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    Module III - The Pediatric Patient Module III - The Pediatric Patient Presentation Transcript

    • Encountering The Pediatric Patient Condell Medical Center EMS System November 2008 ECRN CE Module III Site Code #10-7200E1208 Prepared by: Sharon Hopkins, RN,BSN, EMT-P
    • Objectives
      • Upon successful completion of this module, the ECRN should be able to:
        • Review and understand the components of the Pediatric Assessment Triangle (PAT)
        • Identify the difference between respiratory distress and respiratory failure
        • Choose the appropriate EMS field medication & dose to administer for a variety of conditions
        • (Dextrose, Narcan, Albuterol, Valium,
        • Epinephrine, Atropine, Adenosine,
        • Versed, Benadryl)
        • Calculate medication dosages given the patient’s weight
        • Calculate the GCS given the pt’s responses
        • Identify and appropriately state interventions for a variety of EKG rhythms specific to the pediatric population (VF, SVT, bradycardia)
        • Successfully complete the 10 question
        • quiz with a score of 80% or better
    • Pediatric Assessment Triangle - PAT
      • Establishes a level of severity
      • Assists in determining urgency for life support
      • Identifies key physiological problems using observational & listening skills
    • General Assessment - PAT
      • Performed when first approaching the child
        • Does not take the place of obtaining vital signs
      • Check appearance
      • Evaluate work of breathing
      • Assess circulation to the skin
    • PAT - Appearance
      • Reflects adequacy of :
        • Oxygenation
        • Ventilation
        • Brain perfusion
        • Homeostasis
        • CNS function
    • Assessing Appearance
      • Evaluate as you cross the room and before you touch the child:
        • Muscle tone – can they sit up on own?
        • Mental status / interactivity level
        • Consolability
        • Eye contact or gaze – do they
        • watch you?
        • Speech or cry
    • PAT - Breathing
      • Reflects adequacy of :
        • oxygenation
        • Ventilation
        • In children, work of breathing more accurate indicator of oxygenation & ventilation than respiratory rate or breath sounds (standards used in adults)
    • Assessing Breathing
      • Evaluate:
        • Body position
        • Visible movement of chest or abdominal walls
        • 6-7 years-old & younger are primarily diaphragmatic (belly) breathers
        • Respiratory rate & effort
        • Audible breath sounds
    • PAT - Circulation
      • Reflects :
        • Adequacy of cardiac output and perfusion of vital organs (core perfusion)
    • Assessing Circulation
      • Evaluate skin color:
          • Cyanosis reflects decreased oxygen levels in arterial blood
          • Cyanosis indicates vasoconstriction and respiratory failure
          • Trunk mottling indicates hypoxemia
    • Initial Assessment
      • Airway – is it open?
      • Breathing – how fast, effort being used, is it adequate?
      • Circulation – what is the central circulation status as well as peripheral?
      • Disability – AVPU and GCS
      • Expose – to complete a hands-on
      • examination
    • Priority Patients & Transport Decisions
      • Decide what level of criticality this patient is
      • EMS to decide if the patient must go to the closest emergency department or if they have time to honor the family request if their hospital is not the closest
    • Additional Assessment
      • Includes:
        • Focused history
        • Physical exam
          • Toe to head approach in the very young (infants, toddlers, preschoolers)
          • Head to toe in the older child
        • SAMPLE history
    • SAMPLE History
      • S – signs & symptoms
      • A – allergies
      • M – medications including herbal and over the counter (OTC)
      • P – past pertinent medical history
      • L – last oral intake (anything to eat or drink including water)
      • •E – events leading up to the incident
    • Assessment & Interventions
      • Vital signs
      • Determine weight and age
      • SaO 2 reading preferably before & after O 2 administration
      • Cardiac monitor if applicable
      • Establish IV if indicated
      • Determine blood glucose if indicated
      • • Reassess vital signs, SaO 2 , patient
      • condition
    • Detailed Physical Exam
      • Information gathered builds on the findings of the initial assessment and focused exam
      • Use the toe to head for infants, toddlers, and preschoolers
    • Putting It All Together
      • EMS is called to the scene for a 2 year-old who has fallen off the 2 nd floor porch.
