06 Pediatric Emergencies.doc

  • 714 views
Uploaded on

 

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
No Downloads

Views

Total Views
714
On Slideshare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
65
Comments
0
Likes
1

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. PEDIATRIC EMERGENCIESALS Section F 1
  • 2. INITIAL PEDIATRIC CARE PEDIATRICSNOTE: The pediatric patient is determined by the weight as well as the age. On the average, patients under 14 years of age and less than 90 pounds may fit criteria for pediatric protocol. Consult with Medical Control to determine if a patient should be treated under pediatric or adult protocols.CRITERIA: 1. Any patient under 14 years of age and 90 pounds, who presents with a medical or traumatic problem.TREATMENT: 1. Assess ABC’s; perform advanced airway control measures as needed. 2. Administer OXYGEN by one of the following methods: a. If altered LOC or respiratory distress, administer OXYGEN at 8 – 15 Lpm by non-rebreather, if tolerated. b. If patient is stable, administer OXYGEN at 2 – 6 Lpm by nasal cannula. c. If unable to administer by mask or nasal cannula, administer OXYGEN at 8 – 15 Lpm by blow-by method. 3. Complete initial assessment and obtain SAMPLE history. 4. Repeat assessment every 5 minutes for unstable patients, and every 15 minutes for stable patients. 5. Apply pulse oximeter if available; attempt to maintain pulse oximetry > 97% 6. Consider blood sugar determination. 7. Keep patient warm during transport. 8. Perform detailed secondary assessment (usually enroute to receiving facility) and provide care for any additional conditions or injuries discovered. 9. If patient becomes pulseless and apneic, initiate CPR and refer to Pediatric Arrest protocol. -------------------------------------ALS Section F 2
  • 3. PEDIATRIC COMA SCALE PEDIATRICSIndicator Child Score Infant ScoreEye Opening Spontaneous 4 Spontaneous 4 To verbal stimuli 3 To verbal stimuli 3 To pain only 2 To pain only 2 No response 1 No response 1Verbal Response Oriented, appropriate 5 Coos and babbles 5 Confused 4 Irritable cries 4 Inappropriate 3 Cries to pain 3 Incomprehensible 2 Moans to pain 2 No response 1 No response 1Motor Response* Obeys commands 6 Moves spontaneously 6 Localizes pain 5 Withdraws to touch 5 Withdraws from pain 4 Withdraws to pain 4 Flexion to pain 3 Decorticate posturing 3 Extension to pain 2 Decerebrate posturing 2 No response 1 No response 1 Total PCS: _____*If the patient is intubated, unconscious or preverbal, the most important part ofthis score is motor response. This section should be carefully evaluated.ALS Section F 3
  • 4. ABUSE AND NEGLECT PEDIATRICSNOTE: Illinois Civil Statute 50/3.230 requires all licensed EMS providers to report suspected cases of child abuse or neglect in accordance with the requirements of the Abused and Neglected Child Reporting Act.CRITERIA: Any may be present1. A discrepancy exists between history of injury and physical exam.2. Caregiver provides a changing or inconsistent history.3. A prolonged interval exists between injury and request for medical attention.4. Child has a history of repeated trauma.5. Caregiver responds inappropriately or does not comply with medical advice.6. Suspicious injuries are present: a. Long bone fractures b. Old scars, bruises or burns; especially cigarette burns. c. Rope or belt marks d. Genital or perineal trauma e. Sharply demarcated burns or scalds7. Child < 10 left abandoned or unattended.8. Caregiver incapacitation from drugs, alcohol or disability.9. Child found inadequately fed, sheltered or clothed.10. Child is found intoxicated from drugs or alcohol.11. Child found in a dangerous environment12. Caregiver not providing or refuses medical care.TREATMENT: 1. Initial Pediatric Care. 2. Treat obvious injuries per appropriate trauma protocol. 3. Note discrepancies in child and parent history, environment and interaction. 4. If parent or caregiver refuses treatment or transport, summon law enforcement assistance to place child in protective custody. 5. Contact Medical Control. 6. Report suspicions to ED physician/nurse, and DCFS (1-800-25-ABUSE) ---------------------------------------ALS Section F 4
