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Pediatrics CME 2006


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Pediatrics CME 2006

  1. 1. Pediatrics CME Nick Mark, EMT-C
  2. 2. Outline <ul><li>Background: Pediatrics in EMS </li></ul><ul><li>General Pediatric Assessment Strategies </li></ul><ul><li>Pediatric Emergencies </li></ul><ul><ul><li>Respiratory Emergencies </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><li>Scenarios </li></ul>
  3. 3. Background: Pediatrics in EMS <ul><li>Pediatrics constitute over 50% of ER visits but only about 5% of EMS calls are for pediatric patients. </li></ul><ul><ul><li>Why is this? </li></ul></ul><ul><li>This has two consequences: </li></ul><ul><ul><li>EMS providers have few opportunities to practice working with pediatric patients </li></ul></ul><ul><ul><li>The few calls we do get for pediatric patients tend to be more serious </li></ul></ul>
  4. 4. Background: Pediatrics in EMS <ul><li>Some common pediatric emergencies include: </li></ul><ul><ul><li>FBAO </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Meningitis </li></ul></ul><ul><ul><li>Respiratory distress </li></ul></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>SIDS </li></ul></ul><ul><ul><li>Trauma </li></ul></ul>
  5. 5. Pediatric Age Groups <ul><li>Newborn (first 6 hours) </li></ul><ul><li>Neonate (first 28 days) </li></ul><ul><li>Infant (first year) </li></ul><ul><li>Toddler (1 to 3 years) </li></ul><ul><li>Preschooler (3 to 5 years) </li></ul><ul><li>School age (6 to 12 years) </li></ul><ul><li>Adolescent (12 to adulthood) </li></ul><ul><li>How much does a child weigh at each age? </li></ul>
  6. 6. Pediatric Assessment Techniques <ul><li>Initial Assessment (quick assessment that can be done within seconds of arriving on scene) </li></ul><ul><ul><li>A ppearance </li></ul></ul><ul><ul><ul><li>Mental status (alert, crying, obtunded, no response) </li></ul></ul></ul><ul><ul><ul><li>Muscle tone (moving, not moving, limp) </li></ul></ul></ul><ul><ul><li>B reathing </li></ul></ul><ul><ul><ul><li>Respiratory rate (too fast, too slow, irregular) </li></ul></ul></ul><ul><ul><ul><li>Respiratory effort (use of accessory muscles, nasal flaring, retractions, grunting) </li></ul></ul></ul><ul><ul><ul><li>Check breath sounds </li></ul></ul></ul><ul><ul><li>C irculation </li></ul></ul><ul><ul><ul><li>Skin color (pallor, peripheral cyanosis, central cyanosis) </li></ul></ul></ul><ul><ul><ul><li>Capillary Refill (normal is within 2 seconds) </li></ul></ul></ul><ul><ul><ul><li>Pulse (too fast, too slow, irregular, normal) </li></ul></ul></ul>
  7. 7. Pediatric Assessment Techniques <ul><li>Detailed assessment </li></ul><ul><ul><li>With adults this is typically done head to toe, with pediatrics it is better to do the opposite </li></ul></ul><ul><ul><ul><li>Why? </li></ul></ul></ul><ul><ul><li>Take a SAMPLE history (use the parents for detailed hx if possible) </li></ul></ul><ul><ul><li>Determine </li></ul></ul><ul><ul><ul><li>Hx of fever or infection </li></ul></ul></ul><ul><ul><ul><li>Hx of vomitting or fever and check hydration status (skin turgor, check fontanalles in infants, look for xerosis) </li></ul></ul></ul><ul><ul><ul><li>Frequency of urination </li></ul></ul></ul><ul><ul><ul><ul><li>Why are these important questions to ask? </li></ul></ul></ul></ul><ul><ul><li>Take vitals and measure pulse oximetry </li></ul></ul><ul><ul><ul><li>How is pulse oximetry different in pediatrics than in adults? </li></ul></ul></ul>