      • The toddler landed in the grass
      • The toddler is unresponsive upon EMS arrival; there is a laceration to the right forehead and the right arm
      • is deformed
    • Putting It All Together - Mechanism of Injury
      • Fall from height greater than 3 times the toddler’s height
      • For this 2 year-old, the mechanism of injury indicates a Category I trauma patient based on mechanism of injury (fall from height) and level of consciousness (unresponsiveness)
    • General Impression For This 2 year-old
      • Category I trauma patient with head & orthopedic injuries
      • EMS Region X SOP’s to follow
        • Spinal immobilization
        • Care of the airway with anticipation for need to be bagged or intubated
        • Hemorrhage control / interventions with IV/IO access needing to be obtained
        • Cardiac monitoring
        • Determining blood glucose level
    • What’s The Difference?
      • Respiratory distress
        • The patient exhibits increased work of breathing but the patient is able to compensate for themselves
          • Increased respiratory effort in child who is alert, irritable, anxious, and restless
          • Evident use of accessory muscles
            • Intercostal retractions
            • Seesaw respirations (abdominal breathing)
            • Neck muscles straining
      • Respiratory failure
        • Energy reserves have been exhausted and the patient cannot maintain adequate oxygenation and ventilation (breathing)
          • Sleepy, intermittently combative or agitated child
          • Heart rate usually bradycardic as a result of hypoxia
    • Respiratory Distress
      • Stridor
      • Grunting
      • Gurgling
      • Audible wheezing
      • Tachypnea (increased respiratory rate)
      • Mild tachycardia
      • Head bobbing
      • Abdominal breathing (normal < 6-7 years-old)
      • Nasal flaring
      • Central cyanosis resolved with O 2
    • Stridor
      • Harsh, high-pitched sound heard on inspiration associated with upper airway obstruction
      • Sounds like high-pitched crowing or “seal-bark” sound on inspiration
    • Grunting
      • Compensatory mechanism to help maintain patency of small airways
      • A short, low-pitched sound heard at the end of exhalation
      • Patient trying to generate positive end-expiratory pressure (PEEP) by exhaling against a closed glottis
      • Prolongs the period of oxygen and carbon dioxide exchange
    • Nasal Flaring
    • Retractions
      • A visible sign where the soft tissues sink in during inhalation
      • Most notable are in the areas above the sternum or clavicle, over the sternum, and between the rib spaces
    • Respiratory Failure
      • Decreased level of responsiveness or response to pain
      • Decreased muscle tone
      • Inadequate respiratory rate, effort, or chest excursion
      • Tachypnea with periods of bradypnea slowing to agonal breathing
    • IV Access
      • Peripheral access can be difficult to find in a child
        • More sub Q fat
        • Smaller targets
        • More fragile veins
        • Lack of our experience
    • Hint to Find Peds Veins
      • Hold your penlight across the skin to reflect the veins
      • Hold the penlight under the site to illuminate the veins
    • EMS IO Indications
      • Shock, arrest, or impending arrest
      • Unconscious/unresponsive to stimuli
      • 2 unsuccessful IV attempts or 90 second duration
      • Peds needle used for 3 – 39 kg (up to 88 lbs)
        • - Peds needle 15 G 5 / 8  (G same as adult, length is shorter)
    • EZ IO Landmarks
      • Proximal medial tibia
      • <39 kg (child) – tibial tuberosity often difficult to palpate & if not palpated
        • Go 2 finger breadths below patella and then on flat aspect of medial tibia
      • 40 kg (88 pounds or more)
        • 1-2 finger breadths below patella (this is usually 1 / 2  (1 cm) distal to tibial tuberosity)
        • 1 finger breadth medially from the tibial
        • tuberosity
    • Tibial tuberosity
    • EZ IO Infusion
      • All patients need to have the IO flushed prior to connecting the IV solution
      • The primed extension tubing must be used with a syringe attached
      • Only the syringe is removed after flushing in preparation to attaching IV fluid
      • All IV bags need a pressure bag to
      • flow
    • EMS Altered Level of Consciousness SOP
      • If blood glucose level is <60
        • < 1 year old – Dextrose 12.5% 4 ml/kg
        • > 1 -15 years old – Dextrose 25% 2 ml/kg
      • If no IV/IO access
        • Glucagon 0.1 mg/kg IM
          • Max dose up to 1 mg (max at adult dosage)
      • If you suspect narcotic influence or as a diagnostic tool if blood sugar is okay or patient does not respond to Dextrose
        • Narcan EMS dosing
          • < 20 kg = 0.1 mg/kg IVP/IO/IM
          • >20 kg = 2 mg IVP/IO/IM
          • Max total dose is 2 mg
    • Dextrose
      • The brain is a very sensitive organ to inadequate levels of glucose
      • When the glucose levels drop the patient will have an altered level of consciousness
      • If glucose levels reach a critically low level, the patient may have a seizure
    • Narcan
      • Useful to reverse the effects of narcotics (respiratory depression and depression of the central nervous system)
      • Morphine, hydromorphine (Dilaudid), oxycodone, Demerol, heroin, codeine, percodan, fentanyl, darvon, methadone
      • Consider the children that get into
      • other’s purses and have access to
      • the medicine cabinet & other
      • areas where drugs can be found
    • Calculation Practice
      • Your 8 month-old patient weighs 17 pounds
      • Which strength Dextrose should this patient receive by EMS and how much?