  • 5. AIRWAY CARE PEDIATRICSCRITERIA: Any may be present1. Pediatric partial or full foreign body airway obstruction2. Signs and symptoms of epiglottitis3. Pediatric tracheostomyTREATMENT:1. Initial Pediatric Care.2. Airway and OXYGEN at 8 – 15 Lpm by non-rebreather; Assist ventilations as needed.3. Apply pulse oximeter, if available.4. If partial or complete airway obstruction: a. Encourage patient to cough; reposition airway. b. Perform chest compressions, abdominal thrusts or back blows as appropriate to patient’s age. c. Perform direct laryngoscopy and remove foreign body with Magill forceps if needed.5. If patient presents with stridor, or signs of epiglottitis: a. Keep patient stimulation to a minimum. b. Place child upright in position of comfort. c. Administer OXYGEN at 8 – 15 Lpm blow-by d. Refer to epiglottitis protocol.6. If pediatric tracheostomy: a. Apply OXYGEN by tracheostomy collar or mask. b. Suction as necessary. c. If tracheostomy is obstructed, remove inner cannula and have caregiver replace tracheostomy tube, or insert appropriately sized ET tube into stoma. 7. Transport patient in position of comfort. 8. Contact Medical Control. ---------------------------------------ALS Section F 5
  • 6. ALLERGIC REACTIONANAPHYLAXIS PEDIATRICSCRITERIA:1. History of recent exposure to allergen2. Serious signs and symptoms, including: a. Skin flushing, itching, swelling or hives b. Respiratory difficulty c. Tachycardia d. Decreased SBP e. Dizziness, headache or convulsions. f. Nausea, vomiting, abdominal cramping or diarrhea.TREATMENT: 1. Initial Pediatric Care. 2. Airway and OXYGEN at 15 Lpm by non-rebreather, 3. Assist ventilations as needed; attempt to maintain pulse oximetry > 97%. 4. Perform advanced airway control measures as needed. 5. If local reaction, apply ice pack to site and transport. 6. If mild respiratory distress exists: a. Administer EPINEPHRINE (1:1000) 0.01 cc/kg SQ; maximum 0.3 cc per dose. b. Repeat EPINEPHRINE (1:1000) 0.01 cc/kg SQ q 15 minutes as needed. c. Consider ALBUTEROL 2.5 mg in 3 ml NS nebulizer treatment for wheezing. 7. If severe cardiorespiratory compromise exists: a. Administer EPINEPHRINE (1:1000) 0.01 cc/kg SQ q 15 minutes. b. Administer ALBUTEROL 2.5 mg in 3 ml NS nebulizer treatment for wheezing. c. IV or IO of NS at KVO; consider 20 mL/kg fluid bolus as needed to a total of 60 mL/kg. d. Consider EPINEPHRINE (1:10,000) 0.01 cc/kg IV/IO. Repeat q 5 minutes as needed. e. Consider BENADRYL 1 mg/kg slow IV/IO push. 8. Monitor and transport. 9. Contact Medical Control. ---------------------------------------ALS Section F 6
  • 7. ALTERED LOC PEDIATRICSNOTE: DEXTROSE 50% may be administered at 1 mL/kg for patients over 8 years of age instead of DEXTROSE 25% at 2 mL/kg.CRITERIA: 1. Patient < 14 years old and < 90 pounds. 2. Altered level of consciousness.EXCLUSION: 1. Signs and symptoms of shock – see shock protocol 2. Respiratory distress – see respiratory emergencies protocolTREATMENT: 1. Initial Pediatric Care. 2. Airway and OXYGEN at 15 Lpm by non-rebreather, or BVM as needed. 3. IV or IO of NS at KVO. 4. If blood glucose < 60 mg/dL, administer DEXTROSE 25% at 2 mL/kg (see note above); if IV/IO access is not available, administer GLUCAGON 0.03 mg/kg IM, up to a maximum of 1 mg. 5. If patient is conscious and can maintain gag reflex, administer ORAL GLUCOSE. 6. Monitor. 7. If inadequate respiratory effort, consider NARCAN 0.1 mg/kg IV/IO/SQ/IM to a maximum dosage of 2 mg. 8. Contact Medical Control. ---------------------------------------ALS Section F 7
