Encountering The Pediatric Patient - PowerPoint PPT Presentation

1 / 123
About This Presentation
Title:

Encountering The Pediatric Patient

Description:

6-7 years-old & younger are primarily diaphragmatic (belly) breathers. Respiratory rate & effort ... More sub Q fat. Smaller targets. More fragile veins. Lack ... – PowerPoint PPT presentation

Number of Views:339
Avg rating:3.0/5.0
Slides: 124
Provided by: sha226
Category:

less

Transcript and Presenter's Notes

Title: Encountering The Pediatric Patient


1
Encountering The Pediatric Patient
  • Condell Medical Center
  • EMS System
  • September 2008 CE
  • Site Code 10-7200E1208

Prepared by Sharon Hopkins, RN,BSN, EMT-P
2
Objectives
  • Upon successful completion of this module, the
    EMS provider should be able to
  • Review and understand the components of the
    Pediatric Assessment Triangle (PAT)
  • Identify the difference between respiratory
    distress and respiratory failure
  • State the landmarks for the EZ IO needle
  • Choose the appropriate medication dose to
    administer for a variety of conditions
  • (Dextrose, Narcan, Albuterol, Valium,
  • Epinephrine, Atropine, Adenosine,
  • Versed, Benadryl)

3
  • Calculate medication dosages given the patients
    weight
  • Calculate the GCS given the pts responses
  • Identify and appropriately state interventions
    for a variety of EKG rhythms specific to the
    pediatric population (VF, SVT, bradycardia)
  • Demonstrate the ability to obtain information
    from the Broselow tape and SOP pediatric
    medication tables
  • Participate in calculating and drawing up
    medications
  • -Successfully complete the 10 question
  • quiz with a score of 80 or better

4
Pediatric Assessment Triangle - PAT
  • Establishes a level of severity
  • Assists in determining urgency for life support
  • Identifies key physiological problems using
    observational listening skills

5
General Assessment - PAT
  • Performed when first approaching the child
  • Does not take the place of obtaining vital signs
  • Check appearance
  • Evaluate work of breathing
  • Assess circulation to the skin

6
PAT - Appearance
  • Reflects adequacy of
  • Oxygenation
  • Ventilation
  • Brain perfusion
  • Homeostasis
  • CNS function

7
Assessing Appearance
  • Evaluate as you cross the room and before you
    touch the child
  • Muscle tone
  • Mental status / interactivity level
  • Consolability
  • Eye contact or gaze
  • Speech or cry

8
PAT - Breathing
  • Reflects adequacy of
  • oxygenation
  • Ventilation
  • In children, work of breathing more accurate
    indicator of oxygenation ventilation than
    respiratory rate or breath sounds (standards used
    in adults)

9
Assessing Breathing
  • Evaluate
  • Body position
  • Visible movement of chest or abdominal walls
  • 6-7 years-old younger are primarily
    diaphragmatic (belly) breathers
  • Respiratory rate effort
  • Audible breath sounds

10
PAT - Circulation
  • Reflects
  • Adequacy of cardiac output and perfusion of vital
    organs (core perfusion)

11
Assessing Circulation
  • Evaluate skin color
  • Cyanosis reflects decreased oxygen levels in
    arterial blood
  • Cyanosis indicates vasoconstriction and
    respiratory failure
  • Trunk mottling indicates hypoxemia

12
Initial Assessment
  • Airway is it open?
  • Breathing how fast, effort being used, is it
    adequate?
  • Circulation what is the central circulation
    status as well as peripheral?
  • Disability AVPU and GCS
  • Expose to complete a hands-on
  • examination

13
Priority Patients Transport Decisions
  • Decide what level of criticality this patient is
  • Decide if they must go to the closest emergency
    department or do you have time to honor the
    family request if their hospital is not the
    closest

14
Additional Assessment
  • Includes
  • Focused history
  • Physical exam
  • SAMPLE history

15
Physical Exam
  • Toe to head in the very young
  • Infants, toddlers, and preschoolers
  • Head to toe in the older child

16
SAMPLE History
  • S signs symptoms
  • A allergies
  • M medications including herbal and over the
    counter (OTC)
  • P past pertinent medical history
  • L last oral intake (to eat or drink including
    water)
  • E events leading up to the incident

17
Assessment Interventions
  • Vital signs
  • Determine weight and age
  • SaO2 reading preferably before after O2
    administration
  • Cardiac monitor if applicable
  • Establish IV if indicated
  • Determine blood glucose if indicated
  • Reassess vital signs, SaO2, patient
  • condition