    • 8 month-old
      • < 1 year old receives Dextrose 12.5%
        • More diluted form for smaller, more fragile veins
      • To receive 4 ml/kg
        • 17 pounds  2.2 = 7.7 kg (8kg)
        • Dextrose is 4 ml / kg
          • 4 ml x 8 kg = 32 ml
      • How does EMS give 12.5% Dextrose
      • when they carry 25% as their
      • weakest dilution?
    • Drawing Up 12.5% Dextrose From D25%
      • Use 25% and dilute 1:1 with sterile saline
      • Calculate the total dosage required (ie: 32 ml)
      • Half the syringe will be filled with 25% Dextrose and half the syringe will be filled with sterile saline
      • 16 ml 25% Dextrose mixed with 16 ml sterile normal saline
      • Administer in largest vein possible and at slowed rate
        • Extremely irritating to the veins
    • Narcan Calculation
      • Your patient weighs 19 pounds
      • <20 kg the patient is to get 0.1 mg/kg
      • How much Narcan would be
      • administered? Never give
      • more than the adult dose!
    • Narcan for 19 Pound Infant
      • 19 pounds  2.2 kg = 8.6 kg (9kg)
      • 9kg x 0.1 mg/kg = 0.9 mg
      • (You still need to know how many ml’s to put into the syringe)
      • What type of syringe would you use?
        • Under 1 ml use a TB syringe –
        • much more accurate to draw
        • up medications
    • Broselow Tape
      • Often gives mg but not always the ml to fill the syringe with
      • Mg helpful for accurate documentation
      • Holding a syringe, need to know how many ml’s to draw up into syringe
      • Back of SOP’s has medical and cardiac pediatric reference tables
        • Includes mg and ml of medications
    • GCS For Pediatric Patient
      • Same tool used for the adult population with minor changes to accommodate the young non-verbal infant
      • Most accommodations made in the verbal section
      • Makes sense if this is for the non-verbal patient
    • GCS – Eye Opening
      • Remains the same as the adult:
      • 4 points if eyes open spontaneously with or without focus
      • 3 points if eyes open or flutter to command or noises/voice
      • 2 points if eyes open or eyelids flutter to touch or painful stimuli
      • 1 point if eyes do not open
    • GCS – Peds Verbal Response
      • 5 points if oriented (coos, babbles)
      • 4 points if cry is irritable
      • 3 points if the patient cries to pain
      • 2 points if there is some noise response to pain (similar to moans & groans in the adult)
      • 1 point if there is silence
    • GCS – Peds Motor Response
      • 6 points if the patient moves appropriately
      • 5 points if the patient withdraws to touch
      • 4 points if the patient withdraws to pain
      • 3 points if there is abnormal flexion
      • 2 points if there is abnormal extension
      • 1 point if there is no movement/response
      • of any kind
    • Acute Asthma
      • Many patients will try to self medicate and may try for too long on their own before they call for help
      • The patient can deteriorate fast once they fatigue and their respiratory muscles are exhausted
    • Why Albuterol?