  • 8. ASYSTOLE PEDIATRICSCRITERIA: 1. Pulseless, apneic pediatric patient. 2. Asystole confirmed in 2 leads.TREATMENT: 1. Quick look cardiac monitor. 2. Confirm Asystole in 2 leads. 3. Airway and CPR; perform advanced airway control measures, as needed. 4. Hyperventilate with 100% OXYGEN. 5. IV or IO of NS; consider fluid bolus 20 mL/kg, repeat as needed to a total of 60 mL/kg. 6. EPINEPHRINE (1;10,000) 0.1 cc/kg IV/IO, or EPINEPHRINE (1:1000) 0.1 cc/kg ET. 7. EPINEPHRINE (1:1000) 0.1 cc/kg IV/IO/ET q 3-5 minutes as needed for pulselessness. 8. ATROPINE 0.02 mg/kg IV/IO if bradycardia exists for age range (see bradycardia protocol): a. Minimum dosage 0.1 mg. b. Maximum dosage 0.5 mg for child < 6 years old. c. Maximum dosage 1.0 mg for child > 6 years old. 9. Consider EXTERNAL PACER. 10. If blood sugar < 60 mg/dL, administer DEXTROSE 25% at 2 mL/kg for children under 8; may administer DEXTROSE 50% at 1 mL/kg for children over age 8. 11. Transport and maintain warmth. 12. Consider specific therapy as indicated for treatable causes: a. Severe hypoxemia – Hyperventilation. b. Severe acidosis – SODIUM BICARBONATE 1 mEq/kg IV/IO (should be reserved for unobserved arrests, or resuscitations > 10 minutes). c. Severe hypovolemia – Fluid challenge. d. Tension pneumothorax – Chest decompression. e. Cardiac tamponade – Rapid transport; prepare for pericardiocentesis. f. Profound hypothermia – Passive rewarming; rapid transport. 13. Contact Medical Control. --------------------------------------- Revised: July 2006ALS Section F 8
  • 9. BRADYCARDIA PEDIATRICSCRITERIA: 1. Absolute bradycardia, including: a. HR < 100 in newborn b. HR < 90 for 1 month to 1 year old c. HR < 80 for 1 year to 3 year old d. HR < 70 for 3 year old to 6 year old e. HR < 60 above 6 years old 2. Serious signs and symptoms, including: a. Cyanosis despite OXYGEN administration b. Truncal pallor and coolness c. Respiratory distress d. Hypotension e. Altered LOC f. Weak, thready or absent peripheral pulsesTREATMENT: 1. Initial Pediatric Care. 2. Airway and OXYGEN at 8 – 15 Lpm by non-rebreather. 3. Assist respirations and hyperventilate with 100% OXYGEN, if: a. Respiratory rate < 40 in newborn. b. Respiratory rate < 25 in 1 month to 6 month old. c. Respiratory rate < 20 in 6 month to 6 year old. 4. Apply pulse oximeter if available. 5. If patient shows signs of severe cardiorespiratory compromise, despite oxygenation and airway support: a. Perform chest compressions for HR < 60 in infant or child with poor systemic perfusion. b. IV or IO of NS; consider fluid bolus of 20 mL/kg to a total of 60 mL/kg. c. Administer ATROPINE 0.02 mg/kg IV/IO. i. Minimum dosage 0.1 mg. ii. Maximum dosage 0.5 mg for child < 6 years old. iii. Maximum dosage 1.0 mg for child > 6 years old. iv. ATROPINE may be repeated once, if needed. d. Consider EXTERNAL PACER if continued severe compromise. e. Consider EPINEPHRINE (1:10,000) 0.1 cc/kg IV/IO; may repeat q 3-5 minutes as necessary. 6. If blood glucose < 60 mg/dL, administer DEXTROSE 25% 2 mL/kg for children under 8; administer DEXTROSE 50% 1 mL/kg for children > 8. 7. Transport and maintain warmth. 8. Contact Medical Control.ALS Section F 9
  • 10. BURNS PEDIATRICS NOTE: Use palm of child’s hand to represent 1% of body surface area. All burns in pediatric patients should be assessed for abuse potential.CRITERIA: 1. Patient < 14 years old and < 90 pounds, with: a. Inhalation injury b. Electrical injury c. Significant full or partial thickness burn d. Chemical exposureTREATMENT: 1. Assure rescuer safety; remove patient from source of burn. 2. Initial Pediatric Care. 3. Secure airway and provide 100% OXYGEN by BVM or non-rebreather. 4. Apply pulse oximeter if available. 5. If patient presents with respiratory or traumatic emergency, refer to appropriate protocol. 6. Assess and treat burn according to type: a. THERMAL BURNS – 1st degree i. Assess percentage and depth of burn ii. Cool with water or saline. iii. If < 20% BSA involved, apply sterile saline soaked dressings. b. THERMAL BURNS – 2nd and 3rd degree i. Wear sterile gloves and mask. ii. Cover burns with DRY sterile dressings. iii. Place patient on clean sheet and cover with dry clean sheets. c. ELECTRICAL BURNS i. Immobilize as indicated. ii. Apply cardiac monitor and treat any dysrhythmia. iii. Identify and document entrance and exit wounds. iv. Assess neurovascular status of affected part. d. CHEMICAL BURNS i. Brush away any powdered chemical prior to flushing. ii. Remove affected clothing if possible. iii. If eye involvement, irrigate immediately and continuously during transport with sterile saline. (Do not contaminate uninjured eye) 7. IV/IO of LR as indicated; treat for shock as needed. 8. Consider MORPHINE SULFATE 0.1 mg/kg (max. dose 5mg) as needed for pain control. May repeat x 1 after 15 minutes as needed. 9. Transport and maintain warmth. 10. Contact Medical Control. ---------------------------------------Revised: July 2006ALS Section F 10
