Module III - The Pediatric Patient
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  • 1. 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
  • 2. 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)
  • 3.
      • 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
  • 4. Pediatric Assessment Triangle - PAT
    • Establishes a level of severity
    • Assists in determining urgency for life support
    • Identifies key physiological problems using observational & listening skills
  • 5. 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
  • 6. PAT - Appearance
    • Reflects adequacy of :
      • Oxygenation
      • Ventilation
      • Brain perfusion
      • Homeostasis
      • CNS function
  • 7. 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
  • 8. 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)
  • 9. 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
  • 10. PAT - Circulation
    • Reflects :
      • Adequacy of cardiac output and perfusion of vital organs (core perfusion)
  • 11. Assessing Circulation
    • Evaluate skin color:
        • Cyanosis reflects decreased oxygen levels in arterial blood
        • Cyanosis indicates vasoconstriction and respiratory failure
        • Trunk mottling indicates hypoxemia
  • 12. 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
  • 13. 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
  • 14. 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
  • 15. 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
  • 16. 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
  • 17. 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
  • 18. 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
  • 19. 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)
  • 20. 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
  • 21. 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
  • 22.
    • 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
  • 23. 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
  • 24. Stridor
    • Harsh, high-pitched sound heard on inspiration associated with upper airway obstruction
    • Sounds like high-pitched crowing or “seal-bark” sound on inspiration
  • 25. 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
  • 26. Nasal Flaring
  • 27. 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
  • 28. 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
  • 29. 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
  • 30. 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
  • 31. 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)
  • 32. 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
  • 33. Tibial tuberosity
  • 34. 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
  • 35. 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)
  • 36.
    • 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
  • 37. 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
  • 38. 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
  • 39. Calculation Practice
    • Your 8 month-old patient weighs 17 pounds
    • Which strength Dextrose should this patient receive by EMS and how much?
  • 40. 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?
  • 41. 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
  • 42. 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!
  • 43. 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
  • 44. 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
  • 45. 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
  • 46. 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
  • 47. 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
  • 48. 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
  • 49. 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
  • 50. 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
  • 51. 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
  • 52. 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
  • 53. 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
  • 54. What Are the Risk Factors That Expose Kids To Seizures?
    • Fever – most common
    • Hypoxia
    • Infections
    • Electrolyte imbalance
    • Head trauma
    • Hypoglycemia
    • Toxic ingestions
    • Tumor
  • 55. 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
  • 56. 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
  • 57. 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!
  • 58. 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?
  • 59. 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
  • 60. 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
  • 61.
    • 5 T’s
      • Tablets – drug overdose
      • Tamponade – supportive care in field
      • Tension pneumothorax – needle decompression
      • Thrombosis, coronary or pulmonary
      • Trauma
  • 62. 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
  • 63. 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
  • 64. 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
  • 65. 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!!!
  • 66. 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
  • 67. Peds Symptomatic Brady
    • Severe cardiorespiratory compromise
      • Poor perfusion
      • Bradycardia
      • Weak, thready, absent pulse
      • Hypotension
      • Pallor
      • Cyanosis
      • Respiratory difficulty
  • 68. 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
  • 69. 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
  • 70. 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
  • 71. 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
  • 72. Signs & Symptoms SVT
    • Irritability
    • Poor feeding
    • JVD
    • Hepatomegaly – enlarged liver
    • Hypotension
    • Children can often tolerate the rapid rate fairly well
  • 73. 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)
  • 74. 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
  • 75. 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
  • 76. 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
  • 77. 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
  • 78. 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
  • 79. 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)
  • 80. 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)!
  • 81. 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
  • 82. 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
  • 83. 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)
  • 84. 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
  • 85. 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
  • 86. 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
  • 87. 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)
  • 88. 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
  • 89. 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)
  • 90. 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)
  • 91. Scenarios
    • Read the following case studies
    • Determine your general impression based on the pediatric assessment triangle (PAT)
    • Determine interventions appropriate to the situation
  • 92. 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?
  • 93. 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
  • 94. 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?
  • 95. 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)
  • 96. 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?
  • 97. 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
  • 98. 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
  • 99. 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
  • 100. 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
  • 101. 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?
  • 102. 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
  • 103. 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!
  • 104. 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
  • 105. 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
  • 106. 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
  • 107. 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
  • 108. 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?
  • 109. 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)
  • 110. 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)
  • 111. 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
  • 112. 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
  • 113. Case Study #5
    • What is your general assessment?
    • What is the GCS?
    • What other assessments need to be done?
    • What interventions are needed?
  • 114. 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
  • 115. 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?
  • 116. 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
  • 117. 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?
  • 118. 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?
  • 119. 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
  • 120. 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