First Aid - CPR Kids
The Supporting Children’s Health Workshop was delivered by the NSW Department of Education in partnership with health professionals from the Sydney Children’s Hospitals Network, Red Nose Australia and CPR Kids.
The First Aid video is the last of five presentations from the Workshop. This video provides guidance on recognising and responding to fever in children, and prevention strategies and first aid for choking incidents and head injuries.
By viewing this presentation you will:
- Learn life-saving skills of baby/child first aid
- Understand common first aid situations and how to recognise early when something is a bit more serious
- Learn how to manage fever, including febrile convulsion
- Learn how to identify when a child is choking, and how to administer first aid to a child that is choking
- Understand the importance of supervision and risk management
Regulation 136 of the National Regulations provides requirements relating to current approved first aid qualification, anaphylaxis management training, and emergency asthma management training for centre-based and family day care services.
This video is not an approved qualification or training, and viewing this video will not satisfy the requirements of regulation 136. Services must ensure they continue to meet these requirements by completing qualifications and training approved by ACECQA.
So a little bit of an introduction first, my name is Sarah Hunstead. I'm a paediatric nurse. I spent most of my career in the emergency department of Sydney Children's Hospital. So you name it, I've seen it. But now what I do is that I run a company called CPR kids and what we do is we empower parents and carers of children with the life-saving skills of baby-child first aid in recognition of the sick child. So I am so excited to be up here and talking to you all today. And I look forward to answering any questions that you have as well at the end.
So what we're going to be talking about are some of the really common first aid situations that you actually see in your services and we're also going to cover first, I know we touched on it when Claire was talking about fever, but fever would be, I'm sure one of the most common things that kids tend to do in your centres when it comes to health-related incidences, would you agree with that? I just just out of curiosity, is there anyone here who has not cared for a kid with a fever at some stage in your career? Yes. Oh, I didn't think so. Exactly. So what we'd like to do today is just to help you bring up your skills and knowledge, most importantly to recognise and respond when you need to get help because children, they tend to be a little bit trickier than adults.
When it comes to kids, when they show certain signs and symptoms when they're starting to get unwell, it can really be that they are just showing these general things. When it comes to grown-ups, take a heart attack for example, I bet you guys could rattle off some of the signs and symptoms. So if you can imagine what are, you know, what's one of them? Chest pain? Yeah and maybe looking a bit pale and clammy and sweaty. Might have pain going down the arm. So we kind of know those signs and symptoms. When it comes to kids, they can be a bit different. When it comes to children, even though they might have something like, take meningococcal for example, which is a very serious disease their signs and symptoms that they start off with may be the same as what somebody who's got a common cold they start off with. So their signs and symptoms can be quite general.
So if we can actually recognise early on, when something is a bit more serious, and we need to take fast action, that's a really important thing and that's why there are red flags that children show, that should be those little triggers that make your spidey sense go off and go, ooh, hang on a sec... this can be really serious, we need to really progress this quickly. So that's what we will go through initially today. So what I want you to do by, you know by the end of this and by all the resources that we're going to give you is to be able to react with confidence because that's what it's about and if in doubt always seek help.
So first of all, when is it a fever? Now Claire ruined this for me because she already told you what it is. So you will know when it's a fever. I know you know this, because not only if we just said it but it is a temperature above 38 degrees. Now in your service, can I just ask, you know, I'm going to pick a few of you randomly here... How do you actually measure a child's temperature? Can I ask in your service? What do you do? Okay two thermometers. What kind of thermometers are they? So one that goes under the arm. And one that goes... ah, the scanny thermometers. Okay. All right. Yep. Yep. So under the arm and scanning. Okay this table over here. So I'm just looking at directly. What do you use to measure? Under the arm. Okay, excellent good.
Isn't it good that something that is relatively cheap they cost about $12 in the pharmacy, that is one of the most accurate ways to actually measure a temperature in a child is by a simple digital underarm thermometer. You may have seen the ear thermometers that are around. Yeah, absolutely... And they're all new fancy ones out there that can be really expensive as well. What's really interesting is if you've ever used one of those ear thermometers, have you done it one ear and then the other one... and then that... and it's just different. Yeah, and then you go back you do exactly the same ear exactly the same way and you go it's different again. Hang on a sec. Oh, there we go.
So, why does that happen? It's because you need to have the absolute perfect technique to be able to do that. And what it does is it actually reads the tympanic membrane or the just the covering of the eardrum and when you've got a child with very tiny ear canals, what happens is, is it doesn't read properly. So that's why it's a great idea in your centre, if you've just got that normal digital underarm thermometer. You can stick under their arm, making sure that there's no clothing caught under there and it's not sticking out the back while they're wiggling while you're trying to measure that temperature, is a good thing.
But now that I've told you we're talking about how to measure temperature. I'm going to throw all of that up in the air and say to you... but it's not just about the number... because when it comes to fever, fever is not the illness. Fever is simply a sign that a child is fighting infection and it's really important that we remember this because I know that you know in my experience in the emergency department that we can absolutely get fixated on that number on the thermometer. We do need know this, particularly in your situations, in services, because I know of your exclusion if that a child does develop a fever over 38 you got to do something about it. But what I want you to do is also remember that we need to look at the child too, we don't want to become fixated on that number.
