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  • 1. Pediatrics CME Nick Mark, EMT-C
  • 2. Outline • Background: Pediatrics in EMS • General Pediatric Assessment Strategies • Pediatric Emergencies – Respiratory Emergencies – Seizures • Scenarios
  • 3. Background: Pediatrics in EMS • Pediatrics constitute over 50% of ER visits but only about 5% of EMS calls are for pediatric patients. – Why is this? • This has two consequences: – EMS providers have few opportunities to practice working with pediatric patients – The few calls we do get for pediatric patients tend to be more serious
  • 4. Background: Pediatrics in EMS • Some common pediatric emergencies include: – FBAO – Fever – Meningitis – Respiratory distress – Sepsis – Seizures – SIDS – Trauma
  • 5. Pediatric Age Groups • • • • • • Newborn (first 6 hours) Neonate (first 28 days) Infant (first year) Toddler (1 to 3 years) Preschooler (3 to 5 years) School age (6 to 12 years) • Adolescent (12 to adulthood) How much does a child weigh at each age?
  • 6. Pediatric Assessment Techniques • Initial Assessment (quick assessment that can be done within seconds of arriving on scene) – Appearance • Mental status (alert, crying, obtunded, no response) • Muscle tone (moving, not moving, limp) – Breathing • Respiratory rate (too fast, too slow, irregular) • Respiratory effort (use of accessory muscles, nasal flaring, retractions, grunting) • Check breath sounds – Circulation • Skin color (pallor, peripheral cyanosis, central cyanosis) • Capillary Refill (normal is within 2 seconds) • Pulse (too fast, too slow, irregular, normal)
  • 7. Pediatric Assessment Techniques • Detailed assessment – With adults this is typically done head to toe, with pediatrics it is better to do the opposite • Why? – Take a SAMPLE history (use the parents for detailed hx if possible) – Determine • Hx of fever or infection • Hx of vomitting or fever and check hydration status (skin turgor, check fontanalles in infants, look for xerosis) • Frequency of urination – Why are these important questions to ask? – Take vitals and measure pulse oximetry • How is pulse oximetry different in pediatrics than in adults?
  • 8. Pediatric Assessment Techniques • Detailed assessment (cont.) – Try to invent a game you can play or begin a conversation about something you can talk about for at least several minutes (Batman, Sesame Street, toys, school, etc.). – Explain each step in your assessment (“now I’m going to feel your tummy…”). – With older patients explain why you are doing each step (“I need to make sure your stomach is OK”). – With younger patients, avoid separating them from their parents if possible. • Why?
  • 9. Pediatric Assessment Techniques • Detailed assessment (cont.) – Explain things as simply as possible avoiding technical terminology and jargon. – Do NOT condescend. – Do NOT lie or make promises you cannot be sure to keep. – Be alert for injuries that seem inconsistent with their explanation – this is usually a sign of child abuse. • Examples? – If you suspect child abuse, you must report it by calling 1-800-RICHILD.
  • 10. Normal Vital Signs by Age • In general remember as children age their pulse and breathing rates get slower, and their BP gets higher. • By adolescence these values approach those of adults. • Two general rules (for children 1-10): – Weight in kg = 2 x age (in years) + 8 – Lowest permissible systolic BP = 70 + 2 x age (in years)
  • 11. Normal Vital Signs by Age Age Breaths/Min Beats/Min Minimum Systolic BP Neonate 30-50 120-160 60 Infant 20-30 80-140 70 Toddler 20-30 80-130 74-76 Preschool 20-30 80-120 76-80 School Age 12-30 60-100 80-84 Adolescent 10-20 60-100 84-90
  • 12. Respiratory Emergencies
  • 13. Respiratory Emergencies • Respiratory distress is the leading cause of ER visits and EMS calls for children • Respiratory compromise is one of the leading causes of death in children – What is the leading cause of death in children? • Respiratory emergencies can effect children of all ages • EMS intervention can be life-saving
  • 14. Respiratory Emergencies • Many different etiologies – Choking (FBAO) – Epiglottitis – Croup – Asthma – Bronchiolitis – Which of these is most common? Which is most serious?
  • 15. The Pediatric Airway • Several key differences between adult and pediatric airway – Larger floppier epiglottis • Epiglottitis • More difficult intubations – Smaller, funnel shaped trachea • FBAO is more likely • No blind finger sweeps • Why?
