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Pediatric presentation

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    • 1. SACRAMENTO COUNTY PEDIATRIC PROTOCOLS
    • 2. PT NOT YET DELIVERED CHILDBIRTH-Transport mother in Left Lateral Recumbent position to appropriate facility.**ALS-If Pt (mother) hemodynamically unstable-Obtain IV access with NS; titrate to a systolic blood pressure between 90 - 100 mm Hg. O2- Airway- Transport in proper positionABNORMAL PRESENTATION-(i.e. foot, buttocks, hand or face), place patient in the knee-chest or left lateral position. IMMEDIATE TRANSPORT.DELIVERY IN PROGRESS-Control descent of fully crowned head with your hand over the cranium.-Suction mouth and nose with bulb syringe before newborn takes 1st breath. Ensure - cord around neck*If the cord is around the neck, gently slip it over the head or shoulder if possible.-If the cord cannot be removed, gently clamp the cord in two locations approximately 1cm apart and cut the cord between the clamps-Support the head; keep pressure off the cord ***Prepare to transport immediately.When the head is delivered, it will rotate naturally to face laterally. Gently lower the head to deliver the anterior (upper) shoulder.-When the upper shoulder is delivered, raise the head to deliver the lower shoulder. The remainder of the baby’s body should then deliver smoothly.-Suction the mouth first, then the nose. Hold baby in slightly head down position.-Clamp and cut the cord with scissors/scalpel. Leave a minimum of six (6) inches of cord for the umbilicus.*Do not delay drying and warming the newbornDELIVERY PTA OF EMS, OR ALS-If resuscitation not necessary, suction mouth then nose w/ bulb syringe then dry and place newborn skin to skin with mother, apply cap to babys head.-Clamp and cut cord, leaving 6” from umbilicus, warm baby first. *Begin cardiopulmonary resuscitation as needed. See NEONATAL RESUSCITATION** ALS-If mother’s B/P < 90, heavy bleeding or signs of shock, refer to SHOCK protocol.-Massage abdomen over the uterus (fundus) to aid in contraction. Putting the infant to the mothers breast (if infants condition allows) will also stimulate contraction.-DO NOT attempt to deliver placenta, if delivered, bag and transport in with mother.PROLAPSED CORD VISIBLE AT PERINEUM-High flow O2, place in Knee-Chest position, insert a gloved hand into the vagina and gently push the presenting part off of the cord.If head is crowning with the prolapsed cord, immediate delivery is the most rapid means of restoring oxygen to the infant. If an abnormal presentation is noted- TRANSPORT.Trigger Points:-Of all 11 hospitals, only KHN and SGH are NON-L&D hospitals. (so do not transport there)- The vast majority of deliveries are completely uncomplicated and require minimal, if any, assistance-The major life threats are prenatal/neonatal asphyxia and maternalhemorrhage.- Neonatal hypothermia is an easily preventable threat.APGAR-Assess at birth and at five (5) minutes after birth.If APGAR of 7 or greater - dry, place skin to skin with mother or if mother refuses, wrap and keep warm. Admin. blow-by oxygen w/ trans. NEONATAL protocol as needed SIGN 0 1 2 APPEARANCE COLOR CENTRAL CYANOSIS PERIPHERAL NORMAL PULSE HEART RATE ABSENT CYANOSIS <100 (SLOW) > 100 GRIMACE REFLEX - RESPONSE + GRIMACE COUGH/SNEEZE ACTIVITY MUSCLE TONE LIMP SOME MOVEMENT ACTIVE MOTION RESPIRATIONS RESPIRATIONS ABSENT IRREGULAR/SLOW +CRYING
    • 3. PEDIATRIC PARAMETERS RESPIRATORY ET TUBE AGE WEIGHT (KG) HEART RATE SYSTOLIC B/P ET TUBE SIZE BLADE # RATE DEPTH DIFFICULT TO PREMIE <3 100-190 40-60 2.5 7 0-STRAIGHT OBTAINNEONATE 3-4 90-190 30-60 50-70 3.5 9 1-STRAIGHT6 MONTHS 5-7 80-180 25-40 60-110 3.5 11 1-STRAIGHT 1 YEAR 10 80-150 20-40 70-110 4.0 12 1-STRAIGHT 3-4 YEARS 15 80-140 20-30 80-115 5.0 16 2-STRAIGHT 5-6 YEARS 20 70-120 20-25 80-115 5.5-6.0 16 2-STRAIGHT 7-8 YEARS 25 70-110 20-25 85-120 5.5-6.0 18 2-311-12 YEARS 35 60-110 15-20 95-135 5.5-7.0 20 2-3CAVEATS:A) Unless otherwise stated, pediatric protocols apply to patients 14 AND under. If no known age, work based off pt’s physical signs (puberty, adolescence) boys-armpithair girls-breast developmentB) V/S vary with age, with children BP increases with age, HR decreases with age. Around 12 years old V/S more comparable with AdultsC) Hypotension, late sign of shock, indicates imminent Cardiorespiratory arrest. Children may lose up to 25% of blood volume before becoming hypotensiveD) For ages not listed above use judgementE) Broselow Tape is very helpful in Pt weight determination and proper drug dose administration
    • 4. Y.G.W.I.G.W.T.???