So remembering that what is a fever? Basically what happens is, is our body, or the child's body is invaded by a virus or bacteria. You know, whatever they've got. And our immune system goes woah... hang on a sec. You shouldn't be in here. You're going to make us sick. This isn't good. So therefore, what we're going to do we're going to be really smart. We know that viruses and bacteria, you can't live in a hot environment. So what the brain does, is it actually resets our internal thermoregulation as such so, if you imagine that we've got central heating and cooling in our body, it's controlled by the brain and what it does, is it generally sits around 36.5, 37.5, goes up and down because our temperature does that all day it goes up and down and we've kind of got the central heating set to this, so we're nice and comfortable. What the brain does is that it resets that central heating and goes okay, we're going to now lift up. So we're going to fluctuate maybe between 38 and 39 and go up and down, might drop back down to 37 but it resets that deliberately and the good news is, is that our brains actually control this so it's deliberate.
So fever can't actually damage us, or the child. It's a good thing. So people often worry that if a child's got a really high temperature of, you know, 40, 41, that it's going to cause brain damage. Good news is it's not. The can be the illness that causes the damage but not the fever itself. There is a difference though. What I want you to remember about fever is that it's internal temperature. It's controlled on the inside, whereas hyperthermia which is when your body heats up because of an external heat source, like a child being locked in a car on what well doesn't even have to be a warm day but on a warm day, or that athlete who has been running and has now got heat stroke or heat exhaustion because they've basically cooked themselves. That's different... that can cause severe organ damage. Fever doesn't, okay. We need to remember that there's a difference, but the illness can make the child very very sick. So, fever is just a sign that the child is fighting infection.
What does a child look like when they've got a fever? Shout some things out to me... Are they happy and running around? Sometimes... Sometimes they can be but most of the time they're not no. No, they can have watery eyes. Absolutely. They're bit tired. Yeah pale. Yeah, absolutely. Not quite themselves. Maybe a little bit miserable. Yeah, absolutely. But some of these symptoms, it also depends on what's causing the fever too, isn't it? So, a child doesn't look right. Do they? All these signs and symptoms we're talking about, you know, they can just be generally unwell, they can be just a little miserable. But there are other signs and symptoms that we need to look out for and I'm going to tell you a bit of a story.
Now this just illustrates how we don't always... well we shouldn't be fixated on just the number and I'm just going to just stop for a sec and just say there's an exception to the rule. Is there anybody here who cares for children under the age of three months? Okay, not today, but there are services that do. Yet, you can yeah, so under the age of three months if that baby has a temperature that is 38 degrees or above, no matter how they look that is an automatic ticket to hospital. Because under the age of three months, they don't have the immune systems to that, you know that we do, so it's really important that no matter how they look, that they are getting urgent medical help with a temperature above 38 degrees Celsius in a child under the age of three months. Okay, everybody happy with that.
So now we're going to talk about kids over the age of three months. So I'll tell you a story and this just illustrates about the number. I'm going to use the example of my two kids because they basically have gotten every disease known to the planet which is very handy when you teach this kind of stuff because you can use them as an example. So my two children, they were three and four at the time, you do the maths. It's yep... momentary lapse of judgment may be so three and four at the time. The older one was laying on the couch. She could not lift her head off the pillow. She was sleepy. I was having to rouse her and hold her up and give her sips of fluid. She had a temperature of 38.2. My other one had a temperature of 40.6. She was sitting on the lounge room floor eating a hydralight ice block and saying, shouting to me mummy more Peppa Pig, mummy, more ice blocks. Who am I going to be worried about? The one with its 38.2 temperature or the one with a 40.6 temperature?
Yeah, the one who's laying on the couch who can't lift her head up because she's so sleepy and realising as well later on, I went she hasn't weed in over 12 hours. So that's something that I knew because, and thinking about children in your services, you'll know if it's towards the end of the day and you go, ooh, hang on a sec every time we've had a nappy change here, it's been really dry. That's not normal or just waking up after sleep time, when it's nappy changing, nappies dry, that's that's not right. So they are red flags apart from the number that show you that a child is unwell, generally unwell and so these red flags.
First of all, they might have an abnormal skin colour. So the ladies before were talking about that bluish tinge to the lips. So absolutely it changed. What is something different to normal. You will be around these kids regularly a lot of the time you will know what is normal for them. So that child who becomes mottled. Does anybody know what I mean by mottled? Yeah, so, you know when you go outside on a really really cold day and your skin gets all blotchy and marbly or, and I apologise to the vegetarians in the room, but when you go to the butcher and they've got those big fat Italian sausages and they're all kind of marble, they're full of fat, there's different colours. So that splotchiness in a child that may start on their arms and their legs and work up towards on their torso, might be a bit on their face, but that is really concerning unless they're like that normally, because some, you know, young kids are well, pale-skinned kids are just like that, but if it's different to normal, so if they're mottled, if they're blue, if they're really pale, that should be a red flag that goes off. Now there might be something very wrong, there might not be, but it's a red flag that goes off. So I can see I can see you taking notes now... child looks like Italian sausage... Concerning.
Okay, good. All right. All right we talked about if they are less than three months of age these guys are special, they get a ticket to the hospital. So if you ever do get kids in your care, just be aware of that at this age. If they are floppy, so we heard the anaphylaxis guys say that floppy is concerning. Floppy is concerning, full stop, in children. What are children normally like? Bit busy... running around... getting into everything, you know, they're, you know, they're busy. Even a baby, even when they're sleeping so that, you know, six-month-old that nine-month-old when they're sleeping. Sometimes they can do this, but if you startled and what do they do? They're like this aren't they? Well the younger ones, but they will move they will do this. They don't normally just sleep out like starfish and then when you try and pick them up, they stay like that. They don't normally do that. If they are floppy, this is really concerning.