  • 11. ENVIRONMENTALHYPERTHERMIA PEDIATRICSCRITERIA: 1. Patient < 14 years of age and < 90 pounds. 2. Signs and symptoms of environmental hyperthermia, including: a. Hot, dry, flushed or ashen skin b. Tachycardia or tachypnea c. Diaphoresis d. Decreasing LOC e. Profound weakness and fatigue f. Vomiting and diarrhea g. Hypoperfusion h. Muscle crampsTREATMENT: 1. Initial Pediatric Care. 2. Airway and OXYGEN at 8 – 15 Lpm by non-rebreather; perform advanced airway control measures as needed. 3. Apply pulse oximeter if available. 4. Place patient in cool environment and remove clothing as necessary. 5. If normal level of consciousness, diaphoresis and no signs of shock: a. Administer cool liquids PO. b. Consider IV of NS at KVO. 6. If decreased LOC, dry skin or signs of shock: a. IV/IO of NS; Administer fluid bolus 20 mL/kg. b. Repeat fluid bolus as needed to a total of 60 mL/kg. c. Initiate active cooling: i. Apply cold packs to head, neck, axillae and groin. ii. Apply water or saline soaked sheets to patient’s body. iii. Manually fan patient to promote evaporation. iv. Stop cooling if shivering occurs.7 7. Monitor and transport. 8. Contact Medical Control. ---------------------------------------ALS Section F 11
  • 12. EPIGLOTTITIS PEDIATRICSNOTE: Epiglottitis is a serious medical emergency in children, and can be life- threatening. The signs and symptoms of epiglottitis are similar to partial airway obstruction. Do not insert anything into the child’s mouth. Stimulation of the epiglottis can cause complete airway obstruction. If the patient stops breathing, ventilate with BVM, and use oral airways only as a LAST RESORT.CRITERIA: 1. Patient < 14 years old and < 90 pounds. 2. Signs and symptoms of epiglottitis, including: a. Acute onset with high fever b. Shallow, difficult breathing c. Inspiratory stridor and wheezing d. Drooling, hoarseness and chokingTREATMENT: 1. Initial Pediatric Care. 2. Position patient upright; avoid over-stimulation. 3. Administer OXYGEN at 8 – 15 Lpm blow-by; do not use airway adjuncts unless serious airway compromise exists. 4. Rapid and gentle transport. 5. Contact Medical Control. ---------------------------------------ALS Section F 12
  • 13. FROSTBITE PEDIATRICSNOTE: Do not massage frostbitten extremities.CRITERIA: 1. Cold exposure 2. Signs and symptoms of frostbite, including: a. Red, inflamed tissue b. Gray or mottled tissue c. Waxy tissue that is firm upon palpation.TREATMENT: 1. Remove from cold. 2. Initial Pediatric Care. 3. Cover frostbitten nose or ears with a warm hand. 4. Have patient place frostbitten hand in his/her armpit. 5. Transport immediately. 6. Contact Medical Control. --------------------------------------- 7. If ETA is greater than 60 minutes, begin active rewarming: a. Immerse extremity in water maintained at a temperature of 100-105 F. b. Rewarming should take 30-60 minutes. c. Rewarming is complete when frozen area is warm to touch and deep red or bluish in color. d. After rewarming, dry gently and cover part with dry sterile dressing and elevate on pillow.ALS Section F 13
  • 14. HYPOTHERMIA(MODERATE) PEDIATRICSCRITERIA: 1. Exposure to cold environment 2. Signs and symptoms of moderate hypothermia, including: a. Rectal temp 84-94 F b. Patient conscious - may be lethargic c. Shivering d. Pale, cold skinTREATMENT: 1. Initial Pediatric Care. 2. OXYGEN (humidified) at 15 Lpm by non-rebreather. 3. Handle patient gently; DO NOT massage cold extremities. 4. Replace any wet clothing with dry sheets and blankets. 5. If no cardiorespiratory compromise, heat packs may be applied to axillae, groin and abdominal areas. 6. Monitor. 7. IV/IO of NS; Perform fluid bolus 20 mL/kg; repeat to a total of 60 ml/kg as needed. 8. May repeat fluid bolus as long as lungs remain clear. 9. Assess and treat for other injuries as necessary. 10. Contact Medical Control. ---------------------------------------ALS Section F 14