    • 5. NEONATAL RESUSCITATION -Assess for meconium staining: if newborn not vigorous (HR >100bpm, + respiratory effort and good muscle tone- Tracheal Suction w/ ET tube and Meconium Aspirator. *Meconium-Important to clear airway w/ suction before stimulating newborn to breath -Suction the airway (Mouth then Nose) -Dry Newborn -Stimulate newborn and Warm w/ blanket. Assessment - If breathing inadequate -OR- Cyanotic then PPV w/ O2 @ 40-60 ensuring + chest riseHEART RATE > 100 BPM-Monitor breathing, O2 w/ flow as needed, TransportHEART RATE < 100 BPM-PPV w/ O2 @40-60/min ensuring + chest rise. *30 seconds then reassess, (use proper size BVM)-Airway adjuncts as needed. * most bradycardias corrected w/ good ventilation 100% O2.-ECG monitor and TransportHEART RATE < 60 BPM-PPV w/ O2 @40-60/m ensuring + chest rise. *30 seconds then reassess, (use proper size BVM)-Intubate and ventilate 100% O2. *PPV acceptable alternative to ETI if good seal present-ECG monitoring, ***If HR remains below 60bpm after 30seconds of BVM -Chest compressions 3:1 (90c/30v) for ~120 events/minAfter 30 sec PPV/Comp and still <60HR: Epinephrine 1:10,000- .01mg/kg IV/IO q 3-5 until >80bpm TRANSPORT
    • 6. PEDIATRIC DYSRHYTHMIAS BRADYCARDIA ABC’s, Oxygen, Attach ECG Monitor Begin Chest Compressions if HR <60 BPM post O2/Ventilation ALS Airway as needed Establish IV/IO Access EPINEPHRINE 0.01mg/kg IV/IO 1:10,000 q 3-5 min ATROPINE 0.02 mg/kg IV/IO q 3-5 (minimum dose 0.1mg, max single dose of 1.0mg) TRANSCUTANEOUS PACING @80-100 BPM adjust mA to capture TRANSPORT VENTRICULAR TACHYCARDIA >150 BPM Assess ABC’s, Oxygen, ECG monitor ALS Airway as needed If normal perfusion- Valsalva Maneuver, Transport If not, Consider IV w/ fluid challenge 20ml/kg if possibly hyppovolemic If perfusion diminished or Pt poorly responsive, See BASE ORDER BELOW NARROW TACHYCARDIA >220BPM Assess ABC’s, Oxygen, ECG monitor ALS Airway as needed If normal perfusion-Transport If not, Establish IV/IO Access If perfusion diminished or Pt poorly responsive, See BASE ORDER BELOWBASE HOSPITAL ORDER: PERFUSION DIMINISHED OR POORLY RESPONSIVE PT -VERSED 0.1mg/kg, not to exceed 1mg, SLOW IVP/IM SYNCHRONIZED CARDIOVERSION- 1 Joules/kg, check rhythm, if no response then, SYNCHRONIZED CARDIOVERSION- 2 Joules/kg, check rhythm, if no response then, SYNCHRONIZED CARDIOVERSION- 4 Joules/kg, check rhythm, if no response then... --TRANSPORT--
    • 7. PEDIATRIC CARDIAC ARREST Assess responsiveness, spontaneous respirations and pulses Initiate CPR BVM 100% O2 @15 lpm w/ BLS airway Attach Monitor and prepare for immediate transport VF/VT PEA/ ASYSTOLE DEFIBRILLATE @ 2J/KG Intubate w/ 100% O2 Check rhythm-Shockable? Establish IV/IO access- give 20 ml/kg of NS bolus (may rpt If so; DEFIBRILLATE @ 4J/KG x2)*TKO post bolus Intubate w/ 100% O2 EPINEPHRINE 1;10,000 - 0.01mg/kg IV/IO q 3-5 Establish IV/IO access- give 20 ml/kg of NS bolus TRANSPORT EPINEPHRINE 1;10,000 - 0.01mg/kg IV/IO q 3-5 DEFIBRILLATE @4J/KG SEARCH FOR & TREAT H’S/T’S LIDOCAINE 1.0 mg/kg IV/IO (max 100mg) -HYPOVOLEMIA DEFIBRILLATE @4J/KG -HYPOXIA TRANSPORT -HYDROGEN ION (ACIDOSIS)***DO 5 Cycles (~2 mins) CPR post Shock THEN reassess for return spontaneous circulation -HYPO-HYPERKALEMIA -HYPOGLYCEMIA -HYPOTHERMIA -TOXINS -TAMPONADE-CARDIAC -TENSION PNEUMOTHORAX POST RESUSCITATION CONSIDERATIONS -THROMBOSIS 1.IV fluids should be placed TKO unless Hypotension exists -TRAUMA -Bradycardia- tx per protocol -Hypotension/Shock -20 ml/kg NS, may repeat once, reassess v/s post each bolus -assess Cap Refill 2 secs, brachial/femoral pulses (absent/weak/present) -Systolic BP for >1 year a. 90mmHg + (2x age in years) b. 70mmHg + (2x age in years) LOWER END BASE HOSPITAL ORDER ONLY: DOPAMINE @ 10mcg/kg/min, if Hypotensive
    • 8. PEDIATRIC AIRWAY OBSTRUCTION/RESPIRATORY ARREST PARTIAL AIRWAY OBSTRUCTION BY F.B.O.-Conscious Able to speak, cry or cough -REASSURE PT- Encourage coughing -OXYGEN- Administered as indicated -SUCTION- Per need to control secretions -Transport in position of comfort COMPLETE AIRWAY OBSTRUCTION BY F.B.O.-Conscious Unable to speak, cry or cough -AGE 1 and UNDER- Back blows/Chest Thrusts, 5 each alternating -AGE 1 and OVER- Heimlich, abdominal thrusts, reassess. If not clear repeat until pt unconscious, OXYGEN + TRANSPORT IF Airway cleared AIRWAY OBSTRUCTION BY F.B.O.-Unconscious -Begin chest compressions -Attempt to visualize airway prior to ventilation attempt to remove any potential FBO. - blind finger sweeps ALS-Use proper laryngoscope blade and Magill forceps -Begin ventilations -Transport pt along with FBO removed from airway RESPIRATORY ARREST ABC’S w/ O2, if airway obstructs, go to that protocol TRANSPORT Intubate w/ 100% O2 Attempt IV/IO access TKO Blood Sugar determination DEXTROSE-0.5gm/kg of 25% IV to max of 25g if <60 mg/dl
    • 9. PEDIATRIC RESPIRATORY DISTRESS ASTHMA/BRONCHOSPASM MILD/MODERATE- PT’S w/ intercostal retractions, nasal flaring and >2 sec cap refill O2 flow as needed, Transport ALBUTEROL 2.5mg HHN; reassess after first tx, rpt as needed based on reassessment SpO2-titrate >92% ECG Monitoring SEVERE- Pt may be unable to speak, have decreased/elevated v/s (SBP/Pulse) or AMS BLS/ALS Airway as needed, high flow O2, Transport SpO2-titrate >92% ALBUTEROL 2.5mg HHN continuously EPINEPHRINE 0.01mg/kg 1;10,000 SC, to max .3ml (1mg/ml solution) Establish IV access w/ NS @ TKO. Not to take precedence over Alb/Epi admin ECG Monitoring CROUP/STRIDOR MILD/MODERATE-Slow onset, barking cough, fever and respiratory stridor. *Unilateral stridor may be due to bronchial FBO BLS Airway as needed, Oxygen, Transport in position of comfort NS: 3ml HHN, Reassess after 1st TreatmentSEVERE- Pt unable to speak, pt may have decreased/elevated v/s (SBP/Pulse); Mental status is altered. *Unilateral stridor may be due to bronchial FBO BLS/ALS Airway as needed SpO2-titrate >92% EPINEPHRINE 0.01mg/kg 1;10,000 SC, to max .3ml (1mg/ml solution) Establish IV access w/ NS @ TKO. Not to take precedence over Epi admin ECG Monitoring
