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Curriculum Update: Pediatrics


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Title: Curriculum Update: Pediatrics

Curriculum UpdatePediatrics
  • Condell Medical Center
  • EMS System
  • October 2005
  • Site Code 10-7200-E-1205
  • Revised by Sharon Hopkins, RN, BSN

  • Upon successful completion of this module, the
    EMS provider should be able to
  • discuss injury prevention tactics
  • describe differences in body systems from the
    pediatric patient compared to an adult
  • describe pain assessment scales for the pediatric
  • list pain medications used in the prehospital
    setting for children

Objectives continued
  • list special health care needs noted in the
    pediatric population
  • describe technological equipment used to assist
    in the lives of children
  • describe specific disease processes in the
    pediatric population and the appropriate EMS
  • describe traumatic injuries unique to the
    pediatric population and the appropriate EMS

Objectives continued
  • describe the Broselow tape and demonstrate use of
    the tape
  • describe the placement of an IO needle and
    successfully demonstrate the skill
  • demonstrate infant/child CPR
  • participate in scenario practice regarding
    pediatric situations
  • participate in calculating and drawing up
  • successfully complete the quiz with a score of
    80 or better

  • The EMS providers role in treating infants and
    children are often found in two places
  • Prehospital care
  • providing treatment
  • and primary
  • transportation
  • Interfacility transfers
  • providing secondary
  • transport

  • To maintain pediatric knowledge and clinical
    skills there are a variety of courses and
    certifications available
  • PALS - Pediatric Advanced Life Support
  • APLS - Advanced Pediatric Life Support
  • PPC - Prehospital Pediatric Care/NAEMT
  • PEPP - Pediatric Education for Prehospital
  • Professionals
  • PEP - Pediatric Emergencies for Paramedics
  • PBTLS - Pediatric BTLS
  • ENPC - Emergency Nurse Pediatric Cert
  • System/Region CE programs

Emergency Medical Services for Children - EMSC
  • National effort to reduce child and youth
    disability and death from severe illness and
  • Areas of healthcare concern are
  • Education Emergency Care
  • Data Collection Definitive care
  • Injury Prevention Rehabilitation
  • Prehospital Care Ongoing healthcare
  • Awards grant monies to provide funding to develop
    primary and continuing education, equipment
    guidelines, designation of facilities with
    special capabilities, and instructor resources

EMSC Patient Goals Outcome
  • 1st goal - prevention of illness and injury
  • If 1st goal fails, 2nd goal is to improve
    outcomes in children who are ill or injured by
    teaching recognition of stable and unstable
    conditions specific to children and developing
    clinical skills to expedite and improve

Bottom line To have higher qualified prehospital
and hospital personnel to care for sick and
injured children
Reduction of Pediatric Morbidity and Mortality
  • Data and facts documented in
  • registries
  • epidemiological research
  • Education and prevention programs
  • schools
  • community
  • parents
  • safety inspections

Injury PreventionBirth to 6 Months
  • Avoid shaking baby powder
  • on infant (inhaling powder
  • particles is harmful to lungs)
  • Know emergency procedures
  • for choking and post emergency numbers
  • Dont tie pacifier around infants neck
  • Never leave alone in the bath
  • Beware of cigarette ashes falling on child
  • Properly restrain in motor vehicles, strollers
    and bicycles
  • Avoid placing stuffed animals in the crib

Illinois Car Seat Laws
  • Birth - 7 years-old
  • in approved safety seat or booster
  • 8 - 16 years old
  • secured by seat belt
  • air bag in place
  • All front seat passengers must be restrained
    regardless of age

Injury PreventionFour to Seven Months
  • Avoid feeding hard candy, nuts, hot dogs, and
    coin shaped foods
  • Properly store cleaning fluids out of reach
  • Use non-toxic, lead-free paints
  • Lower mattress and raise crib rails to full
  • Place hot objects out of reach
  • Minimize exposure to sun
  • apply appropriate sunscreens
  • Carefully select toys

