Encountering The Pediatric Patient Condell Medical Center EMS System November 2008 ECRN CE Module III Site Code #10-7200E1...
Objectives <ul><li>Upon successful completion of this module, the ECRN should be able to: </li></ul><ul><ul><li>Review and...
<ul><ul><li>Calculate medication dosages given the patient’s weight </li></ul></ul><ul><ul><li>Calculate the GCS given the...
Pediatric Assessment Triangle - PAT <ul><li>Establishes a level of severity </li></ul><ul><li>Assists in determining urgen...
General Assessment - PAT <ul><li>Performed when first approaching the child </li></ul><ul><ul><li>Does  not  take the plac...
PAT - Appearance <ul><li>Reflects adequacy of : </li></ul><ul><ul><li>Oxygenation </li></ul></ul><ul><ul><li>Ventilation <...
Assessing Appearance <ul><li>Evaluate as you cross the room and before you touch the child: </li></ul><ul><ul><li>Muscle t...
PAT - Breathing <ul><li>Reflects adequacy of  : </li></ul><ul><ul><li>oxygenation </li></ul></ul><ul><ul><li>Ventilation <...
Assessing Breathing <ul><li>Evaluate: </li></ul><ul><ul><li>Body position </li></ul></ul><ul><ul><li>Visible movement of c...
PAT - Circulation <ul><li>Reflects : </li></ul><ul><ul><li>Adequacy of cardiac output and perfusion of vital organs (core ...
Assessing Circulation <ul><li>Evaluate skin color: </li></ul><ul><ul><ul><li>Cyanosis reflects decreased oxygen levels in ...
Initial Assessment <ul><li>Airway – is it open? </li></ul><ul><li>Breathing – how fast, effort being used, is it adequate?...
Priority Patients & Transport Decisions <ul><li>Decide what level of criticality this patient is </li></ul><ul><li>EMS to ...
Additional Assessment <ul><li>Includes: </li></ul><ul><ul><li>Focused history </li></ul></ul><ul><ul><li>Physical exam </l...
SAMPLE History <ul><li>S – signs & symptoms </li></ul><ul><li>A – allergies </li></ul><ul><li>M – medications including he...
Assessment & Interventions <ul><li>Vital signs </li></ul><ul><li>Determine weight and age </li></ul><ul><li>SaO 2  reading...
Detailed Physical Exam <ul><li>Information gathered builds on the findings of the initial assessment and focused exam </li...
Putting It All Together <ul><li>EMS is called to the scene for a  2 year-old who has fallen off the  2 nd  floor porch. </...
Putting It All Together - Mechanism of Injury <ul><li>Fall from height greater than 3 times the toddler’s height </li></ul...
General Impression For This  2 year-old <ul><li>Category I trauma patient with head & orthopedic injuries </li></ul><ul><l...
What’s The Difference? <ul><li>Respiratory distress </li></ul><ul><ul><li>The patient exhibits increased work of breathing...
<ul><li>Respiratory failure </li></ul><ul><ul><li>Energy reserves have been exhausted and the patient cannot maintain adeq...
Respiratory Distress <ul><li>Stridor </li></ul><ul><li>Grunting </li></ul><ul><li>Gurgling </li></ul><ul><li>Audible wheez...
Stridor <ul><li>Harsh, high-pitched sound heard on inspiration associated with upper airway obstruction </li></ul><ul><li>...
Grunting <ul><li>Compensatory mechanism to help maintain patency of small airways </li></ul><ul><li>A short, low-pitched s...
Nasal Flaring
Retractions <ul><li>A visible sign where the soft tissues sink in during inhalation </li></ul><ul><li>Most notable are in ...
Respiratory Failure <ul><li>Decreased level of responsiveness or response to pain </li></ul><ul><li>Decreased muscle tone ...
IV Access <ul><li>Peripheral access can be difficult to find in a child </li></ul><ul><ul><li>More sub Q fat </li></ul></u...
Hint to Find Peds Veins <ul><li>Hold your penlight across the skin to reflect the veins </li></ul><ul><li>Hold the penligh...
EMS IO Indications <ul><li>Shock, arrest, or impending arrest </li></ul><ul><li>Unconscious/unresponsive to stimuli </li><...
EZ IO Landmarks <ul><li>Proximal medial tibia </li></ul><ul><li><39 kg (child) – tibial tuberosity often difficult to palp...