    • 10. ALLERGIC REACTION/ANAPHYLAXIS ALLERGIC REACTIONLocal response to an antigen, involves skin (rash, hives, edema) w/ normal v/s. ANY airway involvement (wheezing, stridor, oral/facial edema) will be treated as Anaphylaxis. Reassess often and prepare to tx for Anaphylaxis. Oxygen, Airway adjuncts as needed, Remove sting/injection, Transport w/ Tx simultanously Consider BENADRYL- 1mg/kg PO, IV, IM to a max of 50mg. ANAPHYLAXIS Systemic response to an antigen involving 2 or more organ systems OR any upper/lower airway involvement OR any derangement in V/S Oxygen, Airway adjuncts as needed, Remove sting/injection, Transport w/ Tx simultaneously EPINEPHRINE 0.01mg/kg of 1:1,000 SC to max of 0.3mg, rpt q 15 to max of 3 doses, until minimal SBP for pt’s age is achieved or + improvement w/ symptoms Establish IV w/ NS (if hypotensive) 20 ml/kg bolus, reassess after each. ECG Monitoring BENADRYL- 1mg/kg IV or IM to a max of 50mg. ALBUTEROL 2.5mg HHN for wheezing, reassess after 1st tx, rpt as needed BASE HOSPITAL ORDER ONLY EPINEPHRINE 0.01 mg increments of 1:10,000, slow IV/IO for stridor AND hypotension, until minimal SBP reached OR total of 0.01mg/kg given.
    • 11. DECREASED SENSORIUM SUSPECTED HYPOGLYCEMIA Suspected hypoglycemia w/ 1) decreased responsiveness (Pedi GCS < 14) OR 2) w/ a Hx of Diabetes Oxygen, Airway, C-Spine (as needed) Perform BG determination Initiate IV w/ NS TKO-titrate SBP DEXTROSE 0.5g/kg IV push, max of 25g if BS <60 GLUCAGON 0.5 mg IM if BS <60 Oral Glucose if pt able to swallow and +gag reflex, test w/ water first. TRANSPORT SUSPECTED NARCOTIC OVERDOSE Clinical findings may include pin-point pupils, dec sensorium, respiratory depression/insufficiency, bradycardia or hypotension Oxygen, Airway, C-Spine (as needed), Protect pt if seizing. Initiate IV w/ NS TKO-titrate SBP Perform BG determinationNARCAN 0.1mg/kg IV/IM (IM if - IV possibility) titrated to respiratory status or max of 2mg If - improvement, consider 2 more doses for total of 3. Continuous reassessment BASE HOSPITAL ORDER ONLY: NARCAN 0.1mg/kg IN - titrate to respiratory status ECG Monitoring TRANSPORT SEIZURES Active generalized seizing, focal seizing w/ respiratory compromise or recurrent seizure w/o lucid interval Oxygen, Airway, C-Spine, Protect PT, Consider cooling if appears febrile in nature Perform BG determination- if <60, go to hypoglycemia protocol if - seizure activity, +improvement, continue transport If seizure activity continues: Initiate IV w/ NS TKO-titrate SBP Continuous Seizures:VERSED- 0.1 mg/kg slow IVP/IM (Max of 4.0mg) in 1-2mg increments, titrated to seizure control IN- 0.2mg/kg (Max of 6.0mg) TRANSPORT