Injury PreventionEight Twelve Months
  • Fence swimming pools
  • Fence off stairways
  • Secure front-loading appliances and cabinets
  • Administer medications as a drug do not refer to
    medicine as candy
  • Use plastic guards on electric outlets
  • Direct supervision is a must

Injury PreventionTwelve Months 4 Years
  • Supervise during play
  • Ensure a properly sized helmet, trikes, bikes,
    and roller blades
  • Teach children to obey pedestrian safety rules
  • Fence pool areas enroll in water safety
    swimming lessons
  • Keep automatic garage door opener inaccessible
  • Teach personal safety (name, address, phone

Injury PreventionFive to Twelve Years
  • Teach proper use of seat belts
  • Teach proper behavior in the event of a fire
  • Teach safe cooking practices
  • Avoid personalized clothing in public places
  • Teach use of hand signals when riding bikes and
    insist on use of helmets at all times
  • Teach Rules of the Road for bicycles

Injury PreventionThirteen to Eighteen Years
  • Reinforce dangers of drugs when
  • operating moving vehicles
  • Instruct in the use and respect of firearms,
    power tools, and firecrackers
  • Be alert to signs of depression as a risk factor
    for suicide
  • Be alert to signs of eating disorders

Children are not
Little Adults
  • Variety of differences in
    anatomy and
  • physiology
  • Head
  • Proportionally larger in size
  • Larger occipital region - challenge to maintain
    proper C-spine alignment
  • Fontanelles open in infancy - anterior closes
    between 9-18 months
  • Face is smaller in comparison
    to size of head


  • Narrower at all levels -
  • easier to obstruct
  • Infants are obligate nose breathers - keep nasal
    passages clear of secretions with bulb syringe
  • Jaw is posteriorly smaller in young children
  • Larynx is higher (C3-C4), more anterior -
    visualization more difficult
  • Cricoid ring is narrowest part of airway - no
    room for a cuff on the ET tube in small airways
  • Tracheal cartilage is softer - easier to compress
    and obstruct
  • Trachea is smaller in length and diameter

small towel
Airway continued
  • Epiglottis
  • Not fully cartilage - floppier
  • straight blade (Miller) preferred for intubation
  • Epiglottis extends at 45 degree angle into airway

To maintain airway position Use small folded
towel or diaper placed from shoulders to hips in
glottic opening
Anterior surface
Respiratory System
  • Tidal volume smaller
  • Metabolic oxygen requirements higher
  • Smaller functional residual capacity
  • smaller oxygen reserves
  • Hypoxia develops rapidly because of increased
    oxygen requirements and decreased oxygen reserve

Chest and Lungs
  • Ribs are more horizontally oriented
  • Chest wall more pliable
  • Ribs offer less protection to organs
  • Chest muscles are immature and fatigue easily
  • Kids are diaphragmatic belly breathers
  • Lung tissue is more fragile - pulmonary
    contusions more common than rib fractures
  • Mediastinum is more mobile
  • Thin chest wall allows for breath sounds to be
    easily transmitted across the entire chest
  • best to auscultate in axillary line as far away
    from opposite lung as possible

Pediatric vs Adult Chest
Pediatric Xray Ribs softer, smaller, more
Adult Xray Ribs more rigid, larger, angle downward
Interventions Related to The Pediatric Chest and
  • CPR is performed using 2 finger tips
  • or thumb tips encircling the chest wall
  • Ribs tend to bend with the force of trauma
  • fractured ribs more common in child abuse
  • Infants are prone to gastric distention
  • Internal injury can be present without external
  • Transmitted breath sounds may cause missing a
    misplaced ET tube or pneumothorax - auscultate
    breath sounds in axillary areas

  • Immature abdominal muscles offer less protection
  • Abdominal organs are closer together
  • Liver/spleen proportionally larger more
    vascular most frequently injured organs
  • Multiple organ injury is more common than
    isolated organ injury
  • Spleenectomy is avoided if possible - do not want
    to lose one of bodys natural defenses to
  • if spleen removed
  • will need a
  • pneumovax
  • shot periodically