      • Albuterol is a bronchodilator
      • Receptors are in the lungs
      • Opens up constricted bronchiole passages
      • Albuterol also triggers receptors in the heart and you may see an increase in heart
      • rate
    • EMS Albuterol Dosing
      • 2.5 mg/3 ml for all patients
      • The drug will be more successful when the patient is coached through use of the nebulizer
      • The drug only works if it is inhaled deeply into the lungs
          • Short, shallow breaths will not help drug absorption
    • Nebulizer Delivery
      • This route is most effective if there is someone “coaching” the patient during use
        • Have someone talk the patient through the process
          • Verbal encouragement essential to success
        • Encourage slower breaths for a few ventilations
        • Then encourage the breaths to be a bit deeper
        • Then encourage the deeper breaths to be
        • held a bit longer to get the drug
        • down into the lungs
    • In-line Albuterol
      • Any patient no longer able to take a deep breath or remain conscious needs this drug “forced” into the lungs
      • The drug must be given in-line
        • Attach nebulizer to the BVM mask as you start bagging the patient to get some drug into the lungs
        • Once intubated, the ambu bag will continue to force the drug into the airway and down into the lungs
    • What Are the Risk Factors That Expose Kids To Seizures?
      • Fever – most common
      • Hypoxia
      • Infections
      • Electrolyte imbalance
      • Head trauma
      • Hypoglycemia
      • Toxic ingestions
      • Tumor
    • Status Epilepticus
      • A series of one or more generalized seizures without any periods of consciousness
      • Concern is with periods of prolonged apnea that can lead to hypoxia
    • Assessment of Seizures
      • ALWAYS obtain a glucose level if level of consciousness is altered
      • Ask if there is a history of recent illness
      • Ask for description of the seizure activity
        • Jerking of both sides of the body, jerking limited to a particular part of the body, eye blinking, staring, lip smacking
    • EMS Seizure Intervention
      • Support the airway
        • Consider BVM if active seizure
      • To terminate current seizure
        • Valium 0.2 mg/kg IVP
        • No IV access, Valium rectally 0.5 mg/kg
        • Max total rectally 10 mg
      • Remove extra clothing if febrile
      • Cool cloths over patient, fan patient
      • Shivering will increase body temp!
    • Valium Calculation
      • Patient with active seizure
      • Patient weighs 26 pounds
        • 26 #  2.2 = 11.8 KG (12 KG)
      • Valium is 0.2 mg/kg
        • 12kg x 0.2 = 2.4 mg
      • Where are your resources to use to check how many ml’s to pull up
      • into the syringe?
    • Medication Resources
      • Back of SOP’s (Medical & Cardiac Pages)
        • Meds by mg for documentation and by ml to draw up into the syringe
      • Broselow tape 2007 Edition B
        • Legend gives the formula
        • Valium (diazepam) exact mg given under each respective weight category
          • Careful!!! – Diazepam broken down by IV AND rectal so read columns carefully
    • Possible Causes of Critical Rhythms
      • 6 H’s
        • Hypovolemia – fluid challenge
        • Hypoxia – supplemental O 2
        • Acidosis – ventilate to blow off CO 2
        • Hyper/hypokalema
        • Hypothermia – warm core
        • Hypoglycemia – check glucose level
      • 5 T’s
        • Tablets – drug overdose
        • Tamponade – supportive care in field
        • Tension pneumothorax – needle decompression
        • Thrombosis, coronary or pulmonary
        • Trauma
    • Peds VF or Pulseless VT
      • After 2 minutes of CPR if unwitnessed, defibrillate 2j/kg or equivalent biphasic
        • AED can be used if >1 years old
      • Immediately resume CPR for 2 minutes / 5 cycles
        • Rhythm checks after 2 minutes CPR
      • Repeat defibrillate is at 4j/kg or equivalent biphasic
      • •Resume CPR after defibrillation
      • •Establish IV/IO
    • VF/VT Peds Region X SOP
      • Meds given during CPR:
      • Epinephrine 1:10,000 0.01 mg/kg IVP/IO
        • Repeat every 3-5 minutes
      • Choose one antidysrhythmic to alternate with Epi
        • Amiodarone 5 mg/kg IVP/IO
        • Lidocaine 1 mg/kg IVP/IO
        • Repeat doses per Medical Control order
    • Why Epinephrine?
      • Epinephrine is a catecholamine and stimulant
      • Epinephrine is a vasoconstrictor to improve blood flow
      • Before drug therapy, always assess/evaluate the status of oxygen delivery and effectiveness of ventilation
    • PEA/Asystole Peds Region X SOP
      • Start CPR and run thru the H & T checklist
      • Secure airway
      • Establish IV/IO
        • Fluid challenge 20 ml/kg
      • Epinephrine 1:10,000 0.01 mg /kg IVP/IO
        • Repeat every 3-5 minutes
        • NO Atropine in SOP for peds!!!