  • 16. Respiratory Emergencies - FBAO • Foreign Body Airway Obstruction (FBAO) – Usual causes are hard candy, nuts, small toys, coins, and balloons • Recognition – Apnea, inspiratory stridor, rales, rhonchi, wheezing, inability to speak, anxiety, decreased breath sounds, muffled voice • Treatment – If the patient is not breathing, open the airway and perform the AHA approved maneuvers for clearing the obstruction • Heimlich, backblows, abdominal or chest compressions. • If properly trained you may use a laryngoscope with Magills forceps to try and remove the obstruction. – If patient is breathing, be as calming and supportive as possible. Do not agitate the patient and transport sitting up as comfortably as possible. Be alert for change in status.
  • 17. Respiratory Emergencies - FBAO • Treatment (cont.) – If patient is not breathing ventilate using a BVM. – Administer oxygen at 15 LPM by NRB. – If patient is wheezing • Contact Medical Control for permission to administer ALBUTEROL 2.5 mg (0.083%) by nebulizer over 5-10 minutes. – For infants younger than 6 months use half the dose.
  • 18. Respiratory Emergencies – Epiglottitis • Inflammation of the epiglottis and surrounding structures caused by bacterial infection. • This condition is a true emergency with mortality rates as high as 10%. • Typically occurs in children 3-7 years old.
  • 19. Respiratory Emergencies – Epiglottitis • Recognition – Rapid onset (6-8 hours) of sore throat, dysphagia, muffled voice, high fever, drooling, inspiratory stridor or rattle – Child is often found obtunded in tripod position – Signs of respiratory distress are often present
  • 20. Respiratory Emergencies – Epiglottitis • Treatment – It is absolutely essential that the patient be handled as calmly as possible. Anxiety or aggravation can cause increased swelling and precipitate respiratory arrest. • Defer all painful procedures. • Transport patient sitting up in position of comfort. • Do not try to visualize the swelling or look in the mouth. – Administer high flow humidified O2 by NRB. – Administer 5 ml of EPINEPHRINE 1:1,000 by nebulizer. This can reduce upper airway swelling. – Have airway equipment (BVM, ET equip) ready in case patient’s condition deteriorates. – Inform medical control early so preparations can be made at hospital for treatment.
  • 21. Respiratory Emergencies – Croup • Inflammation of the upper airways caused by a viral infection. • Very common (50 per 1000 children) • Usually occurs in children aged 6 months to 3 years. (median age of onset is 18 months). Sites of inflammation in pediatric airway infections
  • 22. Respiratory Emergencies – Croup • Recognition – Low grade fever, barking cough, hoarseness, inspiratory stridor, wheezing – Signs of respiratory distress – Often occurs at night • Treatment – Same as for epiglottitis. – The patient is likely to respond well to cool humidified O2.
  • 23. Respiratory Emergencies – Epiglottitis vs. Croup • • • • • • Croup 6 months – 3 years Slow onset Barking cough No drooling Low grade fever (<104°F) • • • • • • Epiglottitis 3 – 7 years Rapid onset No barking cough Copious drooling High fever (>104°F) • Responds well to tx • Moderately serious • Very Serious
  • 24. Respiratory Emergencies – Asthma • In contrast to croup & epiglottitis, asthma is inflammation of the lower airways. • It is very common (effects 50-100 out of 1000 children under 10 YO)
  • 25. Respiratory Emergencies – Asthma • Recognition – Typically it is either exercise, allergy, or infection induced – S/Sx include wheezing, prolonged expiration, tachypnea, dyspnea, and anxiety – A silent chest is an especially bad sign. • Why?
  • 26. Respiratory Emergencies – Asthma • Treatment – Administer cool humidified oxygen. – Provide ventilations if breathing is inadequate. – Contact Medical Control for permission to administer ALBUTEROL 2.5 mg (0.083%) by nebulizer over 5-10 minutes. • For infants younger than 6 months use half the dose. – If patient has severe respiratory distress, administer EPINEPHRINE 1:1,000 0.01 mg/kg SQ. • Maximum dose is – 0.3 mg in pt. > 20 kg – 0.2 mg in pt. < 20 kg – 0.1 mg in pt. < 10 kg • For patients with cardiac problems call medical control before administering EPINEPHRINE. • What are some potential problems that EPINEPHRINE and ALBUTEROL can cause? What should you be alert for when giving these drugs?