  • Bones are softer more porous
  • Immobilize any sprain or strain as it more likely
    could be a fracture
  • IO access - medications go directly into the bone
    marrow, then drains into the central circulation

- Growth plate injury can disrupt bone
growth watch angles of entry with IO
Skin and Body Surface Area (BSA)
  • Skin is thinner and more elastic
  • Larger surface area to body mass
  • Less subcutaneous fat
  • Thermal exposure results in deeper
  • burns
  • Children tend to have a greater loss of fluids
    and heat when the integumentary system (skin) is

Cardiovascular System
  • Cardiac output is rate dependent
  • children unable to adjust contractility cardiac
    output adjusted by changing heart rate
  • Vigorous, but limited, cardiovascular reserve
  • Bradycardia is a response to hypoxia
  • when you see bradycardia, evaluate breathing
  • Maintains blood pressure longer before crashing
  • hypotension becomes a late sign of shock
  • Circulating blood volume larger in proportion
  • but absolute blood volume is
  • smaller volumes of fluid/blood loss
    cause shock

Intervene early to prevent
  • Compensated shock is inadequate tissue perfusion
    with a normal blood pressure
  • Decompensated shock is inadequate tissue
    perfusion with hypotension
  • Underlying cause must be determined and treated
  • Adequate tissue perfusion relies on
  • adequate fluid volume, intact blood vessels,
    functioning pump (heart)
  • Fluid replacement schedule is 20ml/kg NS bolus

Nervous System
  • Develops throughout childhood
  • Neural tissue is more fragile
  • brain injury more devastating in children
  • Brain/spinal cord have minimal protection from
    skull and spinal column
  • Fontanelles remain
  • open in early months

Metabolic Differences
  • Limited glycogen/glucose stores
  • Stressors cause drop in blood glucose - remember
    to check glucose levels PRN
  • Vomiting/diarrhea cause high volume loss - watch
    for hypovolemia
  • Hypothermia due to increased body surface area -
    keep warm, dry, cover head
  • Very young unable to shiver to maintain body
    temperature -
  • mechanism not yet
  • fully matured

Pain Management in Children
  • Always take a childs pain seriously
  • Avoid physical restraint for procedures (usually
    hospital based ones) when sedation can be used
    for painful, anxiety-producing prolonged
  • Accurate assessment
  • requires careful
  • observation of key
  • behaviors appropriately
  • related to the age of
  • child

Pain Assessment in Children
  • Once an infant becomes extremely agitated, it
    takes a great deal of time to get them under
    control and calmed down.
  • Caregivers are good resources for history of how
    a child reacts to different procedures
  • A crying child can easily cry themselves into
    exhaustion be difficult to arouse once asleep

Responses To Pain By Age
  • Infant - intense crying, unable to be consoled,
    tremors, unable to suck without crying, may
    become exhausted from crying and fall into a deep
  • 1-2 year old - intense reaction to painless
    procedures, aggression, regression, physical
  • 3-5 year old - perceive pain as punishment,
    become aggressive with verbal attacks like
    I hate you

Pediatric Responses to Pain continued
  • 6 10 year old - past experience influences
    reaction to pain exaggerated by fear of bodily
    injury and death
  • due to the fear, cover injuries and deformities
  • this age can localize and describe pain.
  • Over 10 years old - can locate and quantify pain
    accurately they fear changes in appearance and
    bodily function able to control their response
    to pain and procedures

Pain Scales Used For
  • Numerical scales OK for older children
  • 1 (mild) to 10 (severe)
  • Scales that measure facial expressions
    (ie FLACC scale)
  • when patient unable to verbalize presence or
    severity of pain
  • appropriate in developmentally delayed
  • non-English speaking individuals

Non-Pharmacologic Pain Management
  • - Reduce anxiety
  • Explain procedures and calm caregivers
  • Allow child access to caregiver for comfort
  • Help child find position of comfort
  • ease for sucking thumb/fingers, holding toy,
    using pacifier
  • Distract the patient with age-appropriate