    • Why No Atropine in Peds PEA, Asystole, or Brady?
      • Atropine will probably not help unless the patient has primary AV block and that is not likely in a young and healthy heart
      • Improving oxygenation and ventilation are the primary treatments for pediatric bradycardia
    • Peds Symptomatic Brady
      • Severe cardiorespiratory compromise
        • Poor perfusion
        • Bradycardia
        • Weak, thready, absent pulse
        • Hypotension
        • Pallor
        • Cyanosis
        • Respiratory difficulty
    • Peds Brady EMS Region X SOP
      • Heart rate <60 & poor systemic perfusion – perform CPR
      • IV/IO access
      • Epinephrine 1:10,000 0.01 mg/kg IVP/IO
        • Repeat every 3-5 minutes
      • If persistent brady, contact Medical control for order of Atropine
        • Atropine if ordered: 0.02 mg/kg (minimum dose to give 0.1 mg) IVP/IO
        • May repeat Atropine x1
        • Max dose 1 mg
        • Consider pacing
    • Peds Shock EMS Region X SOP
      • Hypovolemic or distributive shock
        • IV fluid challenge 20 ml/kg
      • If no response repeat 20 ml/kg up to 60 ml/kg (ie: total 3 challenges)
      • No fluid challenge for peds in cardiogenic shock
    • Peds Tachycardia
      • Bradydysrhythmias are more common in peds patients than tachycardias
      • Sinus Tachycardia
        • Heart rates in infants are under 220 and in children under 180
        • No drug therapy indicated
        • Search for possible causes
    • Probable Supraventricular Tachycardia
      • Narrow complex tachycardia greater than 220 in infants and greater than 180 in a child
      • Typically due to a problem in the cardiac conduction system
      • Rapid heart rates prevent adequate ventricular filling that can lead to
      • CHF and cardiogenic shock
    • Signs & Symptoms SVT
      • Irritability
      • Poor feeding
      • JVD
      • Hepatomegaly – enlarged liver
      • Hypotension
      • Children can often tolerate the rapid rate fairly well
    • EMS Treatment SVT with Adequate OR Poor Perfusion
      • Vagal maneuvers
        • If a straw is available, have child blow thru one
      • Adenosine 0.1 mg/kg rapid IVP followed by 5 ml rapid saline flush
      • Max 1 st dose is 6 mg (max at adult dose)
      • Repeat dose if needed is 0.2 mg/kg with
      • 5 ml saline flush
      • Max 2 nd dose is 12 mg (adult dose)
    • Cardioversion for No Response to Adenosine or For Probable VT
      • Sedate with Versed 0.1 mg/kg IVP slowly over 2 minutes
      • Cardioversion at 1 j/kg
      • If no response, cardiovert at 2 j/kg
    • Why Versed?
      • Amnesic
      • Relaxes patient
      • Shorter acting than Valium
      • Does NOT take away pain!
      • Can cause respiratory depression
        • Have BVM reached & ready whenever Versed or Valium are given in case the patient needs ventilation support
    • Probable VT with Poor Perfusion
      • No time to allow drugs to work to slow or convert rhythm
      • Need to be more aggressive
      • Cardiovert the patient
        • 1 st attempt 1 j/kg
        • 2 nd attempt if needed 2 j/kg
      • If no response to cardioversion, contact Medical Control for possible
      • Amiodarone or Lidocaine order
    • Allergic Reactions – Is Response Life Saving or A Killer?
      • The body’s immune response to an antigen tries to eliminate the antigen (foreign material) from the body
        • Bronchospasm – so no more offending antigen can enter the respiratory tract
        • Coughing – to expel the antigen
        • Leaky capillaries – remove antigen from the blood stream and place it into the interstitial tissue for removal via lymph
        • system
        • Vomiting & diarrhea – remove antigen from GI tract
    • Antigen Exposure & Histamine Release
      • Increased capillary permeability
        • 3 rd spacing (intravascular fluid into interstitial space)
          • Edema
          • Relative hypovolemia
      • Peripheral vasodilation
        • ↓ peripheral vascular resistance (↓ B/P)
      • Smooth muscle constriction
        • Abdominal cramps, vomiting, diarrhea
        • Bronchoconstriction & laryngeal edema
    • Is it an Allergic Reaction or Anaphylaxis?