  • 15. HYPOTHERMIA(SEVERE) PEDIATRICSNOTE: Once CPR has begun on a hypothermic patient, it should continue until the patient is evaluated by an Emergency Department physician.CRITERIA: 1. Patient < 14 years old and < 90 pounds 2. Signs and symptoms of severe hypothermia, including: a. Complains of being cold b. Shivering c. Decreased LOC d. Cyanosis despite oxygen administration e. Increase or decreased respiratory rate f. Dysrhythmias g. Weak, thready or absent peripheral pulses h. Truncal cyanosis and coolness i. Dilated, sluggish pupils j. Decreased reflexes k. Condition may mimic death (Unconsciousness, ice cold skin, rigid muscles, absent pulses and unreactive pupils)TREATMENT: 1. Load and go situation; limit scene time to 10 minutes maximum. 2. Initial Pediatric Care. 3. OXYGEN (humidified) at 15 Lpm by non-rebreather or BVM as necessary. 4. Establish airway WITHOUT using mechanical adjuncts; Assist ventilations if patient is apneic. DO NOT HYPERVENTILATE. 5. Handle patient gently; DO NOT massage cold extremities. 6. Remove patient to warm environment; remove any wet or cold clothing and replace with dry blankets. 7. If no cardiorespiratory compromise, apply heat packs to axillae and groin; avoid direct skin contact. 8. If cardiorespiratory compromise: a. Cardiac monitor b. Perform chest compressions for asystole and V-fib only. c. Establish IV/IO of NS at KVO; A fluid bolus of 20 mL/kg should be the first measure to treat low BP. May repeat bolus as needed to maximum of 60 mL/kg. Hot packs should be placed around the IV fluids. d. Refer to appropriate pediatric arrest protocol as indicated. e. EPINEPHRINE and ATROPINE should be limited to one round only. f. Limit countershocks to THREE total. g. Place heat packs to axillae and groin; avoid direct skin contact. 9. Transport 10. Contact Medical Control. ---------------------------------------Revised: July 2008ALS Section F 15
  • 16. LOAD AND GO SITUATIONS PEDIATRICSNOTE: Activation of the trauma system should occur for a pediatric patient meeting and of these criteria.CRITERIA: Any may be present1. Penetrating injury to the head, neck, chest, abdomen or groin2. Two or more proximal long bone fractures3. Burns > 15% total body surface area; burns of face or airway4. Flail chest segment5. Amputation of extremity6. Paralysis or suspected spinal cord injury7. Evidence of high speed impact, including: a. Falls from 3 times body length of child b. Crash speed greater than 20 mph c. 30” or more of deformity to automobile. d. Passenger compartment intrusion of 18” or more e. Ejection from the vehicle f. Rollover g. Death of occupant in the same vehicle h. Motorcycle accident i. Pedestrian struck at greater than 20 mph8. Revised Trauma Score < 109. Pediatric Coma Scale or GCS < 810. Pediatric multiple trauma11. Extrication time > 20 minutes12. Any traumatic injury and SBP < 80, respiratory distress or altered LOC.TREATMENT: 1. Assure rescuer safety. 2. Initial Pediatric Care; immobilize spine as indicated. 3. Secure and maintain airway with 100% OXYGEN; assist ventilations as needed. 4. Apply pulse oximeter if available. 5. Determine Pediatric Coma Scale: a. Pediatric patient with PCS < 8 should be intubated orally. b. Pediatric patient with PCS 8 – 12 generally require assisted ventilation with BVM and may require intubation. 6. Control external hemorrhage. 7. Transport (maximum 10 minute scene time); Activate trauma system. 8. Cardiac monitor. 9. IV/IO of LR; perform fluid bolus of 20 mL/kg as needed for shock; may repeat as needed to a total of 60 mL/kg. 10. Splint or immobilize secondary injuries as time permits. 11. Contact Medical Control. ---------------------------------------ALS Section F 16