Tibial tuberosity
EZ IO Infusion <ul><li>All patients need to have the IO flushed prior to connecting the IV solution </li></ul><ul><li>The ...
EMS Altered Level of Consciousness SOP <ul><li>If blood glucose level is <60 </li></ul><ul><ul><li><  1 year old – Dextros...
<ul><li>If you suspect narcotic influence or as a diagnostic tool if blood sugar is okay or patient does not respond to De...
Dextrose <ul><li>The brain is a very sensitive organ to inadequate levels of glucose </li></ul><ul><li>When the glucose le...
Narcan <ul><li>Useful to reverse the effects of narcotics (respiratory depression and depression of the central nervous sy...
Calculation Practice  <ul><li>Your 8 month-old patient weighs 17 pounds </li></ul><ul><li>Which strength Dextrose should t...
8 month-old <ul><li>< 1 year old receives Dextrose 12.5% </li></ul><ul><ul><li>More diluted form for smaller, more fragile...
Drawing Up 12.5% Dextrose From D25% <ul><li>Use 25% and dilute 1:1 with sterile saline </li></ul><ul><li>Calculate the tot...
Narcan Calculation <ul><li>Your patient weighs 19 pounds </li></ul><ul><li><20 kg the patient is to get  0.1 mg/kg </li></...
Narcan for 19 Pound Infant <ul><li>19 pounds    2.2 kg = 8.6 kg (9kg) </li></ul><ul><li>9kg x 0.1 mg/kg = 0.9 mg </li></u...
Broselow Tape <ul><li>Often gives mg but not always the ml to fill the syringe with </li></ul><ul><li>Mg helpful for accur...
GCS For Pediatric Patient <ul><li>Same tool used for the adult population with minor changes to accommodate the young  non...
GCS – Eye Opening <ul><li>Remains the same as the adult: </li></ul><ul><li>4 points if eyes open spontaneously with or wit...
GCS – Peds Verbal Response <ul><li>5 points if oriented (coos, babbles) </li></ul><ul><li>4 points if cry is irritable </l...
GCS – Peds Motor Response <ul><li>6 points if the patient moves appropriately </li></ul><ul><li>5 points if the patient wi...
Acute Asthma <ul><li>Many patients will try to self medicate and may try for too long on their own before they call for he...
Why Albuterol? <ul><li>Albuterol is a bronchodilator </li></ul><ul><li>Receptors are in the lungs </li></ul><ul><li>Opens ...
EMS Albuterol Dosing <ul><li>2.5 mg/3 ml  for all patients </li></ul><ul><li>The drug will be more successful when the pat...
Nebulizer Delivery <ul><li>This route is most effective if there is someone “coaching” the patient during use </li></ul><u...
In-line Albuterol <ul><li>Any patient no longer able to take a deep breath or remain conscious needs this drug “forced” in...
What Are the Risk Factors That Expose Kids To Seizures? <ul><li>Fever – most common </li></ul><ul><li>Hypoxia </li></ul><u...
Status Epilepticus <ul><li>A series of one or more generalized seizures without any periods of consciousness </li></ul><ul...
Assessment of Seizures <ul><li>ALWAYS obtain a glucose level if level of consciousness is altered </li></ul><ul><li>Ask if...
EMS Seizure Intervention <ul><li>Support the airway </li></ul><ul><ul><li>Consider BVM if active seizure </li></ul></ul><u...
Valium Calculation <ul><li>Patient with active seizure </li></ul><ul><li>Patient weighs 26 pounds </li></ul><ul><ul><li>26...
Medication Resources <ul><li>Back of SOP’s  (Medical & Cardiac Pages) </li></ul><ul><ul><li>Meds by mg for documentation a...
Possible Causes of Critical Rhythms <ul><li>6 H’s </li></ul><ul><ul><li>Hypovolemia – fluid challenge </li></ul></ul><ul><...
<ul><li>5 T’s </li></ul><ul><ul><li>Tablets – drug overdose </li></ul></ul><ul><ul><li>Tamponade – supportive care in fiel...
Peds VF or Pulseless VT <ul><li>After 2 minutes of CPR if unwitnessed, defibrillate 2j/kg or equivalent biphasic </li></ul...