Distraction by Age
  • Young children can use their imagination
  • to help cope with stressful
  • speak calmly, play music, offer a toy
  • or puppet
  • Young children in severe pain will not be able to
    be distracted

Cognitive Coping Strategies and Pain
  • School age children can close eyes and picture a
    happy place/experience/memory
  • Encourage them to count forward and backward
  • Encourage them to tell you about a school
    experience or sport they play
  • Offer choices to assist you in caring for the
    patient (ie right or left arm for B/P)

Pharmacologic Pain Mangement
  • Analgesia
  • Relief of pain
  • Sedation
  • Pharmacologically induced decreased level of
  • Risk for aspiration
  • greatest if feedings are within 4 hours of
    analgesia or sedation
  • A childs response to analgesia or sedation is
    unpredictable - usually no history of previous

Pharmacological Pain Management
  • Gather a complete history
  • Include history of allergies
  • Be familiar with side effects and
  • complications of medications
  • risk for aspiration hypotension
  • decreased respirations dysrhythmia
  • Have equipment available to handle potential
    complications and side effects

Pharmacological Use
  • You must practice within your Scope of Practice.
    This includes administering only medications that
    are listed on your Region X SOPs. This is the
    list your medical director has approved for your
    use while functioning under their license.
  • Some of the following medications are for
    didactic discussion only are not used in Region
  • The dosages listed for Versed and Valium are
    those listed in the Region X SOPs.

Prehospital Analgesic Pain Management
  • Nitrous Oxide
  • useful for orthopedic soft tissue
  • feeling of disassociation/euphoria
  • used on children that can follow
  • to allow drug to be
  • watch for nausea /or vomiting
  • ? CMC SOG Infield Policy 16 - may
    administer to those 13 and older

Prehospital Analgesic Pain Management
  • Morphine Sulfate
  • narcotic analgesic
  • useful for continuous, significant pain
  • given on order of MD for pediatric patient y/o
  • given based on weight (0.05 to 0.15mg/kg)
  • cannot be used on patient with head injuries
  • patient should have an adequate level of
    consciousness to start with
  • monitor for respiratory depression hypotension
    vomiting possible histamine-release side effects
    (redness, itching, hives)

Prehospital Analgesic Pain Management
  • Fentanyl
  • analgesic, opioid agonist
  • lollipop form for oral dose or IVP route
  • no histamine side effect like morphine
  • dosage by weight (0.5 to 1 mcg/kg) slow IVP
  • chest wall rigidity observed if administration
  • is too rapid
  • ? Not available in Region X SOPs

Prehospital Sedation
  • Drugs used for sedation in children
  • Midazolam (Versed)
  • Diazepam (Valium)
  • Lorazepam (Ativan)
  • Etomidate
  • available to those operating within the Region X

Midazolam (Versed)
  • Short-acting benzodiazepine
  • Rapid onset of action
  • Duration of action-20 minutes-2 hrs
  • Alters response to pain
  • Does not alter perception of pain
  • No analgesic effects
  • Listed in Region X SOP for cardioversion
  • Region X dose 0.1mg/kg slow IV push (2 min)
  • Watch for respiratory depression (assist with
    BVM), hypotension
  • Reversal agent is flumazenil (not carried in
    Region X)

Diazepam (Valium)
  • Longer-acting benzodiazepine
  • Powerful CNS depressant
  • Rapid onset of action
  • Duration of action 4 - 6 hrs
  • Dosage weight based 0.2 mg/kg IVP over 2 - 5 min
    rectally 0.5 mg/kg
  • May induce sleep, sedation, hypnosis, muscle
  • Used for seizure control (Region X)
  • Watch for hypotension respiratory depression

Lorazepam (Ativan)
  • Benzodiazepine with shorter half-life than
  • Useful for long-term sedation, seizure activity
  • Powerful CNS depressant
  • Short shelf life if not refrigerated
  • Dosage weight based (0.05 to 0.1 mg/kg) over 2-5
    minutes IVP or can be given IM or PO
  • Side effects to watch for include respiratory
    depression, sleep, sedation, muscle relaxation,
    amnesia, GI symptoms
  • ? Not available in Region X SOPs