  • 17. NEAR DROWNING PEDIATRICSNOTE: A high potential for associated injury (hypothermia or spinal injury) exists in the near drowning patient. All pediatric patients who experience near drowning must be transported for evaluation and monitoring to prevent Secondary Drowning Syndrome. Aggressive airway management is important. All patients with low core body temperatures should be resuscitated.CRITERIA: 1. Patient < 14 years old and < 90 pounds 2. SubmersionTREATMENT: 1. Assure rescuer safety; remove patient from water with cervical spine immobilization. 2. Initial Pediatric Care. 3. Perform advanced airway measures as needed; ventilate patient with 100% OXYGEN. 4. Apply pulse oximeter as available. 5. Refer to pediatric full arrest, respiratory emergencies or hypothermia protocol as needed. 6. Remove wet clothing; protect from further heat loss; place heat packs to axillae and groin. 7. IV/IO of NS at KVO; Administer fluid bolus 20 mL/kg as needed; repeat to a total of 60 mL/kg. Hot packs should be placed around IV fluids. 8. Monitor and transport; maintain warmth. 9. Contact Medical Control. ---------------------------------------ALS Section F 17
  • 18. POISONING ANDDRUG OVERDOSE PEDIATRICSNOTE: Anticipate vomiting, seizure, respiratory arrest and dysrhythmias. Refer to appropriate protocol as needed. Do not induce vomiting, especially in cases of ingested caustic materials.CRITERIA: 1. Patient < 14 years old and < 90 pounds. 2. Suspected exposure to toxic substance, including: a. Ingestion b. Inhalation c. Absorption d. Injection – accidental or intentionalTREATMENT: 1. Assure rescuer safety; stop patient exposure, but avoid self exposure. 2. Initial Pediatric Care. 3. Airway and OXYGEN at 8 – 15 Lpm by non-rebreather; Assist ventilations as necessary. 4. Intubate for PCS < 8; apply pulse oximeter if available. 5. If inhalation exposure is suspected, use humidified OXYGEN. 6. If absorption exposure: a. Remove all clothing. b. Irrigate with large volume of clear water. c. Avoid rescuer contamination. 7. IV/IO of NS at KVO. 8. Cardiac monitor. 9. Save all bottles and containers; inspect vomitus for pill fragments. 10. If patient’s guardian or parent refuses treatment or transport, request assistance from law enforcement. 11. Consider NARCAN 0.1 mg/kg IV, up to 2 mg maximum, as necessary for altered LOC and suspected opioid overdose. 12. Contact Medical Control.---------------------------------------Revised: April 2005 July 2006ALS Section F 18
  • 19. PULSELESS ELECTRICALACTIVITY PEDIATRICSCRITERIA:1. Pulseless and apneic pediatric patient.2. Organized electrical activity on cardiac monitor.EXCLUSION:1. Ventricular Tachycardia/Fibrillation2. Asystole3. HypothermiaTREATMENT: 1. Determine pulselessness and initiate CPR. 2. Perform advanced airway control measures and ventilate with BVM and 100% OXYGEN. 3. Identify and treat possible causes: a. Severe hypoxemia – Hyperventilation. b. Severe acidosis – Hyperventilate; contact Medical Control. c. Severe hypovolemia – Fluid challenge. d. Tension pneumothorax – Chest decompression. e. Cardiac tamponade – Rapid transport; prepare for pericardiocentesis. f. Profound hypothermia – Passive rewarming; rapid transport. 4. IV/IO of NS; perform fluid bolus of 20 mL/kg, repeat if necessary to a total of 60 mL/kg. 5. Administer EPINEPHRINE (1:10,000) 0.1 cc/kg IV/IO, or EPINEPHRINE (1:1,000) 0.1 cc/kg ET. 6. Administer EPINEPHRINE (1:1,000) 0.1 cc/kg IV/IO/ET q 3 – 5 minutes as needed for pulselessness. 7. If bradycardic rhythm present, administer ATROPINE 0.02 mg/kg IV/IO: a. Minimum dosage 0.1 mg. b. Maximum dosage 0.5 mg for child < 6 years old. c. Maximum dosage 1.0 mg for child > 6 years old. d. ATROPINE may be repeated once, if needed. 8. Transport and maintain warmth. 9. Contact Medical Control. --------------------------------------- 10. Consider SODIUM BICARBONATE 1 mEq/kg IV/IO for unwitnessed arrest or resuscitation greater than 10 minutes.ALS Section F 19