      • Anaphylaxis is the more severe response of the two
        • Usually occurs when a patient is exposed to a specific allergen, especially injected directly into the circulation
      • Anaphylaxis principally affects the cardiovascular, respiratory, GI systems and the skin
      • Faster the reaction, usually the more severe the reaction is
      • In anaphylaxis, the patient will be
      • hypotensive (ominous sign)
    • Why Epinephrine 1:1000 For An Immune Response?
      • Stimulates certain receptors in the body (alpha & beta receptors)
        • Constricts blood vessels to help counter vasodilation effects of anaphylaxis (alpha affect)
        • Opens up airways by reversing bronchospasm of anaphylaxis (beta affect)
        • Max dose calculated at adult dose (0.3ml)!
    • What Does Epinephrine Do?
      • Primary drug used in reactions
      • Increases heart rate
      • Increases strength of cardiac contractions
      • Causes peripheral vasoconstriction
      • Can reverse bronchospasm
      • Can reverse capillary permeability
      • Effects short term
    • Why Benadryl For Immune Response?
      • Antihistamines are the 2 nd line agents to give in reactions
      • Antihistamines block the effects of histamine released in the body by blocking histamine receptors
      • Duration of action is 6-12 hours so anticipate rebound if the patient has not filled a prescription to continue
      • taking the antihistamine
      • •Max dose given is at adult dosing
    • EMS Benadryl Dosing
      • Epinephrine is 1 st line drug if applicable
      • Stable allergic reaction no airway involvement
        • Benadryl 1 mg/kg slow IVP or IM
        • Max 25 mg (adult dose)
      • Stable allergic reaction with airway involvement
        • Benadryl 1 mg/kg slow IVP
        • Max 50 mg (adult dose)
      • Anaphylactic shock
        • - Benadryl 1 mg/kg slow IVP
        • - Max 50 mg (adult dose)
    • Practice Calculating the GCS
      • Remember to use the “PEDS” alternative values when the patient is non-verbal
      • If the patient is old enough to talk, follow the adult prompts to calculate the GCS
    • GCS Calculation #1
      • Patient is 7 months old
      • Eyes are open but do not focus or follow activities
      • The infant has an irritable cry
      • The infant pulls their arms in when the IV stick is attempted
    • GCS Calculation #2
      • Patient is 3 years-old
      • Eyes flutter open when the patient is yelled at
      • The toddler cries after the injured extremity is manipulated
      • The toddler pulls back when the injured extremity is manipulated
    • GCS Calculation #3
      • Patient is 5 months-old
      • Eyes flutter open when the deformed extremity is manipulated
      • The patient moans when the injured extremity is manipulated
      • The patient pulls up their
      • extremities tightly into their
      • chest when touched (flexion)
    • GCS Calculation #4
      • Patient is 5 years-old
      • Patient is watching your movement
      • Patient is using repetitive words and is confused
      • Patient pushes your hands away
      • when you touch them
    • GCS Calculation Answers 1 & 2
      • Pt #1 – GCS 12
        • Eye opening – 4 (spontaneous)
        • Verbal – 4 (irritable cry)
        • Motor 4 – (withdraws to pain)
      • Pt #2 – GCS 10
        • Eye opening -3 (eyes open to voice)
        •  Verbal – 3 (cries to pain)
        •  Motor – 4 (withdraws to pain)
    • GCS Calculation Answers 3 & 4
      • Pt #3 – 7
        • Eye opening – 2 (eyes flutter to pain)
        • Verbal – 2 (moaning is an incomprehensible word/sound)
        • Motor – 3 (flexes extremities into chest)
      • Pt #4 – 13
        • Eye opening – 4 (spontaneous)
        • Verbal – 4 (repetitive words / confused)
        • Motor – 5 ( pushes hands away/purposeful)
    • Scenarios
      • Read the following case studies
      • Determine your general impression based on the pediatric assessment triangle (PAT)
      • Determine interventions appropriate to the situation
    • Case Study #1
      • EMS is at a local high school track meet when a 12 year-old boy collapses while running the 100-yard dash. Initial assessment reveals the child is apneic and pulseless. CPR is started immediately
      • What are the next appropriate steps to take?
      • Can an AED be used on a 12 year-old?