  • Relatively new sedative just being introduced
    into pre-hospital care setting
  • Very short acting
  • No respiratory depression or hypotension or
  • Decreases intracranial pressure and metabolic
    demand so ideal for head injured patients
  • Does not cause respiratory depression or
  • Weight based dosage (0.2 to 0.4mg/kg) given slow
  • Most significant side effects are that it can
    induce twitching and focal seizures

? Not available in Region X SOPs
Special Health Care Needs Created by Many
Different Pathologies
  • Prematurity
  • Lung disease
  • Heart disease
  • Neurological diseases
  • Chronic diseases
  • Injuries or altered
    functions from
  • birth - congenital
  • and acquired

Technology Assisted Children (TAC)
  • Tracheostomy Tube
  • Mechanical device to maintain airway
  • Usual indications include
  • Surgery, prematurity, early need for ventilator,
  • chronic respiratory infections, trauma

Tracheostomy TubeComplications
  • Obstruction
  • Bleeding
  • Air leak
  • Dislodgement
  • Infection

Tracheostomy Tube Management
  • Maintain open airway
  • Suction with 6 - 8 fr suction catheter
  • Position of comfort for the child
  • If trach tube must be replaced, can use ET tube
    of same diameter with MD orders

Home Artificial Ventilators
  • Caregiver usually familiar with operation of unit
    being used
  • If called to the scene to provide treatment
  • Ensure patent airway
  • Artificially ventilate with BVM connected to
    tracheostomy tube
  • Transport with
  • early
  • communication
  • to receiving facility

Ventilator Complications
  • Caregivers are generally skilled in managing the
    equipment and generally call EMS when they run
    out of options
  • Complications
  • Machine malfunction
  • Airway obstruction
  • Respiratory distress
  • BVM
  • Ventilate with enough volume to barely make the
    chest wall rise

Central Venous Lines
  • Generally placed for
  • Chronic illness
  • Need for frequent access to venous circulation
    for drug therapy or fluid therapy

Types of Vascular Access Devices (VAD)
  • Mediport-surgically implanted in chest
  • PICC-peripheral vascular access usually in
    antecubital area with an exposed catheter access
  • Hickman/Groshong-central venous access
  • with exposed ports surgically inserted
  • Portacath - surgically implanted access under the
    skin below the clavicle requires special Huber
    needle to gain access

Central Venous Lines
  • Complications
  • Cracked line - torn or leaking catheter allows
    fluids to infiltrate into surrounding tissue
  • Air embolism
  • Bleeding
  • Obstruction of tubing - seen as sluggish or
    absent flow
  • Local infection - swelling, redness tenderness
    at site

Central Venous Lines
  • Management of complications
  • Maintain sterile technique
  • Bleeding - control with direct pressure
  • Cracked line clamp tubing between crack and
    patient insert point
  • if altered mental status occurs - position
    patient on their left side with the head down
  • head down position prevents air embolism from
    traveling to the brain
  • Obstructed lines
  • may need to be cleared with heparin and saline
    flushes by medically trained personnel

Gastric and Gastrostomy Tubes
  • Placed into the stomach for a method to maintain
    the nutritional status of the patient who is
    unable to feed by mouth
  • Variety of tubes available
  • Need to remain alert for respiratory problems
    when tubes are used
  • Tubes placed via nose or through upper left
    quadrant of abdomen with distal tip remaining in
    the stomach

anterior abdominal wall
Gastric and Gastrostomy Tubes
  • Complications
  • Obstruction to the tubing
  • Pulmonary aspiration
  • GI disturbances (vomiting/diarrhea)
  • Irritation to mucous membranes
  • Electrolyte imbalances
  • Management
  • Assure adequate airway
  • Suction as needed
  • Transport with head elevated