  • 20. RESPIRATORY ARREST/DISTRESS PEDIATRICSCRITERIA: Any may be present 1. Patient apneic with a pulse 2. Severe dyspnea, may include tachycardia and use of accessory muscles 3. Abnormal physical exam findings, such as: a. Wheezing or grunting b. Inspiratory rales or rhonchi c. Decreased breath sounds or air exchange 4. Respiratory history, including: a. Recent respiratory trauma b. Asthma or COPD c. Epiglottitis or bronchitis d. Recent pneumonia e. Foreign body obstructionEXCLUSION: 1. Ventricular Tachycardia 2. Bradycardia 3. HypothermiaTREATMENT: 1. Initial Pediatric Care. 2. Airway and OXYGEN at 8 – 15 Lpm by non-rebreather; Assist ventilations with BVM and suction as necessary. 3. Perform advanced airway control measures as needed and ventilate with BVM and 100% oxygen. 4. Apply pulse oximeter if available. 5. Cardiac monitor. 6. IV/IO of NS at KVO; consider fluid bolus of 20 mL/kg if needed; may repeat to a total of 60 mL/kg. 7. If blood sugar < 60 mg/dL, administer DEXTROSE 25% at 2 mL/kg for children under 8; may administer DEXTROSE 50% at 1 mL/kg for children over 8. 8. Assess for and treat any obvious injuries. 9. Administer ALBUTEROL 2.5 mg in 3 mL NS per nebulizer if needed. May repeat as needed for continued symptomatic relief. 10. If patient shows little improvement with nebulizer treatment, consider TERBUTALINE 0.005 mg/kg SQ (max. of 0.5 mg/dose). May repeat as needed every 15 minutes x 3 doses maximum. 11. Consider NARCAN 0.1 mg/kg IV/IO/ET/SQ to a maximum of 2 mg as necessary for airway compromise and suspected opioid overdose. 12. Contact Medical Control. --------------------------------------- Revised: July 2006 August 2009ALS Section F 20
  • 21. SEIZURES PEDIATRICSCRITERIA: Any may be present1. Active seizure2. Recurrent seizure3. Status epilepticus4. Postictal stateTREATMENT:1. Initial Pediatric Care; protect patient from accidental injury during seizure.2. Airway and OXYGEN at 8 – 15 Lpm by non-rebreather; Perform advanced airway control measures and assist ventilations as needed.3. Apply pulse oximeter, if available.4. IV/IO of NS at KVO.5. If seizure persists longer than 3 minutes: a. Administer VERSED 0.1 mg/kg IV over 2 minutes (max 5 mg). b. If seizure persists, contact Medical Control.6. If unable to obtain IV or IO access: a. Administer VERSED 0.2 mg/kg IM (max 7 mg). b. Continue IV attempts and contact Medical Control if seizure persists.7. If blood sugar < 60 mg/dL, administer DEXTROSE 25% at 2 mL/kg for patient < 8 years old; administer DEXTROSE 50% at 1 mL/kg for patient > 8 years old.8. If blood sugar < 60 mg/dL and IV/IO access not available, administer GLUCAGON 0.03 mg/kg IM to a total dose of 1 mg. Oral glucose may be administered if patient is alert and can maintain gag reflex.9. Cardiac monitor.10. Immobilize cervical spine, if appropriate.11. Obtain history of seizure; if febrile seizure is suspected, attempt to cool patient by removing excessive clothing and use towels moistened with water.12. Contact Medical Control ---------------------------------------Revised: September 2002ALS Section F 21
  • 22. SHOCK (HYPOPERFUSION) PEDIATRICSNOTE: Smaller body mass in children results in hypoperfusion quickly due to vomiting and diarrhea.CRITERIA:1. Patient < 14 years old and < 90 pounds.2. Signs and symptoms of hypoperfusion, including: a. Increased respiratory effort b. Cyanosis despite oxygen administration c. Truncal pallor and coolness d. Hypotension and bradycardia e. Weak, thready or absent peripheral pulses f. Delayed capillary refill in patients < 6 years old g. Decreased LOCTREATMENT: 1. Initial Pediatric Care. 2. Airway and OXYGEN at 8 – 15 Lpm by non-rebreather; Assist ventilation with BVM if necessary. 3. Apply pulse oximeter if available. 4. Control external bleeding with direct pressure. 5. Maintain cervical spine immobilization, if appropriate. 6. Cardiac monitor. 7. IV/IO of NS; Administer fluid bolus of 20 mL/kg if needed and lungs clear; repeat fluid bolus to a total of 60 mL/kg as needed. 8. If blood sugar < 60 mg/dL, administer DEXTROSE 25% at 2 mL/kg for patients < 8 years old; administer DEXTROSE 50% at 1 mL/kg for patients over 8 years old. 9. If IV or IO access is not available and blood sugar < 60 mg/dL, administer GLUCAGON 0.03 mg/kg IM, to a total of 1 mg. 10. Transport with legs raised if able, and maintain warmth. 11. Contact Medical Control. --------------------------------------- 12. Consider DOPAMINE: a. Place 400 mg DOPAMINE in 250 mL NS. b. Start at 1 drop per 5 kg per minute on microdrip tubing. c. Titrate to maintain SBP of 80 if less than 3 years old. d. Titrate to maintain SBP 90 – 100 if greater than 3 years old.ALS Section F 22