Lethargic, so we expect them to be full of beans, full of energy, but if they are not, if you notice that that child, who is normally you know, your problem kid who, well not problem kid, but the energetic one, okay energetic's a great adjective for children, isn't it? So that child who is normally your energetic child who is just sitting on the carpet and you notice that they've kind of just falling asleep. They're doing these ones. It's a bit of a red flag. You're going, hang on a sec... Is that, is that normal for them? No, so that lethargic child is also concerning. That child who went down at nap time and three hours later is still asleep, when normally they're a 40-minute catnapper... definitely a warning sign.
This is a big one particularly in the in the babies, that they are not having as much fluids as usual. So when I say reduce feeding often mean bottle feeding, and I guess it's being off your food as well. But being off your food is not as concerning. So that younger child in care who has reduced feeds is refusing their bottle, who is just a bit lethargic, they're not right. They're not interested, or you know with the older kids who are just not wanting to drink all, they're just not interested in any of that, that is a red flag. And of course, reduced wet nappies or not going to the toilet as much. So you expect them particularly with the amount of fluids that these kids are drinking that they are going and doing a wee pretty frequently that you expect that heavy wet nappy in the toddler. If it's not, it's a red flag.
Now remember, sometimes these symptoms are just normal, they're lethargic because you know what, they went out with their older sibling trick or treating the night before and they didn't get to bed till 8:30. Normally they're in bed at 6:00. Yeah, they might be a bit sleepy, but look at the whole picture of the child, look at them and see have they got a combination of these things. Is your spidey sense saying this child is not right? Always seek medical help and remembering if the child also has breathing problems, difficulty rousing, they're floppy. All of this is a ticket to an ambulance really really quickly.
The other thing that also concerns us with a fever is if they have a rash in combination with the fever. Now, we went through rashes with Claire, a few of those. She talked about the meningococcal rash, but one thing I would really do want you to take away from today is that if you've got a child you've looked over them and you see a rash like a meningococcal rash start to appear, which is the one that when you press on it, it doesn't go away, they are probably progressed down their illness a fair bit because rash isn't usually the first thing you'll see. You will have a really sick child in front of you who will probably be pale and floppy and lethargic and really quite generally unwell before this rash starts to come out. So don't think that that may be the first sign that you see. You're probably going to see this first. And we want to get them treated before that rash starts to appear.
Sometimes, there are always exceptions to the rule, always, so but it's one of the things to consider. Now, as I said before there is no evidence that high fever in, when I say normal, I mean healthy children, that it causes any damage to the brain at all. So that's one thing that I want us all to remember.
Now I know different services have different policies on giving paracetamol or ibuprofen for fever. And one thing that we really do need to remember is that we don't need to reduce it. It's our body's natural defence mechanism. The only reason that we give drugs like paracetamol or ibuprofen for a fever is to make them feel a bit better. Have you had a fever as a grown-up? How do you feel? You feel like crap don't you? You feel awful. I can remember last time I... well last time my husband had a fever. He thought he was dying, but [laughs] I'll leave it there. I'll leave it there. No, but and I must admit I ended up sick as well. And I did too you know, you hurt, you feel achy, and you want something to make you feel better and often kids will feel the same way.
And so if it is depending on your services policy, then you do, but it is only given for comfort, not to reduce the number or the fever. And remembering that paracetamol, it won't take away the fever completely. So if they've got it fever of you know, 39, a temperature of 39, it mainly reduces it to 38 or so. So therefore, and it will fluctuate too, so don't think, ooooh, I've given them some paracetamol, but they've still got a fever... what I'm going to do? No, that's okay. It's just about making them feel better. They might have a headache. It's going to help with that. So that's the important part... not to reduce the fever.
So what other things can we do to make them feel more comfortable? We can just have them in loose comfortable clothing. So if they've got four jumpers on, let's take a couple of them off. We don't want them shivering though, because what shivering does is our muscles actually then start to produce more heat and we don't want that to happen. And they're uncomfortable. So just loose light clothing. We don't need to be going and putting fans on them, and that kind of stuff... don't need to do that. If you want to, you could pop a little cool face washer in the head if it makes them feel better, but, you know, a lot of the treatment used to be put them in a cold bath, have fans all that kind of stuff. We don't need to do that. Loose cool clothing depending on your policy, paracetamol or ibuprofen for comfort only, but I've seen kids with temperatures of 39, who have been running around, you know, they're you know, not quite the same as usual, maybe a little bit errrr.... and then back to you know back to normal again. But it's really important that we only give it for comfort. Everybody happy with that? Good.
Okay. Febrile convulsions. Can I ask a question? Has anybody ever witnessed a febrile convulsion before? Yeah, a lot. Yeah, absolutely. Did it scare the pants off you? Yeah, absolutely because they look scary don't they and, you know, and they come out of nowhere a lot of the time too, like it's all of a sudden just... whoa... hang on we're just doing Thomas the Tank Engine and now there's... he's having a seizure, what's going on? You don't need to diagnose a febrile convulsion. All you need to be able to do is see that this child is having a seizure and apply seizure first aid.