18
Detailed Physical Exam
  • Information gathered builds on the findings of
    the initial assessment and focused exam
  • Use the toe to head for infants, toddlers, and
    preschoolers

19
Putting It All Together
  • You are called to the scene for a 2
    year-old who has fallen off the 2nd floor
    porch.
  • The toddler landed in the grass
  • The toddler is unresponsive upon your arrival
    there is a laceration to the right forehead and
    the right arm
  • is deformed

20
Putting It All Together - Mechanism of Injury
  • Fall from height greater than 3 times the
    toddlers height
  • For this 2 year-old, the mechanism of injury
    indicates a Category I trauma patient based on
    mechanism of injury (fall from height) and level
    of consciousness (unresponsiveness)

21
Putting It All Together - Index of Suspicion
  • For this 2 year-old you are anticipating major
    traumatic injuries due to mechanism of injury
    (minimally anticipating head injury and
    orthopedic fractures)

22
General Impression For This 2 year-old
  • Category I trauma patient with head orthopedic
    injuries
  • SOPs to follow
  • Spinal immobilization
  • Care of the airway with anticipation for need to
    be bagged or intubated
  • Hemorrhage control / interventions with IV/IO
    access needing to be obtained
  • Cardiac monitoring
  • Determining blood glucose level

23
Whats The Difference?
  • Respiratory distress
  • The patient exhibits increased work of breathing
    but the patient is able to compensate for
    themselves
  • Increased respiratory effort in child who is
    alert, irritable, anxious, and restless
  • Evident use of accessory muscles
  • Intercostal retractions
  • Seesaw respirations (abdominal breathing)
  • Neck muscles straining

24
  • Respiratory failure
  • Energy reserves have been exhausted and the
    patient cannot maintain adequate oxygenation and
    ventilation (breathing)
  • Sleepy, intermittently combative or agitated
    child
  • Heart rate usually bradycardic as a result of
    hypoxia

25
Respiratory Distress
  • Stridor
  • Grunting
  • Gurgling
  • Audible wheezing
  • Tachypnea (increased respiratory rate)
  • Mild tachycardia
  • Head bobbing
  • Abdominal breathing (normal
  • Nasal flaring
  • Central cyanosis resolved with O2

26
Stridor
  • Harsh, high-pitched sound heard on inspiration
    associated with upper airway obstruction
  • Sounds like high-pitched crowing or seal-bark
    sound on inspiration

27
Grunting
  • Compensatory mechanism to help maintain patency
    of small airways
  • A short, low-pitched sound heard at the end of
    exhalation
  • Patient trying to generate positive
    end-expiratory pressure (PEEP) by exhaling
    against a closed glottis
  • Prolongs the period of oxygen and carbon dioxide
    exchange

28
Nasal Flaring
29
Retractions
  • A visible sign where the soft tissues sink in
    during inhalation
  • Most notable are in the areas above the sternum
    or clavicle, over the sternum, and between the
    rib spaces

30
Respiratory Failure
  • Decreased level of responsiveness or response to
    pain
  • Decreased muscle tone
  • Inadequate respiratory rate, effort, or chest
    excursion
  • Tachypnea with periods of bradypnea slowing to
    agonal breathing

31
IV Access
  • Peripheral access can be difficult to find in a
    child
  • More sub Q fat
  • Smaller targets
  • More fragile veins
  • Lack of our experience

32
Hint to Find Peds Veins
  • Hold your penlight across the skin to reflect the
    veins
  • Hold the penlight under the site to illuminate
    the veins

33
IO Indications
  • Shock, arrest, or impending arrest
  • Unconscious/unresponsive to stimuli
  • 2 unsuccessful IV attempts or 90 second duration
  • Use Peds needle for 3 39 kg (up to 88 lbs)
  • - Peds needle 15 G 5/8?

