic Abnormality
Circulation to SkinNormal
Work of BreathingNormal
AppearanceAbnormal
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2-week-old infant• Called to the home of 2-week-old
infant who had stopped breathing
• Infant turned pale, limp, revived when sitter “blew in her face”
• Term delivery, no complications
• Two days poor feeding; no fever
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Circulation to SkinFace and trunk normal, hands and feet blue
Work of BreathingAbdomen rises and falls with each breath
AppearanceEyes open, moves arms and legs, strong cry
2-week-old infant
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What do you think of this baby’s
work of breathing?
Are you concerned about her skin
signs?
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23-month-old toddler• Called to home of a 23-month-old
with “trouble breathing”• Child is on mom’s lap, sees you, and
starts to wail!• Patient is alert, with retractions and
audible wheezing. Skin color is normal.
What can we tell from the PAT?
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23-month-old toddler
.
Circulation to SkinNormal color
.
Work of BreathingRetractions, audible wheezing
AppearanceSeated, alert, strong cry
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9-month-old infant
• A 9-month-old presents with 3 days of vomiting, diarrhea and poor oral intake.
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9-month-old infant
Circulation to SkinPale skin color
Work of BreathingNo retractions or abnormal airway sounds
AppearanceAgitated, makes eye contact
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Initial Assessment
– Airway - Open and maintainable – Breathing - RR 50 breaths/min, clear lungs,
good chest rise– Circulation - HR 180 beats/min; cool, dry, pale
skin; CRT 3 seconds; BP 74 mm Hg/palp – Disability - AVPU=A– Exposure - No sign of trauma, weight 8 kg
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What is this child’s physiologic state?
What are your treatment priorities?
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• Assessment: Compensated shock, likely due to hypovolemia with viral illness
• Treatment priorities:– Provide oxygen, as tolerated– Obtain IV access en route
• Provide fluid resuscitation– 20 ml/kg of crystalloid, repeat as needed
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• 160 ml normal saline infused
• HR decreased to 140 beats/min
• Patient alert and interactive, receiving second bolus on emergency department arrival
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General Management of the Pediatric Patient
• Airway Management
• Fluid and Medications
• Electrical Therapy
• C-Spine Consideration and Impact
• Transport Considerations
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Summary of BLS Maneuvers
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Clearing an Infant’s Airway
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Suctioning
• Decrease suction pressure to less than 100 mm/Hg in infants.
• Avoid excessive suctioning time—less than 15 seconds per attempt.
• Avoid stimulation of the vagus nerve.
• Check the pulse frequently.
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Pediatric-size suction catheters. • Top: soft suction catheter. • Bottom: rigid or hard suction catheter.
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Suction Catheter Sizes for Infants and Children
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Oxygenation
Adequate oxygenation is the hallmark of pediatric patient management.
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Inserting an oropharyngeal airway in a child with the use of a tongue blade.
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a. In an adult, the airway is inserted with the tip pointing to the roof of the mouth, then rotated
into position. b. In an infant or small child, the airway is inserted with the tip pointing toward
the tongue and pharynx, in the same position it will be in after insertion.
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Ventilation
• Avoid excessive bag pressure and volume.
• Obtain chest rise and fall.• Allow time for exhalation.• Flow-restricted, oxygen-powered devices
are contraindicated.• Do not use BVMs with pop-off valves.• Apply cricoid pressure.• Avoid hyperextension of the neck.
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In placing a mask on a child, it should fit on the bridge of the nose and cleft of the chin.
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Sellick’s maneuver
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Advanced Airway and Ventilatory
Management
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Infant/Child Endotracheal Tubes
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The Pediatric Airway
• A straight blade is preferred for greater displacement of the tongue.
• The pediatric airway narrows at the cricoid cartilage.
• Uncuffed tubes should be used in children under 8 years of age.
• Intubation is likely to cause a vagal response in children.
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Pediatric Endotracheal Tube Size
• Use a resuscitation tape that estimates ET tube size based on height.
• Estimate the correct diameter, based on the child’s little finger.
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Pediatric Tube Size Formula
(Patient’s age in years + 16)
4
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Indications• Need for prolonged artificial ventilation• Inadequate ventilatory support with a BVM• Cardiac or respiratory arrest• Control of an airway in a patient without a
cough or gag reflex• Providing a route for drug administration• Access to the airway for suctioning
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Placement of the laryngoscope.
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Endotracheal Intubation in the Child
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Hyperventilate the child.
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Position the head.
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Insert the laryngoscope and visualize the airway.
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Insert the tube and ventilate the child.
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Confirm tube placement.
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Nasogastric Intubation
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Nasogastric Intubation
Indications:
• Inability to achieve adequate tidal volume during ventilation due to gastric distention
• Presence of gastric distention in an unresponsive patient
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Oxygenate and continue to ventilate, if possible.
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Measure the NG tube from the tip of the nose, over the ear, to the tip of
the xiphoid process.
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Lubricate the end of the tube. Then pass it gently downward along the
nasal floor to the stomach.
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Auscultate over the epigastrium to confirm correct placement. Listen for bubbling while
injecting 10–20 cc of air into the tube.
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Use suction to aspirate stomach contents.
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Secure the tube in place.
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Rapid Sequence Intubation
• Indicated in pediatric patients when intubation is difficult due to combativeness or clenched teeth.
• Neuromuscular compliance is gained by the use of a paralytic.
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Circulation
Two problems lead to cardiopulmonary
arrest in children:
• Shock
• Respiratory failure
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Vascular Access
• Neck veins
• Scalp veins
• Arms
• Hands
• Feet
• Intraosseous infusion
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Intraosseous Infusion Indications
• Children less than 6 years of age
• Existence of shock or cardiac arrest
• Unresponsive patient
• Unsuccessful peripheral IV
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Intraosseous Infusion Contraindications
• Fracture in the bone chosen for IO• Fracture of the pelvis or extremity fracture
of bone, proximal to the chosen site
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Intraosseous administration.
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Drugs Administered by IO Route
• Epinephrine
• Atropine
• Dopamine
• Lidocaine
• Sodium bicarbonate
• Dobutamine
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Correct needle placement for intraosseous administration.
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Fluid Administration
Accurate fluid dosing in children is crucial!
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Electrical Therapy• Initial dose is 2 joules per kilogram
of body weight.• If unsuccessful, increase to 4 joules
per kilogram.• If still unsuccessful, focus on
correcting hypoxia and acidosis.• Transport to a pediatric critical care
unit, if possible.
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Immobilizing a Patient in a Child Safety Seat
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One paramedic stabilizes the car seat in an upright position and applies and maintains manual inline stabilization
throughout the immobilization process.
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A second paramedic applies an appropriately
sized cervical collar. If one is not available, improvise using a rolled hand towel.
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The second paramedic places a small blanket or towel on the child’s lap, then uses straps or wide tape to secure the
chest and pelvic area to the seat.
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The second paramedic places towel rolls on both sides of the child’s head to fill voids
between the head and seat. He then tapes the head into place, taping over the chin, which would put pressure on the neck. The patient
and seat can be carried to the ambulance and strapped to the stretcher, with the stretcher
head raised.
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Applying a Pediatric Immobilization
System
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Position the patient on the immobilization system.
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Adjust the color-coded straps to fit the child.
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Attach the four-point safety system.
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Fasten the adjustable head-support system.
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The patient fully immobilized to the system.
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Move the immobilized patient onto the stretcher and fasten the loops at both ends to connect to the stretcher
straps.
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Emotional support of the infant or child continues during
transport.
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Never delay transport to perform a procedure that can be done
en route to the hospital!
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Case Studies