Unless you've got a repeat offender. Does anybody have repeat offenders? Yeah, so what I mean by that are the children who at the drop of a hat have a febrile convulsion. Their body just thinks about having a fever and they have a febrile convulsion. These children need to have action plans. So you may well have an action plan from this child written by their paediatrician that says if this happens you may have to give certain medications. You may have to do nothing but call the parents and just time it. That's different that is for this particular child.
A child who isn't a repeat offender who simply is having perhaps a one-off febrile convulsion, you don't need to go... ah, febrile. That's all right. I can still go on my break. We're all good. No, even though we'd perhaps don't have to worry so much, it's important that we still do the first aid and the first aid which I know all you guys know, because you do this when you go out and do your 001, your 004, is the same for any seizure. We're going to keep them safe. We're going to remove anything around them that can hurt them. We're going to roll them on their side when we can. You may not be able to do that until the seizure stops. Nothing in their mouth. And of course, if you can, timing how long the seizure goes for. Febrile convulsions, usually last less than five minutes and they usually self-resolve, which is a really good thing.
But what you are going to do is you're going to call the ambulance because you're not going to diagnose that that's a febrile convulsion leave that up to the doctors, paramedics, the nurses, because it could be something else that's causing this seizure, particularly if it is this child's first seizure, we want an ambulance coming. What is really helpful is that if you can actually time that, that is very very helpful.
And of course, you've got to think about the things about the other children in the centre who may have actually witnessed this because it can be really really scary for them. And being able to explain to them that their friends going to be okay. So that's just a little bit of febrile convulsions. But the good news is, is that febrile convulsions, a simple febrile convulsion does not cause any brain damage. The child is not more likely to have epilepsy or anything like that.
However, child who's had one febrile convulsion, then you know what, there is a higher possibility that they're going to have another one and the other thing I want you to remember is that it's not about how high the temperature goes. So if you've got a child who you think, ooh, they've had a febrile convulsion before, they feel a bit warm, I'd better give them some paracetamol or something to try and prevent it. It doesn't actually prevent it.
So what they believe that causes a febrile convulsion is not how high the temperature goes, it's actually a rapid rise in temperature. So what happens is, it has this rapid rise, the brain just goes, whoa, hang on a sec. It has this little kind of, you know, the synapses and stuff just kind of go a bit crazy it's like having a little electrical storm in your head and then it self-resolves. So they could go from 37 to 38 quickly and have a febrile convulsion. They could climb from 37 to 39 or 40 slowly and not have one. So it's about that rapid rise. So that's just a little bit about febrile convulsions and just, I know it's terribly scary, believe me, I've seen a lot of them and especially when it's a child that you're caring for out of the blue, it is really scary but being able to channel that calmness and being able to just go through the motions of the first aid is really really important. So that's a little bit about fever.
So in summary, it's not just about the number, unless they're under three months of age then it is about the number and how they look. Please, it's not about the number it's about looking at the child. If they are, you know miserable, okay, they may just need something just to help them feel a bit better, of course, it's on the phone to the parents, of course, it's getting them picked up but perhaps it's not as urgent. But if they're showing any of those red flags, that's when we need to go, ooh, hang on a sec, parents are coming, they're an hour away, but this needs escalating before then.
So looking out for those red flags, which can indicate that this illness in this child is quite serious. So please being aware of that is very important. So it's not just about the number. It's about looking at the child. Okay, everybody happy with that? We're going to jump completely into a different topic now... completely.
We're going to talk about my favourite subject in the world and you're going to think I'm absolutely bananas about this, but it's choking first aid. I love talking about this, I absolutely love it. Now let's just start off with a little bit of anatomy. So your airway which is basically the tube that goes from your nose and mouth down into your lungs. So you've heard a little bit about airway before today. In us grown-ups, it's like this. So this is just a piece of hose. It's about that diameter and it's reasonably firm. Sorry, I can hear some laughter down here. We're not going to say why... so... now, what happens is, is that it's reasonably firm and you can kink it off but it's not it's not it's a bit harder.
When it comes to kids and babies and newborns' airway, is like this: it's a straw. So that's the diameter of it. It's soft. It's really quite floppy in comparison and it's easily kinked off. A child... so this, so if you imagine that straw size is probably, you know, a newborn to around 6 months... 6 months to a couple of years old is more like this... a few years old. So it's still like basically the diameter of a Maccas straw. So it's really quite narrow still quite floppy easy and it's a different shape to a grown-up one as well.
So if you can imagine this is really quite easy to obstruct. Really quite easy. And so that's why it's so important that we talk about prevention, recognition and response, when it comes to choking. So when it comes to prevention, there's three things that we can do and we can do it well. Now at CPR kids what we always talk about is that we can't wrap our kids up in cotton wool. We need to let them get out and explore the world. They must take risks. They need to fall over and graze their knees and they'll probably break a bone and they need to learn how to chew and eat whole foods. They need to do this. It's so important for their development.
However, there are some things that we know that is really quite risky. And that's why even though I'm saying all of these things that you should be doing that it's about really, we don't want you basically to be going, okay, then we're just going to wrap pad everything. We're not going to let them get out and do stuff. That's not what I'm trying to say to you today. We need to let them get out there and fall over and do stuff. But when it comes to choking there are things that we should be doing.
So the first one is age appropriate foods in particular pieces. So grapes for example, grapes are notorious for getting stuck in children's airways and a lot of a lot of services have policies where the grapes must be cut into quarters, but I know that there are lots of services that don't do this. The grape what it is the shape of it, that's spherical shape, that skin on it is the perfect size to lodge directly in a child's airway. It is the perfect size. So here's a couple of grapes that I produced earlier, you can see that that spherical size, fishing that out of an airway is really really hard. It's really tricky to get that out. It is really really tricky.