  • 23. SUPRAVENTRICULARTACHYCARDIA PEDIATRICSCRITERIA:1. Narrow complex tachycardia for given age2. Serious signs and symptoms, including: a. Cyanosis despite oxygen administration b. Truncal pallor and coolness c. Respiratory difficulty d. Hypotension e. Decreased LOC f. Weak or absent peripheral pulsesTREATMENT: 1. Initial Pediatric Care. 2. Airway and OXYGEN at 8 – 15 Lpm by non-rebreather; Assist ventilations as needed. 3. Apply pulse oximeter if available. 4. Apply cardiac monitor. 5. If serious signs and symptoms: a. Perform SYNCHRONIZED CARDIOVERSION at 0.5 J/kg. b. Repeat SYNCHRONIZED CARDIOVERSION at 1 J/kg, then 2 J/kg if needed. 6. Refer to pediatric full arrest protocol as needed. 7. IV/IO of NS; Consider fluid bolus of 20 mL/kg, repeat as needed to a total of 60 mL/kg. 8. If mild or moderate signs of cardiorespiratory compromise: a. Administer ADENOSINE 0.1 mg/kg (maximum 6 mg) rapid IV push, followed by immediate 10 mL NS flush. b. Repeat ADENOSINE as needed at 0.2 mg/kg (maximum 12 mg) rapid IV push, followed by 10 mL NS flush. 9. If patient remains in persistent SVT, despite ADENOSINE, consider SYNCHRONIZED CARDIOVERSION as above. 10. Refer to shock protocol as needed. 11. Transport and maintain warmth. 12. Contact Medical Control. ---------------------------------------ALS Section F 23
  • 24. V-FIB AND V-TACHWITHOUT PULSE PEDIATRICSCRITERIA:1. Patient < 14 years old and < 90 pounds, pulseless and apneic2. Ventricular fibrillation or ventricular tachycardiaTREATMENT:1. Quick look cardiac monitor.2. Defibrillate at 2 J/kg; repeat at 4 J/kg x 2 as needed for V-fib or V-tach3. Perform advanced airway control measures; ventilate with 100% OXYGEN by BVM.4. IV/IO of NS; perform fluid bolus 20 mL/kg as long as lungs are clear; repeat to a total of 60 mL/kg as needed.5. Administer EPINEPHRINE (1:10,000) 0.1 cc mg/kg IV/IO, or EPINEPHRINE (1:1000) 0.1 cc/kg ET.6. Administer EPINEPHRINE (1:1000) 0.1 cc/kg IV/IO/ET q 5 minutes as needed for continued pulselessness.7. Continue to defibrillate at 4 J/kg with each medication bolus.8. Administer AMIODARONE 5 mg/kg IV/IO.9. If blood sugar < 60 mg/dL, administer DEXTROSE 25% at 2 mL/kg for patients < 8 years old, or DEXTROSE 50% 1 mL/kg IV for patients greater than 8 years old.10. Transport as soon as possible.11. Contact Medical Control. ---------------------------------------12. Consider SODIUM BICARBONATE 1 mEq/kg IV/IO for unwitnessed arrest or resuscitations longer than 10 minutes.Revised: July 2008ALS Section F 24
  • 25. V-TACH WITH PULSE PEDIATRICSNOTE: For pediatric patients with ventricular tachycardia and no serious signs or symptoms, perform Initial Pediatric Care, transport and contact Medical Control. Synchronized cardioversion is normally reserved for children with HR > 220 with signs of shock.CRITERIA:1. Pediatric ventricular tachycardia2. Serious signs and symptoms, including: a. Cyanosis despite oxygen administration b. Truncal pallor and coolness c. Respiratory difficulty d. Hypotension e. Decreased LOC f. Weak or absent peripheral pulsesTREATMENT: 1. Initial Pediatric Care; quick look cardiac monitor. 2. Airway and OXYGEN at 15 Lpm by non-rebreather; assist ventilations as needed with BVM and 100% OXYGEN. 3. Apply pulse oximeter if available. 4. If signs and symptoms of severe cardiorespiratory compromise: a. Perform SYNCHRONIZED CARDIOVERSION at 0.5 J/kg. b. Repeat SYNCHRONIZED CARDIOVERSION at 1 J/kg, then 2 J/kg. 5. IV or IO of NS; consider fluid bolus of 20 mL/kg, may repeat as needed to a total of 60 mL/kg. 6. If mild to moderate cardiorespiratory compromise: a. Administer AMIODARONE 5 mg/kg diluted in D5W over 20 minutes. 7. If persistent V-tach despite AMIODARONE, perform SYNCHRONIZED CARDIOVERSION as above. 8. Transport and maintain warmth. 9. Contact Medical Control. ---------------------------------------Revised: July 2008ALS Section F 25