34
EZ IO Landmarks
  • Proximal medial tibia
  • difficult to palpate if not palpated
  • Go 2 finger breadths below patella and then on
    flat aspect of medial tibia
  • 40 kg (88 pounds or more)
  • 1-2 finger breadths below patella (this is
    usually 1/2? (1 cm) distal to tibial tuberosity)
  • 1 finger breadth medially from the tibial
  • tuberosity

35
Tibial tuberosity
36
EZ IO Infusion
  • All patients need to have the IO flushed prior to
    connecting the IV solution
  • The primed extension tubing must be used with a
    syringe attached
  • Only the syringe is removed after flushing in
    preparation to attaching IV fluid
  • All IV bags need a pressure bag to
  • flow

37
Altered Level of Consciousness
  • If blood glucose level is
  • 1 -15 years old Dextrose 25 2 ml/kg
  • If no IV/IO access
  • Glucagon 0.1 mg/kg IM
  • Max dose up to 1 mg (max at adult dosage)

38
  • If you suspect narcotic influence or as a
    diagnostic tool if blood sugar is okay or patient
    does not respond to Dextrose
  • Give Narcan
  • 20 kg 2 mg IVP/IO/IM
  • Max total dose is 2 mg

39
Dextrose
  • The brain is a very sensitive organ to inadequate
    levels of glucose
  • When the glucose levels drop the patient will
    have an altered level of consciousness
  • If glucose levels reach a critically low level,
    the patient may have a seizure

40
Narcan
  • Useful to reverse the effects of narcotics
    (respiratory depression and depression of the
    central nervous system)
  • Morphine, hydromorphine, oxycodone, Demerol,
    heroin, Dilaudid, codeine, percodan, fentanyl,
    darvon, methadone
  • Consider the children that get into
  • others purses and have access to
  • the medicine cabinet other
  • areas where drugs can be found

41
Calculation Practice
  • Your 8 month-old patient weighs 17 pounds
  • Which strength Dextrose should this patient
    receive and how much?

42
8 month-old
  • To receive 4 ml/kg
  • 17 pounds ? 2.2 7.7 kg (8kg)
  • Dextrose is 4 ml / kg
  • 4 ml x 8 kg 32 ml
  • How do you give 12.5 Dextrose when you carry 25?

43
How To Draw Up 12.5 Dextrose
  • Use 25 and dilute 11 with sterile saline
  • Calculate the total dosage required (ie
    32 ml)
  • Half the syringe will be filled with 25 Dextrose
    and half the syringe will be filled with sterile
    saline
  • 16 ml 25 dextrose mixed with 16 ml sterile
    normal saline
  • Administer in largest vein possible and at slowed
    rate
  • Extremely irritating to the veins

44
Narcan Calculation
  • Your patient weighs 19 pounds
  • How much Narcan would you
  • administer? Never give more than the adult
    dose!

45
Narcan for 19 Pound Infant
  • 19 pounds ? 2.2 kg 8.6 kg (9kg)
  • 9kg x 0.1 mg/kg 0.9 mg
  • (You still need to know how many mls to put into
    the syringe)
  • What type of syringe would you use?
  • Under 1 ml use a TB syringe
  • much more accurate to draw
  • up medications

46
GCS For Pediatric Patient
  • Same tool used for the adult population with
    minor changes to accommodate the non-verbal
    infant
  • Most accommodations made in the verbal section
  • Makes sense if this is for the non-verbal patient

47
GCS Eye Opening
  • Remains the same as the adult
  • 4 points if eyes open spontaneously with or
    without focus
  • 3 points if eyes open or flutter to command or
    noises/voice
  • 2 points if eyes open or eyelids flutter to touch
    or painful stimuli
  • 1 point if eyes do not open

48
GCS Verbal Response
  • 5 points if oriented (coos, babbles)
  • 4 points if cry is irritable
  • 3 points if the patient cries to pain
  • 2 points if there is some noise response to pain
    (similar to moans groans in the adult)
  • 1 point if there is silence

49
GCS Motor Response
  • 6 points if the patient moves appropriately
  • 5 points if the patient withdraws to touch
  • 4 points if the patient withdraws to pain
  • 3 points if there is abnormal flexion
  • 2 points if there is abnormal extension
  • 1 point if there is no movement/response
  • of any kind

50
Acute Asthma
  • Many patients will try to self medicate and may
    try for too long on their own before they call
    for help
  • The patient can deteriorate fast once they
    fatigue and their respiratory muscles are
    exhausted

51
Why Albuterol?
  • Albuterol is a bronchodilator
  • Receptors are in the lungs
  • Opens up constricted bronchiole passages
  • Albuterol also triggers receptors in the heart
    and you may see an increase in heart
  • rate

52
Albuterol Dosing
  • 2.5 mg/3 ml for all patients
  • The drug will be more successful when the patient
    is coached through use of the nebulizer
  • The drug only works if it is inhaled deeply into
    the lungs
  • Short, shallow breaths will not help drug
    absorption