    • 12. PEDIATRIC OVERDOSE/POISONING OVERDOSE Oxygen, Airway adjuncts, Transport ECG Monitoring Follow appropriate protocol if PT seizing or is hypotensive If non-responsive, - gag, - ability to swallow, unstable or unprotected airway, go to Dec. Sensorium CALCIUM CHANNEL BLOCKER OVERDOSE Initiate IV/IO w/ NS- TKO rate FLUID CHALLENGE- 20ml/kg NS if SBP < age appropriate ATROPINE 0.02mg/kg IV/IO;minimum 0.1mg q 5 for age specific Bradycardia AND Hypotension EPINEPHRINE-up to 1.0mg in 0.1mg increments:10,000 slow IVP/IO, over 60 seconds if SBP remains low. Repeat until SBP increases for minimum age. BETA BLOCKER OVERDOSE Initiate IV w/ NS- TKO rate FLUID CHALLENGE- 20ml/kg NS if SBP < age appropriate ATROPINE 0.02mg/kg IV/IO;minimum 0.1mg q 5 for age specific Bradycardia AND Hypotension GLUCAGON 0.05 mg/kg IV/IO if HR/SBP below normal for age.EPINEPHRINE-up to 1.0mg in 0.1mg increments:10,000 slow IVP/IO, over 60 seconds if SBP remains low. Repeat until SBP increases for minimum age. TRICYCLIC AND RELATED COMPOUNDS Initiate IV/IO w/ NS- TKO rate FLUID CHALLENGE- 20ml/kg NS if SBP < age appropriate SODIUM BICARBONATE- 1 mEq/kg IV/IO if ANY of following signs of cardiac toxicity: 1) HR 20 bpm >than max for age 2) SBP < Minimum for age 3) QRS > .12 msec 4) Seizures 5) PVC’s > 6/min
    • 13. PEDIATRIC BURNS TREATMENT -Remove PT from burn source, also remove burning/smoldering clothing Oxygen, Airway Adjuncts as needed ESTABLISH LARGE BORE IV ACCESS >9% TBSA - 20 ml/kg NS fluid bolus if Hypotensive for age (major burns) IV ACCESS as follows: 1) unburned upper extremity or Jugular 2) unburned lower extremity 3) burned upper extremity 4) burned lower extremity 5) IO infusion if Hypotensive ECG Monitoring-Follow appropriate Protocol Assess for inhalation injuries, singed nasal hair, facial/neck/chest burns, soot around mouth, Chemicals suspected DRY STERILE DRESSINGS TO BE PLACED ON BURNED AREAS CAUSTIC CHEMICAL BURNS Remove source, remove all clothing, flush w/ copious amounts of water, DO NOT SCRUB. Wear proper PPE, Sterile water or NS PAIN MANAGEMENT If partial OR full thickness w/o evidence or mechanism of internal HEAD, CHEST or ABDOMINAL injury then administer:MORPHINE 0.1 mg/kg IV/IM for max loading of 10mg, titrate to effect, q 15 on standing orders, MAX 20mg. ***Must contact base hospital for further MS doses. TRANSPORT GUIDELINES UCDMC-Partial thickness >9%, ANY electrical/chemical burn, Evidence of poss. Inhalation injury, ANY burn to Face, hands, feet, genitalia, perineum or major joints -Look for assossiated injuries, Treat SHOCK if present. DO NOT USE creams/ointments/ice Child Body Part/% TBS Palms or hands = 1% Arm (shoulder to fingertips) = 9% Head and neck = 18% Anterior trunk = 18% Posterior trunk = 18% Leg (groin to toe) = 14%
    • 14. PEDIATRIC SHOCK DEFINITIONWhere inadequate tissue perfusion is occurring w/ inability to meet the bodies metabolic demands. S/S: Tachycardia, ALOC, Weak Central Pulses, Weak or Absent peripheral pulses, >4 sec cap refill, Bradycardia, Hypotension and Irregular respirations TREATMENT Oxygen, Airway, Assess/Tx for Trauma (C-Spine?), Maintain Body Temp ECG Monitoring ESTABLISH IV/IO ACCESS w/ NS 20 ml/kg fluid bolus, repeat bolus. Then titrate to a minimal SBP for Pt’s age.