Cerebrospinal Fluid (CSF) Shunts
  • Used to treat hydrocephalus -
  • a condition caused by imbalance of CSF production
    and CSF removal in the cerebral ventricular
  • subarachnoid space unable to properly reabsorb
    fluid or there is an obstruction to outflow of
  • when fluid levels increase, intracranial pressure
    increases and ventricles dilate creating
    neurological symptoms

Types of CSF Shunts
  • Ventriculoperitoneal (VP) shunt
  • fluid transported from ventricles of brain to
    peritoneal space
  • reservoir can usually be palpated over the
    mastoid area just behind the ear
  • Ventriculoatrial (VA) shunt
  • fluid carried from ventricles of brain to right
    atrium of the heart
  • Ventriculopleural (V-pleural) shunt
  • CSF drained into the pleural space

Shunt Complications
  • Child has outgrown shunt and requires
  • Obstruction from clotted blood or fluid
  • Catheter displacement
  • Infection
  • Signs symptoms of increased intracranial
  • headaches, crankiness, high pitched cry
  • nausea vomiting
  • visual disturbances
  • Cushings triad - ?B/P, bradycardia, irregular

Management of CSF Shunts
  • Shunt problems are surgical emergencies that
    require transport to prevent brainstem herniation
  • Patient prone to respiratory arrest
  • Routine medical care with head elevated during
  • transport
  • Monitor for
  • seizure activity

Neurological Emergencies
  • Seizures can develop due to
  • noncompliance with seizure medications
  • head trauma
  • intracranial infection
  • metabolic disturbance
  • poisoning
  • fever
  • Febrile Seizures
  • Most common between ages of 6 months-6 years
  • Fever is part of inflammatory process response
  • Seizure often triggered by sudden fever or rapid
    rise more than the actual temperature in degrees

The Febrile Child
  • Low-grade fever - 1000 - 102.50F
  • High-grade fever - above 102.50F
  • Key signs of potential serious illness
  • fever above 100.50F in child
  • altered mental status
  • respiratory distress
  • signs of shock
  • history recent seizures
  • bruising or spotty rash
  • stiff neck

Seizures in Children
  • Very common reason for 911 calls
  • Most seizures in children are benign
  • EMS should focus on supporting airway and
  • Few other interventions are usually necessary
  • Remember to evaluate for harmful, but reversible,
    causes of seizures
  • hypoglycemia
  • hypoxia
  • poisonings

Febrile Seizures
  • Prevention steps to teach caregiver
  • to have working thermometer in household and know
    how to use it
  • to understand importance of compliance with
  • to understand significance of high fevers and
    know when to call the doctor
  • how to care for the child
  • with a fever
  • avoid alcohol baths
  • avoid overlayering the child
  • with too much clothing
  • use antipyretics (Motrin,
  • Tylenol) PRN
  • maintain hydration status

Traumatic Emergencies
  • Trauma, blunt and penetrating, is the predominant
    cause of injury and death in children
    over medical causes

Circulatory Adequacy in Children
  • B/P in children often difficult to obtain is a
    late marker of hypoperfusion
  • To monitor circulatory status in children, best
    to assess focus on
  • mental status changes
  • heart rate
  • capillary refill
  • pulse character
  • changes in urinary output

Traumatic Emergencies - Falls
  • Single most common cause of injury
  • Serious injury/death resulting from accidental
    falls is uncommon unless fall is from a
    significant height
  • When children fall,
  • they tend to fall
  • head first

  • Raise crib rails
  • Appropriately restrain children in
  • strollers/highchairs
  • Fence stairways
  • Avoid walkers but especially near stairways
  • Remove scatter rugs
  • Install non-skid mat in tub/shower
  • Supervise all play
  • Install safety locks on windows that limit the
    amount a window can be opened

Motor Vehicle Crash
  • Leading cause of permanent brain injury
  • Leading cause of death and serious injury
  • Minors cannot sign a release
  • Emancipated minor
  • girl under 18 who is pregnant
  • a child under 18 who is a parent
  • once a child is no longer a parent, the
    emancipated status is void