53
Nebulizer Delivery
  • This route is most effective if there is someone
    coaching the patient during use
  • Have someone talk the patient through the process
  • Verbal encouragement essential to success
  • Encourage slower breaths for a few ventilations
  • Then encourage the breaths to be a bit deeper
  • Then encourage the deeper breaths to be
  • held a bit longer to get the drug
  • down into the lungs

54
In-line Albuterol
  • Any patient no longer able to take a deep breath
    needs this drug forced into the lungs
  • The drug must be given in-line
  • Attach nebulizer to the BVM as you start bagging
    the patient to get some drug into the lungs
  • Once intubated, the ambu bag will continue to
    force the drug into the airway and down into the
    lungs

55
What Are the Risk Factors That Expose Kids To
Seizures?
  • Fever most common
  • Hypoxia
  • Infections
  • Electrolyte imbalance
  • Head trauma
  • Hypoglycemia
  • Toxic ingestions
  • Tumor

56
Status Epilepticus
  • A series of one or more generalized seizures
    without any periods of consciousness
  • Concern is with periods of prolonged apnea that
    can lead to hypoxia

57
Assessment of Seizures
  • ALWAYS obtain a glucose level if level of
    consciousness is altered
  • Ask if there is a history of recent illness
  • Ask for description of the seizure activity
  • Jerking of both sides of the body, jerking
    limited to a particular part of the body, eye
    blinking, staring, lip smacking

58
Seizure Intervention
  • Support the airway
  • Consider BVM if active seizure
  • To terminate current seizure
  • Valium 0.2 mg/kg IVP
  • No IV access, Valium rectally 0.5 mg/kg
  • Max total rectally 10 mg
  • Remove extra clothing if febrile
  • Cool cloths over patient, fan patient
  • Shivering will increase body temp!

59
Valium Calculation
  • Patient with active seizure
  • Patient weighs 26 pounds
  • 26 ? 2.2 11.8 KG (12 KG)
  • Valium is 0.2 mg/kg
  • 12kg x 0.2 2.4 mg
  • Where are your resources to use to check how many
    mls to pull up
  • into the syringe?

60
Medication Resources
  • Back of SOPs
  • Meds by mg for documentation and by ml to draw up
    into the syringe
  • Broselow tape 2007 Edition B
  • Legend gives the formula
  • Valium (diazepam) exact mg given under each
    respective weight category
  • Careful!!! Diazepam broken down by IV AND
    rectal so read columns carefully

61
Possible Causes of Critical Rhythms
  • 6 Hs
  • Hypovolemia fluid challenge
  • Hypoxia supplemental O2
  • Acidosis ventilate to blow off CO2
  • Hyper/hypokalema
  • Hypothermia warm core
  • Hypoglycemia check glucose level

62
  • 5 Ts
  • Tablets drug overdose
  • Tamponade supportive care in field
  • Tension pneumothorax needle decompression
  • Thrombosis, coronary or pulmonary
  • Trauma

63
Peds VF or Pulseless VT
  • After 2 minutes of CPR if unwitnessed,
    defibrillate 2j/kg or equivalent biphasic
  • AED can be used if 1 years old
  • Immediately resume CPR for 2
    minutes / 5 cycles
  • Rhythm checks after 2 minutes CPR
  • Repeat defibrillate 4j/kg or equivalent biphasic
  • Resume CPR
  • Establish IV/IO

64
VF/VT
  • Meds given during CPR
  • Epinephrine 110,000 0.01 mg/kg IVP/IO
  • Repeat every 3-5 minutes
  • Choose one antidysrhythmic to alternate with Epi
  • Amiodarone 5 mg/kg IVP/IO
  • Lidocaine 1 mg/kg IVP/IO
  • Repeat doses per Medical Control order

65
Why Epinephrine?
  • Epinephrine is a catecholamine and stimulant
  • Epinephrine is a vasoconstrictor to improve blood
    flow
  • Before drug therapy, always assess/evaluate the
    status of oxygen delivery and effectiveness of
    ventilation

66
PEA/Asystole
  • Start CPR and run thru the H T checklist
  • Secure airway
  • Establish IV/IO
  • Fluid challenge 20 ml/kg
  • Epinephrine 110,000 0.01 mg /kg IVP/IO
  • Repeat every 3-5 minutes
  • NO Atropine in SOP for peds!!!