    • 15. PEDIATRIC TRAUMA GUIDELINES/ T.P.’s Time on scene not to exceed 10 minutes under normal circumstances Document occurrences where >10 minute on scene time exists Tx for Trauma varies from Adults w/ Orthopedic trauma, IV Fluids and Transport Destination TREATMENT Oxygen, Airway, ALS Airway as needed, C-Spine, TransportEstablish IV access w/ NS if Hypotensive for age, 20 ml/kg reassess after each bolus. If in extremis thenestablish IO. Same fluid bolus. Titrate SBP to minimal SBP for Pt’s age.1) Amputations- dress stump w/ dry sterile dressing, place part in dry, sterile bag/container and seal closed. Place in melting ice, notdirectly on.2) Evisceration- Cover w/ large saline-soaked dressing-DO NOT replace abdominal contents3) Flail Chest- Hand or pillow to make Pt more comfortable, remove if respirations deteriorate. Assist ventilations as needed.4) Hemorrhage Control- Direct Pressure, Immediate transport essential5) Impaled Object- Only remove if affecting CPR or Respirations, otherwise, secure in place6) Open chest wounds- Occlusive dressing, if (JVD/-bs on one side/falling SBP/Cyanosis/Tracheal shift/Dyspnea) “Burp” dressing TENSION PNEUMOTHORAX 1) Decreased LOC 2) Severe Respiratory Distress 3) S/S of Shock 4) Unilateral decreased BS on w/ hx chest trauma DECOMPRESS SUSPECTED TENSION PNEUMOTHORAX on affected side, 2nd or 3rd intercostal space, mid-clavicular line, w/ 14g catheter, if other side meets same criteria, Decompress it. CAVEAT: If you are unable to access 2nd-3rd intercostal, you may go for 4th-5th intercostal Mid-Axillary line7) Eye Injuries - Chemical- flush w/ NS profusely until at hospital, remove contacts, -Trauma- Cover both eyes loosely, avoid pressure to globes, C-Spine?, Position of comfort, Stabilize impaled objects, cover both eyes8) Head Trauma - Oxygen, Airway, C-Spine, Transport, Tx SHOCK if present -Pressure dressing for scalp bleeds Further Assess: AVPU
    • 16. ORTHOPEDIC TRAUMA ***IF AGE <5 YEARS OLD, CONTACT BASE FOR MORPHINE ADMINISTRATION. FOR PT’S 5 Years old and above w/ severe pain due to amputation, suspected extremety fx (including hip fx) or dislocations where ALL of following exist: 1) Severe pain present 2) No Hx of syncope 3) No evidence of head injury and GCS=15 4) No evidence of torso injury upon complete physical exam 5) SBP > age appropriate MORPHINE 2mg increments @ 1 minute intervals per increment, to a max of 0.1mg/kg OR 10mg Must meet criteria prior to each incremental dose. SPLINTING -If angulated w/ NO pulse- attempt to straighten unless pain/resistance, splint. -If angulated, STABLE w/ GOOD pulses, Splint in position found unless hinders transport. -If SEVERELY angulated, gently straighten, check pulse before/after positioning. Open Fractures- moist, sterile dressings, not to be reduced unless open femur fx. Document presence of open Fx’s.All Critical Trauma Patients less than 15 years of age :will be transported to UCDMC with exceptions below:1. Pediatric patients without an effective airway-Transport to nearest available facility for airway establishment.2. Pediatric trauma patients under CPR will be transported to the time closest trauma facility (MSJ/KHS/SRMC) **do not use SRMC for “Trauma Base”