Pediatrics CME 2006
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Pediatrics CME 2006

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    Pediatrics CME 2006 Pediatrics CME 2006 Presentation Transcript

    • Pediatrics CME Nick Mark, EMT-C
    • Outline
      • Background: Pediatrics in EMS
      • General Pediatric Assessment Strategies
      • Pediatric Emergencies
        • Respiratory Emergencies
        • Seizures
      • Scenarios
    • 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
    • Background: Pediatrics in EMS
      • Some common pediatric emergencies include:
        • FBAO
        • Fever
        • Meningitis
        • Respiratory distress
        • Sepsis
        • Seizures
        • SIDS
        • Trauma
    • 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?
    • Pediatric Assessment Techniques
      • Initial Assessment (quick assessment that can be done within seconds of arriving on scene)
        • A ppearance
          • Mental status (alert, crying, obtunded, no response)
          • Muscle tone (moving, not moving, limp)
        • B reathing
          • Respiratory rate (too fast, too slow, irregular)
          • Respiratory effort (use of accessory muscles, nasal flaring, retractions, grunting)
          • Check breath sounds
        • C irculation
          • Skin color (pallor, peripheral cyanosis, central cyanosis)
          • Capillary Refill (normal is within 2 seconds)
          • Pulse (too fast, too slow, irregular, normal)
    • 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?
    • 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?
    • 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.
    • 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)
    • 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
    • Respiratory Emergencies
    • 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
    • Respiratory Emergencies
      • Many different etiologies
        • Choking (FBAO)
        • Epiglottitis
        • Croup
        • Asthma
        • Bronchiolitis
        • Which of these is most common? Which is most serious?
    • 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?
    • 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.
    • 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.
    • 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.
    • 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
    • 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 O 2 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.
    • 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
    • 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 O 2 .
    • Respiratory Emergencies – Epiglottitis vs. Croup
      • Croup
      • 6 months – 3 years
      • Slow onset
      • Barking cough
      • No drooling
      • Low grade fever (<104 °F )
      • Responds well to tx
      • Moderately serious
      • Epiglottitis
      • 3 – 7 years
      • Rapid onset
      • No barking cough
      • Copious drooling
      • High fever (>104 °F)
      • Very Serious
    • 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)
    • 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?
    • 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?
    • 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.
    • 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 β -agonists (EPI, ALBUTEROL)
    • Respiratory Emergencies – Asthma vs. Bronchiolitis
      • Asthma
      • Occurs in all ages, more common in children > 2 YO
      • Occurs throughout the year
      • Family hx of asthma
      • Responds well to β -agonists (EPI and ALBUTEROL)
      • Bronchiolitis
      • Usually occurs in children under 2 YO
      • Most common in winter, spring
      • No family hx
      • Does NOT respond well to EPI/ALBUTEROL
    • 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.
    • Seizures
    • 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?
    • 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
    • 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.
    • Pediatric Seizures
      • Recognition
        • Seizure phase: unresponsiveness, involuntary skeletal muscle contractions, dyspnea, apnea
        • Postictal phase: confusion, altered LOC, retrograde amnesia
    • 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
    • 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?
    • 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.
    • 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.
    • Scenarios