  8. 8. Pediatric Assessment Techniques <ul><li>Detailed assessment (cont.) </li></ul><ul><ul><li>Try to invent a game you can play or begin a conversation about something you can talk about for at least several minutes ( Batman , Sesame Street , toys, school, etc.). </li></ul></ul><ul><ul><li>Explain each step in your assessment (“now I’m going to feel your tummy…”). </li></ul></ul><ul><ul><li>With older patients explain why you are doing each step (“I need to make sure your stomach is OK”). </li></ul></ul><ul><ul><li>With younger patients, avoid separating them from their parents if possible. </li></ul></ul><ul><ul><ul><li>Why? </li></ul></ul></ul>
  9. 9. Pediatric Assessment Techniques <ul><li>Detailed assessment (cont.) </li></ul><ul><ul><li>Explain things as simply as possible avoiding technical terminology and jargon. </li></ul></ul><ul><ul><li>Do NOT condescend. </li></ul></ul><ul><ul><li>Do NOT lie or make promises you cannot be sure to keep. </li></ul></ul><ul><ul><li>Be alert for injuries that seem inconsistent with their explanation – this is usually a sign of child abuse. </li></ul></ul><ul><ul><ul><li>Examples? </li></ul></ul></ul><ul><ul><li>If you suspect child abuse, you must report it by calling 1-800-RICHILD. </li></ul></ul>
  10. 10. Normal Vital Signs by Age <ul><li>In general remember as children age their pulse and breathing rates get slower, and their BP gets higher. </li></ul><ul><li>By adolescence these values approach those of adults. </li></ul><ul><li>Two general rules (for children 1-10): </li></ul><ul><ul><li>Weight in kg = 2 x age (in years) + 8 </li></ul></ul><ul><ul><li>Lowest permissible systolic BP = 70 + 2 x age (in years) </li></ul></ul>
  11. 11. Normal Vital Signs by Age <ul><li>Age Breaths/Min Beats/Min Minimum Systolic BP </li></ul><ul><li>Neonate 30-50 120-160 60 </li></ul><ul><li>Infant 20-30 80-140 70 </li></ul><ul><li>Toddler 20-30 80-130 74-76 </li></ul><ul><li>Preschool 20-30 80-120 76-80 </li></ul><ul><li>School Age 12-30 60-100 80-84 </li></ul><ul><li>Adolescent 10-20 60-100 84-90 </li></ul>
  12. 12. Respiratory Emergencies
  13. 13. Respiratory Emergencies <ul><li>Respiratory distress is the leading cause of ER visits and EMS calls for children </li></ul><ul><li>Respiratory compromise is one of the leading causes of death in children </li></ul><ul><ul><li>What is the leading cause of death in children? </li></ul></ul><ul><li>Respiratory emergencies can effect children of all ages </li></ul><ul><li>EMS intervention can be life-saving </li></ul>
  14. 14. Respiratory Emergencies <ul><li>Many different etiologies </li></ul><ul><ul><li>Choking (FBAO) </li></ul></ul><ul><ul><li>Epiglottitis </li></ul></ul><ul><ul><li>Croup </li></ul></ul><ul><ul><li>Asthma </li></ul></ul><ul><ul><li>Bronchiolitis </li></ul></ul><ul><ul><li>Which of these is most common? Which is most serious? </li></ul></ul>
  15. 15. The Pediatric Airway <ul><li>Several key differences between adult and pediatric airway </li></ul><ul><ul><li>Larger floppier epiglottis </li></ul></ul><ul><ul><ul><li>Epiglottitis </li></ul></ul></ul><ul><ul><ul><li>More difficult intubations </li></ul></ul></ul><ul><ul><li>Smaller, funnel shaped trachea </li></ul></ul><ul><ul><ul><li>FBAO is more likely </li></ul></ul></ul><ul><ul><ul><li>No blind finger sweeps </li></ul></ul></ul><ul><ul><ul><li>Why? </li></ul></ul></ul>
  16. 16. Respiratory Emergencies - FBAO <ul><li>Foreign Body Airway Obstruction (FBAO) </li></ul><ul><ul><li>Usual causes are hard candy, nuts, small toys, coins, and balloons </li></ul></ul><ul><li>Recognition </li></ul><ul><ul><li>Apnea, inspiratory stridor, rales, rhonchi, wheezing, inability to speak, anxiety, decreased breath sounds, muffled voice </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>If the patient is not breathing, open the airway and perform the AHA approved maneuvers for clearing the obstruction </li></ul></ul><ul><ul><ul><li>Heimlich, backblows, abdominal or chest compressions. </li></ul></ul></ul><ul><ul><ul><li>If properly trained you may use a laryngoscope with Magills forceps to try and remove the obstruction. </li></ul></ul></ul><ul><ul><li>If patient is breathing, be as calming and supportive as possible. Do not agitate the patient and transport sitting up as comfortably as possible. Be alert for change in status. </li></ul></ul>