Federally Approved Car Seats
  • Child under 20 pounds and 1 year old must face
    backwards (immature neck muscles)
  • Seat should be professionally installed or at
    least evaluated
  • Child should be transported to ED in the car seat
  • possible
  • Immobilize C-spine
  • with towel rolls

Pedestrian Vehicle Crash
  • Lethal form of trauma in children
  • Initial injury due to impact with vehicle
  • Then child thrown from force of impact causing
    additional injury from impact with other
    secondary objects
  • Child often run over by the same vehicle
  • Waddells triad - the bumper-hood- ground
    mechanism of injury when car strikes child often
    producing injuries to left femur, spleen, and

Pedestrian Safety Prevention
  • Teach children pedestrian safety rules
  • Dont allow children to stand behind parked cars
  • Lock fences and doors
  • Rules of the Road
  • for bicycles- must
  • ride with traffic

Special Considerations For Traumatic Emergencies
  • Head injury most common cause of death in trauma
  • Large mass of head and lack of neck muscle
    strength provide increased momentum in
    acceleration-deceleration injury
  • 60-70 of fractures in children occur at the
    level of C1 or C2
  • watch for respiratory arrest

Pediatric Head Injuries
  • Focal (localized)
    injuries to one area of the brain are rare,
    injuries tend to be more diffuse
  • Soft tissue, skull, brain more compliant than in
  • Significant bleeds in an infant can produce
  • Stretching of cranial vault possible because
    fontanelles are still open

  • 3rd leading cause of injury/death
  • in children of all ages
  • Defined as death by suffocation
  • from submersion
  • Causes approximately 2000
  • deaths annually
  • Severe, permanent brain damage occurs in
    5-20 of those injured
  • Wet drowning - water aspirated into lungs
  • Dry drowning - laryngospasm prevents water from
    entering lungs death by asphyxiation or airway

Prevention of Water Related Emergencies
  • Did you know - a child only needs a few inches of
    water in a bucket to drown
  • Lock front-loading appliance doors
  • Keep bathroom doors closed and toilet lids down
  • Fence swimming pools
  • Teach water safety and offer swimming lessons
  • Learn infant and child CPR and foreign body
    airway obstruction techniques

Penetrating Injury
  • Risk of death from firearms increases with age
  • Stab wounds/firearm injury account for 10-15 of
    pediatric hospital admissions
  • Visual inspection of external injury cant fully
    evaluate internal involvement
  • Store dangerous tools, firearms, garden equipment
    in locked cabinets

  • Leading cause of accidental death under 14 years
    of age
  • Burn survival is a function of burn size and
    related injuries
  • Modified Rule of Nines - used to determine
    percentage of area involved
  • Palmar method - childs palm equals 1 of their
    body surface area

Rule of Nines
  • Region X SOP Breakdown of Percentages
  • (equals 101)
  • Full head, anterior thorax (includes chest and
    abdomen), back 18 each
  • Full upper extremity 9 each
  • Full lower extremity 14 each
  • Perineum 1

Numbers equal 100
Burn Prevention
  • Test formula/food prior to feedings
  • Install smoke detectors in home one/level
  • Beware of cigarette ashes
  • Minimize sun exposure use sunscreen
  • Cover electric outlets with plastic guards
  • Turn pot handles toward back of stove
  • Teach dangers of fire/flame
  • Teach fire safety
  • If hot liquid spilled on infant, remove diaper

Abuse Neglect
  • Child abuse
  • child suffered intentional physical or emotional
    injury by an individual responsible for the
    childs care
  • Child neglect
  • childs physical, mental, or emotional condition
    has been endangered due to failure to provide for
    basic needs including food, clothing, shelter,
    supervision, or medical care
  • Prehospital care providers should never confront
    or accuse parents or caregivers - document
    objectively carefully

Abuse and Neglect
  • 5 indicators or opportunities to observe signs of
    abuse or neglect
  • environmental indicators
  • historical indicators
  • physical indicators
  • abuser indicators
  • abused child indicators
  • What would you consider suspicious in each of the
  • Presence of indicators are not proof of abuse or
    neglect but their presence should raise suspicions