67
Why No Atropine in Peds PEA or Asystole?
  • Atropine will probably not help unless the
    patient has primary AV block and that is not
    likely in a young and healthy heart
  • Improving oxygenation and ventilation are the
    primary treatments for pediatric bradycardia

68
Peds Symptomatic Brady
  • Severe cardiorespiratory compromise
  • Poor perfusion
  • Bradycardia
  • Weak, thready, absent pulse
  • Hypotension
  • Pallor
  • Cyanosis
  • Respiratory difficulty

69
Peds Brady
  • Heart rate perform CPR
  • IV/IO access
  • Epinephrine 110,000 0.01 mg/kg IVP/IO
  • Repeat every 3-5 minutes
  • If persistent brady, contact Medical control for
    order of Atropine
  • Atropine if ordered 0.02 mg/kg (minimum dose to
    give 0.1 mg) IVP/IO
  • May repeat Atropine x1
  • Max dose 1 mg
  • Consider pacing

70
Peds Shock
  • Hypovolemic or distributive
  • IV fluid challenge 20 ml/kg
  • If no response repeat 20 ml/kg up to 60 ml/kg
    (ie total 3 challenges)
  • No fluid challenge for peds in cardiogenic shock
    too much fluid
  • for the heart to handle

71
Peds Tachycardia
  • Bradydysrhythmias are more common in peds
    patients than tachycardias
  • Sinus Tachycardia
  • Heart rates in infants are under 220 and in
    children under 180
  • No drug therapy indicated
  • Search for possible causes

72
Probable Supraventricular Tachycardia
  • Narrow complex tachycardia greater than 220 in
    infants and greater than 180 in a child
  • Typically due to a problem in the cardiac
    conduction system
  • Rapid heart rates prevent adequate ventricular
    filling that can lead to
  • CHF and cardiogenic shock

73
Signs Symptoms SVT
  • Irritability
  • Poor feeding
  • JVD
  • Hepatomegaly enlarged liver
  • Hypotension
  • Children can often tolerate the rapid rate fairly
    well

74
Treatment SVT with Adequate OR Poor Perfusion
  • Vagal maneuvers
  • If a straw is available, have child blow thru one
  • Adenosine 0.1 mg/kg rapid IVP followed by 5 ml
    rapid saline flush
  • Max 1st dose is 6 mg (max at adult dose)
  • Repeat dose if needed is 0.2 mg/kg with
  • 5 ml saline flush
  • Max 2nd dose is 12 mg (adult dose)

75
Cardioversion for No Response to Adenosine or For
Probable VT
  • Sedate with Versed 0.1 mg/kg IVP slowly over 2
    minutes
  • Cardioversion at 1 j/kg
  • If no response, cardiovert at 2 j/kg

76
Why Versed?
  • Amnesic
  • Relaxes patient
  • Shorter acting than Valium
  • Does NOT take away pain!
  • Can cause respiratory depression
  • Have BVM reached ready whenever Versed or
    Valium are given in case the patient needs
    ventilation support

77
Probable VT with Poor Perfusion
  • No time to allow drugs to work to slow or convert
    rhythm
  • Need to be more aggressive
  • Cardiovert the patient
  • 1st attempt 1 j/kg
  • 2nd attempt if needed 2 j/kg
  • If no response to cardioversion, contact Medical
    Control for possible
  • Amiodarone or Lidocaine order

78
Allergic Reactions Is Response Life Saving or
A Killer?
  • The bodys immune response to an antigen tries to
    eliminate the antigen (foreign material) from the
    body
  • Bronchospasm so no more offending antigen can
    enter the respiratory tract
  • Coughing to expel the antigen
  • Leaky capillaries remove antigen from the blood
    stream and place it into the interstitial tissue
    for removal via lymph
  • system
  • Vomiting diarrhea remove antigen from GI tract

79
Antigen Exposure Histamine Release
  • Increased capillary permeability
  • 3rd spacing (intravascular fluid into
    interstitial space)
  • Edema
  • Relative hypovolemia
  • Peripheral vasodilation
  • ? peripheral vascular resistance (? B/P)
  • Smooth muscle constriction
  • Abdominal cramps, vomiting, diarrhea
  • Bronchoconstriction laryngeal edema

80
Is it an Allergic Reaction or Anaphylaxis?
  • Anaphylaxis is the more severe response of the
    two
  • Usually occurs when a patient is exposed to a
    specific allergen, especially injected directly
    into the circulation
  • Anaphylaxis principally affects the
    cardiovascular, respiratory, GI systems and the
    skin
  • Faster the reaction, usually the more severe the
    reaction is
  • In anaphylaxis, the patient will be
  • hypotensive (ominous sign)

81
Why Epinephrine 11000 For An Immune Response?
  • Stimulates certain receptors in the body (alpha
    beta receptors)
  • Constricts blood vessels to help counter
    vasodilation effects of anaphylaxis (alpha
    affect)
  • Opens up airways by reversing bronchospasm of
    anaphylaxis (beta affect)
  • Max dose calculated at adult dose (0.3ml)!