So please what I encourage you to do is that in your services make it policy that grapes are always cut into quarters. That things like carrots and sausages, they are the perfect size to actually lodge in a child's airway as well, so anything that is that spherical shape. It is better for the little ones to grab a baton of sausage or a baton of carrot and actually be gnawing on that because yes, they might gag and it slides down and but they'll be out of cough that back out again. So it's those shapes that are perfect to stick in an airway that we need to avoid.
And the important thing to remember is that gagging is completely different to choking. I'm sure all of you have seen kids gag all the time, especially when they're just starting on solids, things like that. Perhaps you've got, you know, nine months old, you know, so on where there's still shoving that spoon down their throat and they gag they cough their eyes get watery, you know, they turn red, they vomit up what they're eating and then they pick it up again and eat it, it's disgusting, but it's normal. That's what you know gagging is fine. It's the natural reflex, choking is different.
Choking is when something is obstructing the airway and we may well need to intervene. So cherry tomatoes, anything of that spherical shape is what we need to be chopping. So remember don't just chop it in half, chop it into quarters or chop it into long bits where they can actually pick it up and gnaw on it and eat it.
We also need to encourage the children to sit down while eating and I know that certainly with experience of going in and teaching a lot of the accredited training that that's policy for you know, so many centres where everybody is on their bottoms and sitting around the table and eating before they do that, but that child who actually picks something up shoves it in their cheek like a hamster to save for later and then runs off, they are at more risk of choking because when you're running around and you're occupied, and then....hic... down it goes, that's what happens. So encouraging them to sit down and the other thing is supervision. And I also know that this is something that is often done incredibly well, incredibly well, but when you have, you can be distracted with another child, you may have to you know, do something that takes your focus away.
We need to be aware that choking can be silent, that there may not be a whole lot of coughing and sputtering, that having your eyeball on these kids and going yep, okay, because it'll be that child who's silent, who's just doing this... at the table who has got a complete airway obstruction and it's just important that we are eyeballing the kids while they're eating, very very important. So cutting up into appropriate age appropriate pieces, sitting them down always and supervising and it's a really good way of choking prevention, and of course thinking about the items that you've got around.
Children don't just choke on food. They can choke on random things. You know, from bouncy balls to puzzle pieces to bread tags to leaves. Leaves can act as a flap over the airway as well because kids developmentally should be shoving everything in their mouths because that's how they learn. However, we need to be aware of what's happening in there. If I had a dollar for every time I've fished something out of my children's mouths that shouldn't have been in there. They do it. It happens. It is normal. We just need to be aware. So that's a bit about prevention.
But what about response? So what do we do when the inevitable actually does happen because it is actually quite common. First of all, we need to understand... are they able to clear it themselves? So what we call a moderate obstruction, so you've got the child who has say, for example, they've got that piece of grape stuck in their airway. However, they've actually chewed it already and so it's mushed up so it's not blocking their whole airway, thank goodness. But what they're doing is, is they're to able to take a big breath in and then they have a big cough out. I just don't want to blast everybody's ears with the microphone on here. So that big breath [breath in] in and [breath out] then you think oh my goodness they're choking quick and you run over to them. And never carry your children like this either it's not good.
So you run over to them, and I bet the first thing you want to do is give them a nice big whack on the back, because isn't that what we want to do when somebody is choking? You want to help them you want to get in there, but if they are actually taking that nice big breath in [breath in] and we whack them on the back what can happen is, is we can actually dislodge that object and they can inhale it further down. So potentially completely blocking off their airway. So if they have what we call that strong effective cough, then we need to encourage them to keep coughing really really hard.
So another story, sorry. It's the children again. But as I said, they've done pretty much everything and suffered from every disease on this planet. So my youngest was eating, you know, those round rice crackers. She grabbed it. She shoved it in her mouth. She looked at me, raised an eyebrow and she ran off because she knew that she was meant to be sitting on her bottom to eat, but she didn't, she was two at the time. So that's what she did. And as I'm, you know, calmly calling her or maybe yelling at her to come and sit back down, what she did was she just stopped, and she did this. And then she went [breath in] and I went, oh she's choking.
But what she was doing is instincts incredible. She was automatically extending her own airway to try and get air in. I thought that was... that's amazing. I look back now and go that's amazing. At the time I didn't, it was like oh... and the first thing I did was I ran over to her and I looked in her mouth, because if that object is right at the front of the mouth and you are able to easily remove it, please by all means do so. So we're talking about those kids who were choking on that piece of sausage that's coming out of their mouth, that they've got that bit of leaf that the bit sticking out there that you can easily remove, by all means do so.
What we are not doing is a big finger sweep right to the back to try and get that out, because what we would do, because the shape of a child's palate is different to ours, we will actually push that object further down. So front of the mouth and easily removed do so. I looked in her mouth and I way, oh, that cracker is right at the back, like I could see this cracker side on 'cos she's like this. And I could see it there, and I thought if I go and try and get that out, I actually will push that further down and I must admit don't judge me for this. I've always thought, I'm a nurse, if my kids choked on something I reckon I'll give it a go and try to get it out and it was like this lightbulb moment. That just went, I can't do that. I will actually push that further down.