  • 27. Respiratory Emergencies – Bronchiolitis • Bronchiolitis is a viral inflammation of the lower airways. • It usually effects children under 2 YO. • Usually presents with symptoms similar to those of asthma. • Can be very serious in infants. – Why do you think this is? • More common in the winter months.
  • 28. Respiratory Emergencies – Bronchiolitis • Recognition – Wheezing and tachypnea are most common symptoms. Also anxiety, shortness of breath, and cyanosis. • Treatment – Same as asthma – Patient is not as likely to respond well to βagonists (EPI, ALBUTEROL)
  • 29. Respiratory Emergencies – Asthma vs. Bronchiolitis • Asthma • Occurs in all ages, more common in children > 2 YO • Occurs throughout the year • Family hx of asthma • Bronchiolitis • Usually occurs in children under 2 YO • Responds well to βagonists (EPI and ALBUTEROL) • Does NOT respond well to EPI/ALBUTEROL • Most common in winter, spring • No family hx
  • 30. Respiratory Emergencies General Notes • Treat respiratory emergencies aggressively. Be prepared for patients to decompensate. • Do not hesitate to give neonates oxygen if you suspect they need it. • Remember to treat the parents too.
  • 31. Seizures
  • 32. Pediatric Seizures • A seizure is caused by abnormal electrical activity in the brain. • Seizures can cause impaired consciousness and/or abnormal behavior. • There are many causes of seizures including: – Epilepsy – Infection – Trauma – Neoplasm – Metabolic problems (electrolytes, uremia, hypoxia, acidosis, etc.) – Hypoglycemia – Poisoning – Hyperthermia Which of these causes do you think is most common in children? Which do you think is usually most serious?
  • 33. Pediatric Seizures • Types of pediatric seizures – Grand mal (tonic clonic) – Petit mal (absence) – Partial – Status epilepticus Which type is most common is children? • Stages of a grand-mal – Aura – Tonic-clonic – Postictal
  • 34. Pediatric Seizures - Febrile • Febrile seizures are caused by fever resulting from a viral infection. • Very common (20-50 per 1000) in children under 7 YO. • Most common in children aged 6 months to 5 years. • There is usually a family history. • They are usually benign. – If they are longer than 20 minutes they are probably not febrile and indicate something much more serious.
  • 35. Pediatric Seizures • Recognition – Seizure phase: unresponsiveness, involuntary skeletal muscle contractions, dyspnea, apnea – Postictal phase: confusion, altered LOC, retrograde amnesia
  • 36. Pediatric Seizures • Treatment – Protect the airway • Place patient LLR • Suction to clear vomit • Use airway adjunct and ventilate if patient is apneic – Protect patient from injury
  • 37. Pediatric Seizures • Treatment (cont.) – Take a thorough history of the parents to try and R/O differentials • • • • • Hx of medical problems Medication use Possibility of head injury Recent illness (fever, nucal rigidity, photophobia, phonophobia) Possibility of poisoning – Other important questions • • • • • Did patient vomit during the seizure? Duration of seizure? Description of seizure Condition of child when found Last meal – Why are these important questions to ask?
  • 38. Pediatric Seizures • Treatment – Manage the airway and provide oxygen – If patient is febrile (temp > 102°F) administer ACETAMINOPHEN 15 mg/kg rectally. – Check blood glucose using glucometer – If bG is < 60 mg/dl (or if you suspect hypoglycemia) • If patient is awake with intact gag reflex who can swallow, administer ORAL GLUCOSE 15 gm PO. (If pt. is younger than one year, contact medical control.) • For patients without an intact gag reflex, contact medical control and administer GLUCAGON 0.1 mg/kg (max dose 1.0 mg) IM.
  • 39. Pediatric Seizures General Notes • Never assume “it’s just a febrile seizure.” • All patients who have a seizure should be transported for evaluation. • Always consider differential causes especially trauma, hypoglycemia, and OD. • Seizure activity ALWAYS extremely serious in a neonate. • Remember to treat the parents too.
  • 40. Scenarios

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