82
What Does Epinephrine Do?
  • Primary drug used in reactions
  • Increases heart rate
  • Increases strength of cardiac contractions
  • Causes peripheral vasoconstriction
  • Can reverse bronchospasm
  • Can reverse capillary permeability
  • Effects short term

83
Why Benadryl For Immune Response?
  • Antihistamines are the 2nd line agents to give in
    reactions
  • Antihistamines block the effects of histamine
    released in the body by blocking histamine
    receptors
  • Duration of action is 6-12 hours so anticipate
    rebound if the patient has not filled a
    prescription to continue
  • taking the antihistamine
  • Max dose given is at adult dosing

84
Benadryl Dosing
  • Epinephrine is 1st line drug if applicable
  • Stable allergic reaction no airway involvement
  • Benadryl 1 mg/kg slow IVP or IM
  • Max 25 mg (adult dose)
  • Stable allergic reaction with airway involvement
  • Benadryl 1 mg/kg slow IVP
  • Max 50 mg (adult dose)
  • Anaphylactic shock
  • - Benadryl 1 mg/kg slow IVP
  • - Max 50 mg (adult dose)

85
Practice Calculating the GCS
  • Remember to use the PEDS alternative values
    when the patient is non-verbal
  • If the patient is old enough to talk, follow the
    adult prompts to calculate the GCS

86
GCS Calculation 1
  • Patient is 7 months old
  • Eyes are open but do not focus or follow
    activities
  • The infant has an irritable cry
  • The infant pulls their arms in when the IV stick
    is attempted

87
GCS Calculation 2
  • Patient is 3 years-old
  • Eyes flutter open when the patient is yelled at
  • The toddler cries after the injured extremity is
    manipulated
  • The toddler pulls back when the injured extremity
    is manipulated

88
GCS Calculation 3
  • Patient is 5 months-old
  • Eyes flutter open when the deformed extremity is
    manipulated
  • The patient moans when the injured extremity is
    manipulated
  • The patient pulls up their
  • extremities tightly into their
  • chest when touched (flexion)

89
GCS Calculation 4
  • Patient is 5 years-old
  • Patient is watching your movement
  • Patient is using repetitive words
  • Patient pushes your hands away when you touch them

90
GCS Calculations 1 2
  • Pt 1 GCS 12
  • Eye opening 4 (spontaneous)
  • Verbal 4 (irritable cry)
  • Motor 4 (withdraws to pain)
  • Pt 2 GCS 10
  • Eye opening -3 (eyes open to voice)
  • ?Verbal 3 (cries to pain)
  • ?Motor 4 (withdraws to pain)

91
GCS Calculations 3 4
  • Pt 3 7
  • Eye opening 2 (eyes flutter to pain)
  • Verbal 2 (responds to pain)
  • Motor 3 (flexes extremities into chest)
  • Pt 4 13
  • Eye opening 4 (spontaneous)
  • Verbal 4 (repetitive words / confused)
  • Motor 5 ( pushes hands away/purposeful)

92
Scenarios
  • Read the following case studies
  • Discuss your general impression based on the
    pediatric assessment triangle (PAT)
  • Discuss interventions appropriate to the
    situation
  • Discuss documentation to include specific to the
    call

93
Case Study 1
  • You are 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
  • What are the next appropriate steps to take?
  • Can an AED be used on a 12 year-old?

94
Case Study 1
  • AEDs can be used in patients over 1
    years-old
  • Use the child pads for 1 8 year olds
  • If no child pads available, use adult pads
  • Cannot use child pads though on the adult
  • CPR for 12 year-old is adult standards
  • CPR 1 person infant child is 302 2 person is
    152 once intubated ventilations are
  • delivered once every 6-8 seconds

95
Case Study 1
  • Attach a monitor as soon as possible
  • Stop CPR (witnessed arrest) as soon as monitor
    applied ready
  • Whats the rhythm treatment?