So what I did, is I knelt down on the floor next to her. She was leaning on my arm like this and to make me feel like I was doing something, it was just rubbing her in the back going. It's okay. It's alright keep coughing... three big coughs later, cracker comes flying out, lunch comes flying out. She vomits everywhere. She's in tears. I'm in tears and she didn't eat that brand of crackers for about two years afterwards because it was the crackers fault.
So, but that just goes to show that the important thing is, is recognising if the child in your care has a strong effective cough, you simply need to encourage them to keep coughing and be aware that if that coughs stops because the objects move and is blocking off the airway. We need to then move on to the next step. So if they have what we call a severe obstruction, so it's... they're conscious but their cough is ineffective there either [coughs] that's not a lung full of air in or out. Or they're silent, you know, the really scary one that... that's terrifying.
What we're going to do is give back blows and chest thrusts. Now, I know you learn this in your day, that what you have to do, but we're going to go through it again now anyway, because it's really important that we have this at front of mind because we don't want panic taking over, we want that cool calm cucumber who's able to deliver those really good effective back blows. So I'm going to demonstrate on both the baby and the child, and I'm going to get you to demonstrate on your thighs, on your legs. And what I expect is, I expect you to... I don't you to bruise yourself, but I expect it to be really quite uncomfortable. If you're doing back blows and you're fine, it's not uncomfortable, it is not hard enough. Okay, really important.
So this is better done in a chair because that way you won't drop the child on its head, because we don't want to cause a head injury as well. We'll talk about head injury next, by the way, but we want to be able to hold them in a position that's, I mean you can do this standing up and if you do if there's anybody here from OSHC, then often they will be too big for you to put across your lap. So you can simply kneel next to them or stand and lean them across your arm like this so that their feet are still on the ground. So, but I'll demonstrate sitting down because it is much easier.
So let's call this guy Bruce. So Bruce is here. And he is silent. He's choking. The first thing I'm going to do is I'm actually going to lay Bruce across my legs if he's small enough for me to do this. I'm going to hold him in a way that he is not going to fall on his head. So he is being supported on my legs. So ways I could do this, I could potentially hold him around his shoulders. What we are not doing is this... I see this all the time where they'll grab the child around the neck. Don't do that. Yeah. Poor child and if you're quite panicked like that.
So downwards, feet maybe on the floor, feet maybe out and we are going to give up to five back blows between the shoulder blades. So using the heel of our hand, really important between the shoulder blades and it's not [bang] a whack down [bang] [bang]... that actually is just shaking around the air in the lungs. What we want to do is if you can imagine that we want to expel the air in the lungs to force it out behind that object to pop it out. That's what you want to do. So you kind of like a pendulum when you're doing this. So it's a [bang] one check... [bang] two check... [bang] three check... [bang] four check... [bang] five check again. Okay.
Now I've seen children who have had back blows who've ended up with bruises all over their back. I've seen kids who've had back blows who have ended up with the capillaries in their eyes broken because they've been hit so hard. As a parent I know what I'd rather... I'd rather a child who's alive who's object that they were choking on his come out. I'll live with a few bruises. You do what you need to do to get this out. Obviously if it's a very small baby that you're looking after, you know, we're not going to go quite as hard as what we would do on a two-year-old to be completely honest, but we need to do it firmly.
If that doesn't work we are going to turn them over. We're going to support them again and remember they're conscious here. They're aware of what's going on. If we can if they're small enough for them to lay across our leg great. Otherwise, what we can do is that we can actually sit them in a chair to do this to be able to do our chest thrusts, or we can even sit them on our lap and proper hands on their chest. But the one thing that's really important is we are not doing this on their abdomen or their tummy. We are not doing the Heimlich manoeuvre and the reason for that is, is because children have really soft internal organs. We can cause a lot of damage to their internal organs if we are going and doing the Heimlich manoeuvre.
So it's really important that what we do is actually a chest thrust. So I want you to feel it yourself. Can you feel that hard sternum that you've got there? Okay, that's where we want to be. We want to be in the middle of that... go down and feel a little bit lower... squishy, stomach. No good. Okay, too low. Make sure you can feel that hard breastbone underneath. So I've got that hard breastbone. Aiming for the centre of the chest. In a small baby, you would use two fingers, but I don't think that's going to be really applicable for you guys. You're going to be using the heel of your hand. So we're not going to do a run up and just whack them like this like, you know, a Pulp Fiction kind of thing. That's not happening.
We are going to, on that centre of the chest, we're going to give up to five short sharp thrusts. So, one... check.... two... check... three... check.. four... check... five... check... that hasn't helped, we're going back into our back blows [bang] five, five, five, until either the obstruction comes out or they become unconscious and if they become unconscious, what are we going to do? CPR. Doctors ABCD. Now, we don't want to be stuck doing this on our own. So we need to hopefully by now have had an ambulance called and on the way.
What I would encourage you to do is that start your back blows while you are calling for help. Somebody needs to be on that phone calling for an ambulance. We don't want to be stuck doing this by the time you get into your chest thrusts, I want somebody on the phone calling an ambulance. It's really important. Okay? Really important. So I want you to have a practice while I grab my baby and I can show you on the baby as well.