    • Case Study #1
      • AED’s can be used in patients over 1 years-old
        • Use the child pads for 1 – 8 year olds
        • If no child pads available, use adult pads
        • Cannot use child pads though on the adult
      • CPR for 12 year-old is adult standards
      • CPR 1 person infant & child (1-8 years-old per AHA) is 30:2; 2 person is 15:2; once
      • intubated ventilations are delivered
      • once every 6-8 seconds
    • Case Study #1
      • Attach a monitor as soon as possible
      • Stop CPR (witnessed arrest) as soon as monitor applied & ready
      • What’s the rhythm & treatment?
    • Case Study #1
      • Rhythm: Torsades
        • Most likely this young athlete has long QT syndrome (conduction defect) that makes them prone to arrest during physical exertion
      • Treat like VF (follow Region x SOP for EMS)
        • Defibrillate 1 st at 2j/kg (peds pt < 15)
        • Repeat defibrillations at 4j/kg
        • Epinephrine 1:10,000 0.01 mg/kg IV/IO
          • Repeat every 3-5 minutes
        • •Choose one antidysrhythmic (Amiodarone or Lidocaine; one dose)
    • Case Study #2
      • A 2 year-old at preschool fell from a sitting position and the teacher witnessed jerking of the arms and legs that lasted for 1-2 minutes. Parent told teacher the child was not feeling well during the night.
      • On arrival, the child is drowsy, will open their eyes to voice but does not answer questions, moans & withdraws when touched.
      • VS: B/P 110/58; HR 100; RR 30; skin warm to the touch
      • What is your impression based on the assessment triangle?
      • What is the GCS?
    • Case Study #2
      • Patient appears physiologically stable
        • Drowsy, no extra effort or noise for breathing, skin pink and warm
        • GCS 10 (3, 2, 5) (currently post-ictal)
      • Initial impression is febrile seizure (no history trauma, history of being ill last night, feels warms to touch)
      • Field treatment limited to cooling measures
        • Remove extra clothing, cool cloths on forehead
      • Reevaluate GCS watching for improvement
      • as level of consciousness improves
    • Case Study #2 - Is Valium Indicated Now?
      • No active seizure currently, so no drug
      • Valium stops the current seizure but does not prevent future seizures
      • Valium indicated if multiple seizures occur or seizure lasts longer than a few minutes
      • Long lasting seizure can cause hypoxia
      • Side effects of valium are
      • respiratory depression
    • Case Study #3
      • You are on the scene for an 18 month-old child who is having difficult breathing
      • The mother states a 2 day hx of slight fever and wheezing esp when crying
      • Pt suddenly woke tonight short of breath with loud noises on inhalation
      • Child sitting on mother’s lap, anxious, watches you and cries weakly when you
      • approach
    • Case Study #3
      • Color pink, has retractions with nasal flaring
      • HR 180; RR 42
      • Strong pulses, cap refill 2 seconds
      • Loud, harsh breath sounds bilaterally
    • Case Study #3
      • How sick is this child?
        • PAT (pediatric assessment triangle)
          • Evaluate appearance, work of breathing, & circulation to skin
      • What is your general impression?
        • Do you think this is an upper or lower airway problem?
      • •How should you care for this
      • child in the field?
    • Case Study #3
      • PAT: makes eye contact & cries when EMS approaches; exhibiting stridor & increased work of breathing; skin pink & warm
      • This child is in respiratory distress , not failure, with an upper airway problem
        • Stridor indicates upper airway obstruction and history of a few days
        • of respiratory infection is
        • consistent with croup
    • Case Study #3
      • Management upper airway obstruction based on severity of symptoms
        • Position of comfort – usually best to leave child sitting upright
        • O 2 – best if humidified
          • Can humidified O 2 be given in the field? Yes!
    • Humidified Oxygenation in the Field
      • Place 6 ml normal saline into the nebulizer
      • Finish assembling the nebulizer
      • Connect tubing to the O 2 source
      • Turn up the liter flow to generate a flow of mist
      • Aim the mist near the child’s face
      • Helpful for croup & epiglottitis
    • Case Study #3
      • If wheezing, EMS gives Albuterol 2.5 mg
        • Used as bronchodilator
        • FYI: Research indicates Albuterol does not have much affect in croup
      • Place Albuterol into nebulizer
      • Place nebulizer mask over patient’s face if child too small to place lips
      • around mouthpiece or direct
      • mist near child’s face
    • Case Study #4
      • 911 called to the scene for a 3-month old who has had 3 days of cough, runny nose & low-grade fever.