96
Case Study 1
  • Rhythm Torsades
  • Most likely this young athlete has long QT
    syndrome (conduction defect) that makes them
    prone to arrest during physical exertion
  • Treat like VF
  • Defibrillate 1st at 2j/kg
  • Repeat defibrillations at 4j/kg
  • Epinephrine 110,000 0.01 mg/kg IV/IO
  • Repeat every 3-5 minutes
  • Choose one antidysrhythmic (Amiodarone or
    Lidocaine one dose)

97
Case Study 2
  • A 2 year-old at preschool fell from a sitting
    position and the teacher witnessed jerking of the
    arms and legs that lasted for 1-2 minutes. Parent
    told teacher the child was not feeling well
    during the night.
  • On arrival, the child is drowsy, will open their
    eyes to voice but does not answer questions,
    cries withdraws when touched.
  • VS B/P 110/58 HR 100 RR 30 skin warm to the
    touch
  • What is your impression based on the assessment
    triangle?
  • What is the GCS?

98
Case Study 2
  • Patient appears physiologically stable
  • Drowsy, no extra effort or noise for breathing,
    skin pink and warm
  • GCS 11 (3, 3, 5) (currently post-ictal)
  • Initial impression is febrile seizure (no history
    trauma, history of being ill last night, feels
    warms to touch)
  • Field treatment limited to cooling measures
  • Remove extra clothing, cool cloths on
  • forehead

99
Case Study 2 - Is Valium Indicated
Now?
  • Valium stops the current seizure but does not
    prevent future seizures
  • Valium indicated if multiple seizures occur or
    seizure lasts longer than a few minutes
  • Long lasting seizure can cause hypoxia
  • Side effects of valium are
  • respiratory depression

100
Case Study 3
  • You are on the scene for an 18 month-old child
    who is having difficult breathing
  • The mother states a 2 day hx of slight fever and
    wheezing esp when crying
  • Pt suddenly woke tonight short of breath with
    loud noises on inhalation
  • Child sitting on mothers lap, anxious, watches
    you and cries weakly when you
  • approach

101
Case Study 3
  • Color pink, has retractions with nasal flaring
  • HR 180 RR 42
  • Strong pulses, cap refill 2 seconds
  • Loud, harsh breath sounds bilaterally

102
Case Study 3
  • How sick is this child?
  • PAT (pediatric assessment triangle)
  • Evaluate appearance, work of breathing,
    circulation to skin
  • What is your general impression?
  • Do you think this is an upper or lower airway
    problem?
  • How should you care for this
  • child in the field?

103
Case Study 3
  • PAT makes eye contact cries when EMS
    approaches exhibiting stridor increased work
    of breathing skin pink warm
  • This child is in respiratory distress, not
    failure, with an upper airway problem
  • Stridor indicates upper airway obstruction and
    history of a few days
  • of respiratory infection is
  • consistent with croup

104
Case Study 3
  • Management upper airway obstruction based on
    severity of symptoms
  • Position of comfort usually best to leave child
    sitting upright
  • O2 best if humidified
  • Can you give humidified O2 in the field?

105
Humidified Oxygenation
  • Place 6 ml normal saline into the nebulizer
  • Finish assembling the nebulizer
  • Connect tubing to the O2 source
  • Turn up the liter flow to generate a flow of
    mist
  • Aim the mist near the childs face
  • Helpful for croup epiglottitis

106
Case Study 3
  • If wheezing, give Albuterol 2.5 mg
  • Used as bronchodilator
  • FYI Research indicates Albuterol does not have
    much affect in croup
  • Place Albuterol into nebulizer
  • Place nebulizer mask over patients face if child
    too small to place lips
  • around mouthpiece or direct
  • mist near childs face

107
Case Study 4
  • 911 called to the scene for a 3-month old
    who has had 3 days of cough, runny nose
    low-grade fever.
  • Caregiver concerned because the child is working
    harder to breathe and having hard time feeding
  • Child is in caregivers lap
  • Child is sleepy, no eye contact
  • or response to the exam

108
Case Study 4
  • Child limp, audible wheezing, deep retractions,
    nasal flaring, skin mottled, diaphoretic
  • VS HR 180 RR 70 SaO2 on room air 74
  • Breath sounds tight with only fair air movement
    with high-pitched inspiratory expiratory
    wheezes

109
Case Study 4
  • Is this child in respiratory distress or
    respiratory failure?
  • What is your general impression?
  • What do you need to do to manage this patient?