VF/VT Peds Region X SOP <ul><li>Meds given during CPR: </li></ul><ul><li>Epinephrine 1:10,000 0.01 mg/kg IVP/IO </li></ul>...
Why Epinephrine? <ul><li>Epinephrine is a catecholamine and stimulant </li></ul><ul><li>Epinephrine is a vasoconstrictor t...
PEA/Asystole Peds Region X SOP <ul><li>Start CPR and run thru the H & T checklist </li></ul><ul><li>Secure airway </li></u...
Why No Atropine in  Peds  PEA, Asystole, or Brady? <ul><li>Atropine will probably not help unless the patient has primary ...
Peds Symptomatic Brady <ul><li>Severe cardiorespiratory compromise </li></ul><ul><ul><li>Poor perfusion </li></ul></ul><ul...
Peds Brady EMS Region X SOP <ul><li>Heart rate <60 & poor systemic perfusion – perform CPR </li></ul><ul><li>IV/IO access ...
Peds Shock EMS Region X SOP <ul><li>Hypovolemic or distributive shock </li></ul><ul><ul><li>IV fluid challenge 20 ml/kg </...
Peds Tachycardia <ul><li>Bradydysrhythmias are more common in peds patients than tachycardias </li></ul><ul><li>Sinus Tach...
Probable Supraventricular Tachycardia <ul><li>Narrow complex tachycardia greater than 220 in infants and greater than 180 ...
Signs & Symptoms SVT <ul><li>Irritability </li></ul><ul><li>Poor feeding </li></ul><ul><li>JVD </li></ul><ul><li>Hepatomeg...
EMS Treatment  SVT  with Adequate  OR  Poor Perfusion <ul><li>Vagal maneuvers </li></ul><ul><ul><li>If a straw is availabl...
Cardioversion for  No  Response to Adenosine or For Probable VT <ul><li>Sedate with Versed 0.1 mg/kg IVP slowly over 2 min...
Why Versed? <ul><li>Amnesic </li></ul><ul><li>Relaxes patient </li></ul><ul><li>Shorter acting than Valium </li></ul><ul><...
Probable VT with Poor Perfusion <ul><li>No time to allow drugs to work to slow or convert rhythm </li></ul><ul><li>Need to...
Allergic Reactions – Is Response Life Saving or  A Killer? <ul><li>The body’s immune response to an antigen tries to elimi...
Antigen Exposure & Histamine Release <ul><li>Increased capillary permeability </li></ul><ul><ul><li>3 rd  spacing (intrava...
Is it an Allergic Reaction or Anaphylaxis? <ul><li>Anaphylaxis is the more severe response of the two </li></ul><ul><ul><l...
Why Epinephrine 1:1000 For An Immune Response? <ul><li>Stimulates certain receptors in the body (alpha & beta receptors) <...
What Does Epinephrine Do? <ul><li>Primary drug used in reactions </li></ul><ul><li>Increases heart rate </li></ul><ul><li>...
Why Benadryl For Immune Response? <ul><li>Antihistamines are the 2 nd  line agents to give in reactions </li></ul><ul><li>...
EMS Benadryl Dosing <ul><li>Epinephrine is 1 st  line drug if applicable </li></ul><ul><li>Stable allergic reaction  no  a...
Practice Calculating the GCS <ul><li>Remember to use the “PEDS” alternative values when the patient is  non-verbal </li></...
GCS Calculation #1 <ul><li>Patient is 7 months old </li></ul><ul><li>Eyes are open but do not focus or follow activities <...
GCS Calculation #2 <ul><li>Patient is 3 years-old </li></ul><ul><li>Eyes flutter open when the patient is yelled at </li><...
GCS Calculation #3 <ul><li>Patient is 5 months-old </li></ul><ul><li>Eyes flutter open when the deformed extremity is mani...
GCS Calculation #4 <ul><li>Patient is 5 years-old </li></ul><ul><li>Patient is watching your movement </li></ul><ul><li>Pa...
GCS Calculation Answers 1 & 2 <ul><li>Pt #1 – GCS 12 </li></ul><ul><ul><li>Eye opening – 4 (spontaneous) </li></ul></ul><u...
GCS Calculation Answers 3 & 4 <ul><li>Pt #3 – 7 </li></ul><ul><ul><li>Eye opening – 2 (eyes flutter to pain) </li></ul></u...