  17. 17. Respiratory Emergencies - FBAO <ul><li>Treatment (cont.) </li></ul><ul><ul><li>If patient is not breathing ventilate using a BVM. </li></ul></ul><ul><ul><li>Administer oxygen at 15 LPM by NRB. </li></ul></ul><ul><ul><li>If patient is wheezing </li></ul></ul><ul><ul><ul><li>Contact Medical Control for permission to administer ALBUTEROL 2.5 mg (0.083%) by nebulizer over 5-10 minutes. </li></ul></ul></ul><ul><ul><ul><ul><li>For infants younger than 6 months use half the dose. </li></ul></ul></ul></ul>
  18. 18. Respiratory Emergencies – Epiglottitis <ul><li>Inflammation of the epiglottis and surrounding structures caused by bacterial infection. </li></ul><ul><li>This condition is a true emergency with mortality rates as high as 10%. </li></ul><ul><li>Typically occurs in children 3-7 years old. </li></ul>
  19. 19. Respiratory Emergencies – Epiglottitis <ul><li>Recognition </li></ul><ul><ul><li>Rapid onset (6-8 hours) of sore throat, dysphagia , muffled voice, high fever , drooling , inspiratory stridor or rattle </li></ul></ul><ul><ul><li>Child is often found obtunded in tripod position </li></ul></ul><ul><ul><li>Signs of respiratory distress are often present </li></ul></ul>
  20. 20. Respiratory Emergencies – Epiglottitis <ul><li>Treatment </li></ul><ul><ul><li>It is absolutely essential that the patient be handled as calmly as possible. Anxiety or aggravation can cause increased swelling and precipitate respiratory arrest. </li></ul></ul><ul><ul><ul><li>Defer all painful procedures. </li></ul></ul></ul><ul><ul><ul><li>Transport patient sitting up in position of comfort. </li></ul></ul></ul><ul><ul><ul><li>Do not try to visualize the swelling or look in the mouth. </li></ul></ul></ul><ul><ul><li>Administer high flow humidified O 2 by NRB. </li></ul></ul><ul><ul><li>Administer 5 ml of EPINEPHRINE 1:1,000 by nebulizer. This can reduce upper airway swelling. </li></ul></ul><ul><ul><li>Have airway equipment (BVM, ET equip) ready in case patient’s condition deteriorates. </li></ul></ul><ul><ul><li>Inform medical control early so preparations can be made at hospital for treatment. </li></ul></ul>
  21. 21. Respiratory Emergencies – Croup <ul><li>Inflammation of the upper airways caused by a viral infection. </li></ul><ul><li>Very common (50 per 1000 children) </li></ul><ul><li>Usually occurs in children aged 6 months to 3 years. (median age of onset is 18 months). </li></ul>Sites of inflammation in pediatric airway infections
  22. 22. Respiratory Emergencies – Croup <ul><li>Recognition </li></ul><ul><ul><li>Low grade fever , barking cough , hoarseness, inspiratory stridor, wheezing </li></ul></ul><ul><ul><li>Signs of respiratory distress </li></ul></ul><ul><ul><li>Often occurs at night </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Same as for epiglottitis. </li></ul></ul><ul><ul><li>The patient is likely to respond well to cool humidified O 2 . </li></ul></ul>
  23. 23. Respiratory Emergencies – Epiglottitis vs. Croup <ul><li>Croup </li></ul><ul><li>6 months – 3 years </li></ul><ul><li>Slow onset </li></ul><ul><li>Barking cough </li></ul><ul><li>No drooling </li></ul><ul><li>Low grade fever (<104 °F ) </li></ul><ul><li>Responds well to tx </li></ul><ul><li>Moderately serious </li></ul><ul><li>Epiglottitis </li></ul><ul><li>3 – 7 years </li></ul><ul><li>Rapid onset </li></ul><ul><li>No barking cough </li></ul><ul><li>Copious drooling </li></ul><ul><li>High fever (>104 °F) </li></ul><ul><li>Very Serious </li></ul>