Okay, so if you practice on your leg, so this child here, she's coughing. She's obviously got something stuck in her airway, but she's coughing really quite strongly. What are we going to do? Encourage her to keep coughing. That's right. Great. Okay, good. We're going to watch her really closely. It's okay. Annie keep coughing. Good girl. Ooh, ooh, hang on a sec. Now she's just like... Yep, she's looks like she's completely obstructed actually, what do we do now? Back blows, fantastic, so she's still conscious but it doesn't look like she's just... this isn't good. So we're going to put her over our leg. We're going to hold her so we don't drop her on her head, and I want you to practice your back blows with me on your legs. Okay.
Remember it's not a whack down. It is like this. So one... check... two... check... three... check... four... check... five... check. No not come out. What are we going to do now? Chest thrusts, fantastic. So we turn her over, we hold her. So once again with a bit of gravity helping us here, we are going to use the heel of our hand, where? On her tummy? No, on her chest on the hard breastbone. Okay, good up to 5 chest thrusts one... check... two... check... three... check... four... check... five. Okay, and then back into your back blows again five, five, five, until it comes out or if she's unconscious, what are we going to do? CPR doctors ABCD.
Absolutely and usually this is where we get a question that says am I still going to do breaths on but what happens if they're airways completely obstructed. What's the point of doing breaths? Still do them if you are willing and able to you never know what you might be able to pass by there. You may push it further down. Oooh, might go into one lung, good we got another one. So keep doing your breaths, 30 to 2 as you are taught. Please do that. Okay, really important. And of course, if the obstruction comes out after one back blow you don't need to do all 5. You may feel like it but you don't do it. So not just jokes, just jokes, just jokes.
So no really important that you are, that's why we check in between each one as well because likely it will come out followed by a torrent of vomit and that's okay. So if a child has had a major choking episode they do need to be reviewed in hospital. Really important. So you can see the different positions here. Babies and kids, some guidelines say that you should lay the child on the floor to do their chest thrusts. Good luck trying to lay a choking child on the floor. Can you imagine how panicked you would feel if somebody was trying to make you lay down when you can't breathe? Be terrible, okay.
Do I have some guesses? First one? What's this one here? It's a grape. That is exactly right. That is a grape blocking an airway all these children were okay, by the way, just so you're aware. Okay. What is this one here? Any guesses? Coin, carrot, anything else? Bottle cap. It's two coins. It's a 10-cent and a 20-cent coin. Okay one wasn't enough. Obviously. Yep. And what about this one? What's this one? It's a button battery. It is a button battery.
So button batteries that are in many different types of toys, devices, car keys, musical birthday cards, you name it. They are incredibly dangerous to children. So a button battery that a child may ingest, so just swallow so you may not realise or they may actually choke on it that it can actually burn through a child, and cause significant life-threatening damage within two hours. So button batteries. Keep them completely out of reach. You have them where you lock your poisons. Okay, really important.
So button batteries, they are so dangerous. If a child in your care swallows a button battery you get immediately on to poisons information. Unless they have trouble breathing, then you are calling triple zero, but the first aid is straight onto poisons information, they will give you instructions because depending on timing and where you are, you may get given different instructions. So it's really important 13 11 26 poisons information unless they are choking and having difficulty breathing then of course, it's triple zero and what we've gone through here.
Okay. So, there you go. Right guessing everyone very very good. All right. Now we're going to go straight on to head injury and then we'll have a couple of minutes for questions. So save any questions you have for the moment. So we've done this we've talked about choking but now head bumps. Now I can imagine for the majority of you here. You have cared for a child or had a child in your service who has whacked their head at some stage. I have no doubt about it. I looked after a child once who was actually brought in by a mother and they had been playing on a on an oval she said there was not even a tree on this in about a hundred-meter radius there was one pole and he ran into it. It attracts them. It really does.
So that's why things are actually really quite easy when it comes to head injury about knowing whether or not you need to call for help or not because let's talk about prevention first though, because we are talking about prevention recognition response. So prevention always. Safety helmets. So what I do see a lot of is even having you know little kids on scooters or even the you know those little I don't even know what they are those little bike things that all you need to do is wiggle around a little bit and they... pardon? Balance bikes. Yep, all of that kind of stuff that, they're little they don't go that fast they don't need to wear a helmet just put the bigger kids in a helmet no.
No helmet, no wheels. Absolutely not, because even a little little ones and I know you guys know this they can, it doesn't even matter how fast they go because you end up with a head injury. If I fell and hit the ground here, I could have a head injury but velocity they can get fast. Please always remember no wheels if there is no helmet. It's that simple. Also thinking about if you do have helmets and wheeled stuff in your services which I think is brilliant for kids, so please don't think I'm saying don't have them. I think they're amazing. The kids who wear the helmet that's the wrong size and it sits up here and all this is exposed may as well not be wearing a helmet. Okay, so make sure that the helmet actually does fit properly and come down because this is the impact zone here, you know, especially toddlers, impact zone here, here and here. Because let's face it their heads are massive. No offense to the children, but their heads are a third the size of their body aren't they? I mean really, it's sometimes I'm astounded that we make it through toddlerhood, but we're designed for impact.
So the impact zones here here and here so that helmet that is not fitting well that's sitting back here and you know, they've got the helmet on but when they fall headfirst and they hit and they impact right here that helmet then may as well have not been wearing it. So make sure it fits well. If you have you know, for example, if you're in family day care and you are taking the kids around you've got the car seat, you know, I know my daughters used to go off in the bus that would come around to all the family day cares and then take the kids around, making sure that it is the correct car seat for their age and fitted well. Same thing as well making sure that the maintenance on any pram and high chair seats that the straps are effective and working well and that they are always used correctly is really important because if I had once again if I had a dollar for every child has looked at who has actually fallen out of a pram or a highchair, it's extraordinary.