      • Caregiver concerned because the child is working harder to breathe and having hard time feeding
      • Child is in caregiver’s lap
      • • Child is sleepy, no eye contact
      • or response to the exam
    • Case Study #4
      • Child limp, audible wheezing, deep retractions, nasal flaring, skin mottled, diaphoretic
      • VS: HR 180; RR 70; SaO 2 on room air 74%
      • Breath sounds: tight with only fair air movement with high-pitched inspiratory & expiratory wheezes
    • Case Study #4
      • Is this child in respiratory distress or respiratory failure?
      • What is your general impression?
      • What do you need to do to manage this patient?
    • Case Study #4
      • You note increased work of breathing, abnormal appearance, and poor circulation
      • This patient is in respiratory failure
      • With the wheezing, the problem is most likely a lower airway obstruction
        • Most likely bronchiolitis (inflammation of the bronchioles often caused by RSV – a viral infection)
    • Case Study #4
      • Rapid and urgent transport
      • This patient most likely does not have an easily reversible respiratory problem and is likely to deteriorate further
      • Enroute EMS to administer a bronchodilator (Albuterol) via nebulizer via mask (won’t be able to
      • put mouth around mouthpiece)
    • Case Study #4
      • Respiratory status monitored closely
        • If decreased respiratory effort or slowing of the rate, support with BVM considered using a slow rate and long expiratory time
      • AHA ventilatory rate for rescue breathing infant < 1 & child < 8
        • 1 breath every 3-5 seconds (12 – 20 breaths per minute)
        • Give each breath over 1 second
    • Case Study #5
      • EMS is called to the scene for an unresponsive 3 year-old child
      • There are no abnormal airway sounds
      • Patient is pale & slightly diaphoretic
      • VS: B/P 80/60; HR 160; RR 20
      • Pupils small, slow to react
      • Withdraws from pain & moans
      • •Was playful before his nap and
      • appeared healthy
    • Case Study #5
      • What is your general assessment?
      • What is the GCS?
      • What other assessments need to be done?
      • What interventions are needed?
    • Case Study #5
      • This patient is critical: unresponsive, no abnormal appearance for work of breathing, pale & diaphoretic & tachycardic
      • GCS - 7
        • Eye opening – 1 (none)
        • Verbal response – 2 (moans)
        • Motor response – 4 – (withdraws)
      • Need to obtain glucose level (40)
      • Keep airway open, supplemental O 2 ,
      • establish IV access
      • •Needs D25% 2 ml/kg slow IVP
    • Case Study #5
      • Calculating & administrating Dextrose
        • D25% ages 1 – 15 is 2 ml/kg
        • This 3 year-old weighs 29 pounds
        • How much D25% do you administer?
        • Where are your resources to
        • find the information?
    • Case Study #5
      • Check the back of the SOP’s
      • Check the Broselow tape
      • Divide pounds by 2.2 to determine kg
        • 29  2.2 = 13 kg
      • Multiply kg by the formula (2 ml/kg)
        • 13 kg x 2 ml/kg = 26 ml D25%
      • D25% is packaged in 10 ml prefilled syringe
      • Administer IV dose slowly to
      • minimize vein irritation from the med
    • Case Study #6
      • You run the call:
        • EMS has a 6 year-old who was found listless with a GCS of 9
        • The monitor shows:
        • What’s the rhythm?
        • What do you do?
    • Case Study #7
      • Pediatric bradycardia is a hypoxia problem until proven otherwise
      • CPR started with attention to ventilation
      • IV or IO access established
      • What drug therapy is necessary for
      • the pediatric symptomatic bradycardia?
    • Case Study #7
      • EZ IO landmarks
        • 2 fingerbreadths down from patella over tibial tuberosity
        • 1 fingerbreadth toward medial surface away from tibial tuberosity
      • Peds bradycardia treatment
        • Epinephrine 1:10,000 0.01 mg/kg IV/IO
        • Repeated every 3-5 minutes
        • Persistent , Medical
        • Control would need to order Atropine
    • Bibliography
      • Aehlert, B. PALS Study Guide. Elsevier. 2007.
      • American Academy of Pediatrics. Pediatric Education for Prehospital Professionals. 2 nd edition. Jones & Bartlett. 2006.
      • Rahm, S. Pediatric Case Studies for the Paramedic. AAOS. 2006.
      • Region X SOP’s. Amended 1/08.
      • www.peds.umn.edu/.../teaching/lung/
      • stridor.jpg