Scenarios <ul><li>Read the following case studies </li></ul><ul><li>Determine your general impression based on the pediatr...
Case Study #1 <ul><li>EMS is at a local high school track meet when a 12 year-old boy collapses while running the 100-yard...
Case Study #1 <ul><li>AED’s can be used in patients  over   1 years-old </li></ul><ul><ul><li>Use the child pads for 1 – 8...
Case Study #1 <ul><li>Attach a monitor as soon as possible </li></ul><ul><li>Stop CPR (witnessed arrest) as soon as monito...
Case Study #1 <ul><li>Rhythm: Torsades </li></ul><ul><ul><li>Most likely this young athlete has long QT syndrome (conducti...
Case Study #2 <ul><li>A 2 year-old at preschool fell from a sitting position and the teacher witnessed jerking of the arms...
Case Study #2 <ul><li>Patient appears physiologically stable </li></ul><ul><ul><li>Drowsy, no extra effort or noise for br...
Case Study #2 -  Is Valium Indicated Now? <ul><li>No active seizure currently, so no drug </li></ul><ul><li>Valium stops t...
Case Study #3 <ul><li>You are on the scene for an 18 month-old child who is having difficult breathing </li></ul><ul><li>T...
Case Study #3  <ul><li>Color pink, has retractions with nasal flaring </li></ul><ul><li>HR 180; RR 42 </li></ul><ul><li>St...
Case Study #3 <ul><li>How sick is this child? </li></ul><ul><ul><li>PAT (pediatric assessment triangle) </li></ul></ul><ul...
Case Study #3 <ul><li>PAT: makes eye contact & cries when EMS approaches; exhibiting stridor & increased work of breathing...
Case Study #3 <ul><li>Management upper airway obstruction based on severity of symptoms </li></ul><ul><ul><li>Position of ...
Humidified Oxygenation in the Field <ul><li>Place 6 ml normal saline into the nebulizer </li></ul><ul><li>Finish assemblin...
Case Study #3 <ul><li>If wheezing, EMS gives Albuterol 2.5 mg </li></ul><ul><ul><li>Used as bronchodilator </li></ul></ul>...
Case Study #4 <ul><li>911 called to the scene for a  3-month old who has had 3 days  of cough, runny nose & low-grade feve...
Case Study #4 <ul><li>Child limp, audible wheezing, deep retractions, nasal flaring, skin mottled, diaphoretic </li></ul><...
Case Study #4 <ul><li>Is this child in respiratory distress or respiratory failure? </li></ul><ul><li>What is your general...
Case Study #4 <ul><li>You note increased work of breathing, abnormal appearance, and poor circulation </li></ul><ul><li>Th...
Case Study #4 <ul><li>Rapid and urgent transport </li></ul><ul><li>This patient most likely does  not  have an easily reve...
Case Study #4 <ul><li>Respiratory status monitored closely </li></ul><ul><ul><li>If decreased respiratory effort or slowin...
Case Study #5 <ul><li>EMS is called to the scene for an unresponsive 3 year-old child </li></ul><ul><li>There are no abnor...
Case Study #5 <ul><li>What is your general assessment? </li></ul><ul><li>What is the GCS? </li></ul><ul><li>What other ass...
Case Study #5 <ul><li>This patient is critical: unresponsive,  no abnormal appearance for work of breathing, pale & diapho...
Case Study #5 <ul><li>Calculating & administrating Dextrose </li></ul><ul><ul><li>D25% ages 1 – 15 is 2 ml/kg </li></ul></...
Case Study #5 <ul><li>Check the back of the SOP’s </li></ul><ul><li>Check the Broselow tape </li></ul><ul><li>Divide pound...
Case Study #6 <ul><li>You run the call: </li></ul><ul><ul><li>EMS has a 6 year-old who was found listless with a GCS of 9 ...
Case Study #7 <ul><li>Pediatric bradycardia is a hypoxia problem until proven otherwise </li></ul><ul><li>CPR started with...
Case Study #7 <ul><li>EZ IO landmarks </li></ul><ul><ul><li>2 fingerbreadths down from patella over tibial tuberosity </li...
Bibliography <ul><li>Aehlert, B. PALS Study Guide. Elsevier. 2007. </li></ul><ul><li>American Academy of Pediatrics. Pedia...
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Module III - The Pediatric Patient

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Module III - The Pediatric Patient

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

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