  24. 24. Respiratory Emergencies – Asthma <ul><li>In contrast to croup & epiglottitis, asthma is inflammation of the lower airways. </li></ul><ul><li>It is very common (effects 50-100 out of 1000 children under 10 YO) </li></ul>
  25. 25. Respiratory Emergencies – Asthma <ul><li>Recognition </li></ul><ul><ul><li>Typically it is either exercise, allergy, or infection induced </li></ul></ul><ul><ul><li>S/Sx include wheezing , prolonged expiration, tachypnea , dyspnea, and anxiety </li></ul></ul><ul><ul><li>A silent chest is an especially bad sign. </li></ul></ul><ul><ul><ul><li>Why? </li></ul></ul></ul>
  26. 26. Respiratory Emergencies – Asthma <ul><li>Treatment </li></ul><ul><ul><li>Administer cool humidified oxygen. </li></ul></ul><ul><ul><li>Provide ventilations if breathing is inadequate. </li></ul></ul><ul><ul><li>Contact Medical Control for permission to administer ALBUTEROL 2.5 mg (0.083%) by nebulizer over 5-10 minutes. </li></ul></ul><ul><ul><ul><li>For infants younger than 6 months use half the dose. </li></ul></ul></ul><ul><ul><li>If patient has severe respiratory distress, administer EPINEPHRINE 1:1,000 0.01 mg/kg SQ. </li></ul></ul><ul><ul><ul><li>Maximum dose is </li></ul></ul></ul><ul><ul><ul><ul><li>0.3 mg in pt. > 20 kg </li></ul></ul></ul></ul><ul><ul><ul><ul><li>0.2 mg in pt. < 20 kg </li></ul></ul></ul></ul><ul><ul><ul><ul><li>0.1 mg in pt. < 10 kg </li></ul></ul></ul></ul><ul><ul><ul><li>For patients with cardiac problems call medical control before administering EPINEPHRINE. </li></ul></ul></ul><ul><ul><ul><li>What are some potential problems that EPINEPHRINE and ALBUTEROL can cause? What should you be alert for when giving these drugs? </li></ul></ul></ul>
  27. 27. Respiratory Emergencies – Bronchiolitis <ul><li>Bronchiolitis is a viral inflammation of the lower airways. </li></ul><ul><li>It usually effects children under 2 YO. </li></ul><ul><li>Usually presents with symptoms similar to those of asthma. </li></ul><ul><li>Can be very serious in infants. </li></ul><ul><ul><li>Why do you think this is? </li></ul></ul><ul><li>More common in the winter months. </li></ul>
  28. 28. Respiratory Emergencies – Bronchiolitis <ul><li>Recognition </li></ul><ul><ul><li>Wheezing and tachypnea are most common symptoms. Also anxiety, shortness of breath, and cyanosis. </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Same as asthma </li></ul></ul><ul><ul><li>Patient is not as likely to respond well to β -agonists (EPI, ALBUTEROL) </li></ul></ul>
  29. 29. Respiratory Emergencies – Asthma vs. Bronchiolitis <ul><li>Asthma </li></ul><ul><li>Occurs in all ages, more common in children > 2 YO </li></ul><ul><li>Occurs throughout the year </li></ul><ul><li>Family hx of asthma </li></ul><ul><li>Responds well to β -agonists (EPI and ALBUTEROL) </li></ul><ul><li>Bronchiolitis </li></ul><ul><li>Usually occurs in children under 2 YO </li></ul><ul><li>Most common in winter, spring </li></ul><ul><li>No family hx </li></ul><ul><li>Does NOT respond well to EPI/ALBUTEROL </li></ul>
  30. 30. Respiratory Emergencies General Notes <ul><li>Treat respiratory emergencies aggressively. Be prepared for patients to decompensate. </li></ul><ul><li>Do not hesitate to give neonates oxygen if you suspect they need it. </li></ul><ul><li>Remember to treat the parents too. </li></ul>
  31. 31. Seizures
  32. 32. Pediatric Seizures <ul><li>A seizure is caused by abnormal electrical activity in the brain. </li></ul><ul><li>Seizures can cause impaired consciousness and/or abnormal behavior. </li></ul><ul><li>There are many causes of seizures including: </li></ul><ul><ul><li>Epilepsy </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Neoplasm </li></ul></ul><ul><ul><li>Metabolic problems (electrolytes, uremia, hypoxia, acidosis, etc.) </li></ul></ul><ul><ul><li>Hypoglycemia </li></ul></ul><ul><ul><li>Poisoning </li></ul></ul><ul><ul><li>Hyperthermia </li></ul></ul><ul><ul><li>Which of these causes do you think is most common in children? Which do you think is usually most serious? </li></ul></ul>