So adult supervision and also thinking about things like windows, balconies and heavy items. I know that you've probably got all of that sorted but just thinking about maintenance on these things is also really important. And I've seen children who have just even though they know they're not allowed to do this, they climb up onto that bookshelf and their body weight with their friends they end up with that bookshelf on top of them. So what needs to be secured to the walls. And of course making sure that everybody who's coming in and out is shutting that stair gate properly.
So, often what we see is that all these things are implemented but it's sometimes that they're not checked and it's the maintenance that causes the issues. So that's what we need to make sure regularly checked. So first aid for a head injury. Now what do you often see when a child hits their head? What's kind of the first thing that you expect them to do? Cry, yes, good great. If they cry, that is awesome. We want them to cry and the louder they cry the better it is. Why? Because the crying child is conscious, and they can breathe so really important, that is fantastic the louder they cry the better it is.
That quiet child worries me. That child who has hit their head and is silent, that child who has had a loss of consciousness gets triple zero straight away because even a five second loss of consciousness in a child is significant. Okay, so unconscious, ambulance to hospital, even if they wake up and they seem okay, we need to have them seen. So we are going to go over to them, try and calm them down and assess injuries they have. Try and keep them calm and still but we're not going to force them down. We're going to let them find a position of comfort. If they have got a bleeding wound, we're going to apply firm direct pressure. Firm direct pressure for 10 minutes with something clean and dry putting pressure directly over the spot. We don't get a towel and just put the towel on because all that towel is going to do is just mop up the blood and absorb the blood. We need firm direct pinpoint pressure over that wound and they're going to get cranky.
So get your distraction kit out. Because a first aid kit is important, a distraction kit is just as important and this is stuff that they don't normally get to see this is special stuff that only bring out when they have an injury. If it is part of your policy to give pain relief, please do so. This can be extremely painful and apply a cold pack if they will tolerate it. So we need to look for concerning signs. And this is the biggest thing I want you to take away from this head injury sections. I've just got to a couple of minutes left, is when do you need? Oh, hang up. There you go. Is that better? There you go.
Now all of what will be available in the resources as well is that we've got an e-guide of all these subjects and you'll be able to see all of this on there. Okay. So what we are going to worry about if they fall from a significant height or speed, so if that child who has, you know, climbed up onto the table, for me if I fell off here, that's probably not quite as significant, but if that child is only as tall as the table, that's that's their height that they're falling off that's significant in a child.
So thinking about that but remembering don't discount that child who's just fallen over their shoelaces. Okay. Don't think oh they were just standing up. It's okay. You still need to look at them too. If they have had an unconscious episode or they have a seizure, triple zero. On the phone straight away. If they don't return to their normal selves after a quick cuddle consolation and then off they go and they're happy again, if their behaviour is not normal, that is a red flag.
What we expect is for them to get straight back into what they were doing. They're busy. They don't have time for a cold pack on their head. Thank you very much. I've got books to read and I've got stuff to do. Thank you very much. You know, that's what we expect if they are different to normal, that is a red flag. If they are complaining if their head hurting and they won't say headache. They might just be touching and feeling or they're miserable or they're doing this... that is a red flag.
If they have, and this is the avocado analogy, this is, you're going to be, so that thing that you go home and tell, you know your family at the end of the day you're going to say this lady, she talked about guacamole with head injuries. So what we talk about is a boggy swelling on the head so, you know, how kids when they smack their heads they end up with a nice big lump like that... feel it. It should feel like an avocado that's almost ready for your salad. So reasonably firm. Okay, if it feels like an avocado that you go, woah... guacamole only there's no way that's going on my sandwich, guacamole only, so that feels boggy and squishy, that can indicate that there may be a fracture or significant bleeding underneath there. That is a big red flag. Okay, so that boggy swelling.
Clear fluid or blood from nose ears, I'm not talking just a nosebleed but talking that child who's really hit their head and has clear fluid that can mean that they have a fracture. Unusual behaviour and vomiting after their injury. So something, you know, you have kids who just cry and then they spew. Okay fine, then they're back to normal afterwards. But if they've had that head injury they vomit and then they may have another vomit or a delayed vomit. That is a red flag. Okay, vomiting after head injury. And that is pretty much head injury. It's cut and dried.
So they will either be normal with a bit of a bump on their head, of course, you're documenting everything and importantly the exact mechanism of the incident exactly what happened because if these symptoms start 24 hours later, then parents need to know this because sometimes it can be delayed. So that's why it's so important, even if it doesn't seem significant at the time, we need to make sure that they know because I've seen lots of kids who have very delayed presentations up to 48 hours later because they've had a very slow bleed something like that. So that's why your documentation is so important and letting the parents know.
So that is everything for today. Now we've also got some information on burns which will be on the downloadable resources for you too. And I hope you have enjoyed this and I hope you never need to use any of the information that you have been given today. Okay?
Resources and websites
- The CPR Kids First Aid e-Guide (PDF, 1.5MB)
- CPR Kids – DRSABCD Poster (PDF, 714KB)
- CPR Kids – Additional slides on burns (PDF, 450KB)
Video topics overview
- 03:08 – Fever: recognising and responding to a sick child
- 27:18 – Choking prevention and first aid demonstration
- 50:45 – Head injury prevention, first aid and concerning signs