110
Case Study 4
  • You note increased work of breathing, abnormal
    appearance, and poor circulation
  • This patient is in respiratory failure
  • With the wheezing, the problem is most likely a
    lower airway obstruction
  • Most likely bronchiolitis (inflammation of the
    bronchioles often caused by RSV a viral
    infection)

111
Case Study 4
  • Rapid and urgent transport
  • This patient most likely does not have an easily
    reversible respiratory problem and is likely to
    deteriorate further
  • Enroute administer a bronchodilator (Albuterol)
    via nebulizer via mask (wont be able to put
    mouth around
  • mouthpiece)

112
Case Study 4
  • Monitor respiratory status closely
  • If decreased respiratory effort or slowing of the
    rate, consider BVM support using a slow rate and
    long expiratory time
  • AHA ventilatory rate for rescue breathing infant
  • 1 breath every 3-5 seconds (12 20 breaths per
    minute)
  • Give each breath over 1 second

113
Case Study 5
  • You are called for an unresponsive 3 year-old
    child
  • There are no abnormal airway sounds
  • Patient is pale slightly diaphoretic
  • VS B/P 80/60 HR 160 RR 20
  • Pupils small, slow to react
  • Withdraws from pain moans
  • Was playful before his nap and
  • appeared healthy

114
Case Study 5
  • What is your general assessment?
  • What is the GCS?
  • What other assessments need to be done?
  • What interventions are needed?

115
Case Study 5
  • This patient is critical unresponsive, no
    abnormal appearance for work of breathing, pale
    diaphoretic tachycardic
  • GCS - 7
  • Eye opening 1 (none)
  • Verbal response 2 (moans)
  • Motor response 4 (withdraws)
  • Need to obtain glucose level (40)
  • Keep airway open, supplemental O2,
  • establish IV access
  • Needs D25 2 ml/kg slow IVP

116
Case Study 5
  • Calculating administrating Dextrose
  • D25 ages 1 15 is 2 ml/kg
  • This 3 year-old weighs 29 pounds
  • How much D25 do you administer?
  • Where are your resources to
  • find the information?

117
Case Study 5
  • Check the back of the SOPs
  • Check the Broselow tape
  • Divide pounds by 2.2 to determine kg
  • 29 ? 2.2 13 kg
  • Multiply kg by the formula (2 ml/kg)
  • 13 kg x 2 ml/kg 26 ml D25
  • D25 is packaged in 10 ml prefilled syringe
  • Administer IV dose slowly to
  • minimize vein irritation

118
Case Study 6
  • You run this call
  • 8 year-old patient in full arrest
  • Monitor shows VF
  • What tasks need to be assigned?
  • Remember to assign someone to take care of the
    family
  • Now run the call

119
Case Study 7
  • You run the call
  • Your 4 month-old is hypoglycemic with a glucose
    level of 35
  • How are you going to handle this call?
  • Go through the steps as a
  • team draw up the meds

120
Case Study 8
  • You run the call
  • Your 6 year-old is found listless with a GCS of 9
  • The monitor shows
  • Whats the rhythm?
  • What do you do?

121
Case Study 8
  • Pediatric bradycardia is a hypoxia problem until
    proven otherwise
  • Start CPR with attention to ventilation
  • Establish IV/IO
  • Where are the IO landmarks?
  • How do you place an IO needle?
  • What drug therapy is necessary for
  • the pediatric symptomatic
  • bradycardia?

122
Case Study 8
  • EZ IO landmarks
  • 2 fingerbreadths down from patella
  • 1 fingerbreadth toward medial surface away from
    tibial tuberosity
  • Peds bradycardia treatment
  • Epinephrine 110,000 0.01 mg/kg IV/IO
  • Repeated every 3-5 minutes
  • Persistent brady, contact Medical
  • Control for Atropine order

123
Bibliography
  • Aehlert, B. PALS Study Guide. Elsevier. 2007.
  • American Academy of Pediatrics. Pediatric
    Education for Prehospital Professionals. 2nd
    edition. Jones Bartlett. 2006.
  • Rahm, S. Pediatric Case Studies for the
    Paramedic. AAOS. 2006.
  • Region X SOPs. Amended 1/08.
  • www.peds.umn.edu/.../teaching/lung/
  • stridor.jpg
Write a Comment
User Comments (0)
About PowerShow.com