  33. 33. Pediatric Seizures <ul><li>Types of pediatric seizures </li></ul><ul><ul><li>Grand mal (tonic clonic) </li></ul></ul><ul><ul><li>Petit mal (absence) </li></ul></ul><ul><ul><li>Partial </li></ul></ul><ul><ul><li>Status epilepticus </li></ul></ul><ul><ul><li>Which type is most common is children? </li></ul></ul><ul><li>Stages of a grand-mal </li></ul><ul><ul><li>Aura </li></ul></ul><ul><ul><li>Tonic-clonic </li></ul></ul><ul><ul><li>Postictal </li></ul></ul>
  34. 34. Pediatric Seizures - Febrile <ul><li>Febrile seizures are caused by fever resulting from a viral infection. </li></ul><ul><li>Very common (20-50 per 1000) in children under 7 YO. </li></ul><ul><li>Most common in children aged 6 months to 5 years. </li></ul><ul><li>There is usually a family history. </li></ul><ul><li>They are usually benign. </li></ul><ul><ul><li>If they are longer than 20 minutes they are probably not febrile and indicate something much more serious. </li></ul></ul>
  35. 35. Pediatric Seizures <ul><li>Recognition </li></ul><ul><ul><li>Seizure phase: unresponsiveness, involuntary skeletal muscle contractions, dyspnea, apnea </li></ul></ul><ul><ul><li>Postictal phase: confusion, altered LOC, retrograde amnesia </li></ul></ul>
  36. 36. Pediatric Seizures <ul><li>Treatment </li></ul><ul><ul><li>Protect the airway </li></ul></ul><ul><ul><ul><li>Place patient LLR </li></ul></ul></ul><ul><ul><ul><li>Suction to clear vomit </li></ul></ul></ul><ul><ul><ul><li>Use airway adjunct and ventilate if patient is apneic </li></ul></ul></ul><ul><ul><li>Protect patient from injury </li></ul></ul>
  37. 37. Pediatric Seizures <ul><li>Treatment (cont.) </li></ul><ul><ul><li>Take a thorough history of the parents to try and R/O differentials </li></ul></ul><ul><ul><ul><li>Hx of medical problems </li></ul></ul></ul><ul><ul><ul><li>Medication use </li></ul></ul></ul><ul><ul><ul><li>Possibility of head injury </li></ul></ul></ul><ul><ul><ul><li>Recent illness (fever, nucal rigidity, photophobia, phonophobia) </li></ul></ul></ul><ul><ul><ul><li>Possibility of poisoning </li></ul></ul></ul><ul><ul><li>Other important questions </li></ul></ul><ul><ul><ul><li>Did patient vomit during the seizure? </li></ul></ul></ul><ul><ul><ul><li>Duration of seizure? </li></ul></ul></ul><ul><ul><ul><li>Description of seizure </li></ul></ul></ul><ul><ul><ul><li>Condition of child when found </li></ul></ul></ul><ul><ul><ul><li>Last meal </li></ul></ul></ul><ul><ul><li>Why are these important questions to ask? </li></ul></ul>
  38. 38. Pediatric Seizures <ul><li>Treatment </li></ul><ul><ul><li>Manage the airway and provide oxygen </li></ul></ul><ul><ul><li>If patient is febrile (temp > 102 °F) administer ACETAMINOPHEN 15 mg/kg rectally. </li></ul></ul><ul><ul><li>Check blood glucose using glucometer </li></ul></ul><ul><ul><li>If bG is < 60 mg/dl (or if you suspect hypoglycemia) </li></ul></ul><ul><ul><ul><li>If patient is awake with intact gag reflex who can swallow, administer ORAL GLUCOSE 15 gm PO. (If pt. is younger than one year, contact medical control.) </li></ul></ul></ul><ul><ul><ul><li>For patients without an intact gag reflex, contact medical control and administer GLUCAGON 0.1 mg/kg (max dose 1.0 mg) IM. </li></ul></ul></ul>
  39. 39. Pediatric Seizures General Notes <ul><li>Never assume “it’s just a febrile seizure.” </li></ul><ul><li>All patients who have a seizure should be transported for evaluation. </li></ul><ul><li>Always consider differential causes especially trauma, hypoglycemia, and OD. </li></ul><ul><li>Seizure activity ALWAYS extremely serious in a neonate. </li></ul><ul><li>Remember to treat the parents too. </li></ul>
  40. 40. Scenarios