Abuse Prevention
  • Teach stranger danger
  • Supervise children at all times
  • Recognize the possibility of abuse, call report
    to 1-800-25-ABUSE
  • Prehospital providers must phone in a report and
    follow-up with paperwork
  • Transport to the ED where additional services can
    be made available
  • Be alert for abuse/neglect in children with
    special needs

Pediatric Transport Considerations
  • Transport should not be delayed to
    perform procedures that can be done en route
  • Transport to the appropriate facility that has
    expertise in pediatric care
  • The earlier the better to call in report
  • allows appropriate personnel and equipment to be
  • Maintaining patient temperature very important -
    avoid hypothermia

Interventions for the Pediatric Patient
  • Broselow Tape
  • length-based resuscitation device
  • lists medication dosages and equipment based on
    length or weight of child
  • precalculated dosages based on weight in
  • legend section is a reference for calculations
    and pediatric trauma score
  • there are no vital signs on 2002 edition

Broselow Tape
  • Place red end of tape (with arrow)
  • at top of childs head
  • Read the colored box at the heel of the child
    (not to where the toes
  • stretch to)
  • Information listed
  • both sides of tape

Big Bag? Little Bag?
  • 250 ml normal saline (little bag)
  • when a drug route needs to be available
  • when control of volume is essential
  • pediatric patients
  • patients in CHF pulmonary edema
  • frail elderly patients
  • 1000 ml normal saline (big bag)
  • when fluids are needed or anticipated

To Calculate Medication Dosages
  • Convert pounds to kilograms
  • 1 pound 2.2 kilograms (kg)
  • for older adults acceptable to divide pounds in
    half (150 ? 2 75 kg)
  • for children divide pounds by 2.2
  • 22 pounds ? 2.2 10 kg
  • Multiply the kg by the formula given (example 0.2
  • 10 kg x 0.2 mg 2 mg to give
  • ?

Medication Calculation
  • Need to calculate the amount of solution to
    administer the required amount of mg (example
    give 3 mg morphine comes 10 mg/ml). Use a
  • 1 mg on hand mg ordered
  • ml on hand ml desired (x ml)
  • 10 mg 3 mg
  • 1 ml X ml (cross
  • 10 X 3
  • 10 X / 10 3 / 10
  • X 3 ? 10 0.3 ml

Formula for Medication Calculation
  • Formula 2
  • X ml (desired dose) (vol on hand)
  • dose on hand (mg)
  • X ml (3 mg) (1 ml)
  • 10 mg
  • X ml 3
  • 10
  • X ml 3 ? 10 0.3 ml

Airway Control in the Pediatric Population
  • Intubation skill similar as in adults with
    changes in equipment and positioning
  • Airway positioning
  • due to large occiput, to maintain neutral c-spine
    shoulders to hips
  • Pulse oximetry cardiac monitoring
  • pediatric patients will demonstrate bradycardia
    in presence of hypoxia
  • correct bradycardia with ventilations versus
    giving medications

Intubation Equipment
  • BVM - ventilate with enough volume to make chest
    rise gently oxygenate at least for 30 seconds
    prior to ETT attempts
  • straight Miller blade - easier to lift floppy
  • ET tube (? Broselow for sizing)
  • stylet - recess 1/2? from distal tip of ETT
  • suction catheter (turn suction down time limit to
  • ETCO2 built into BVM to confirm tube placement
    after several breaths
  • tape towels or C-collar to help secure

ET Tube as a Drug Route
  • L - lidocaine
  • A - atropine
  • N - narcan
  • E - epinephrine
  • To use ETT route, double the amount calculated
    for the IVP route
  • Flush with 1-5 ml saline the smallest amount for
    the smallest of patients
  • flushing washes the medication off the wall of
    the ETT and assures placement in lungs

Confirming ETT Placement
  • Bilateral rise fall of chest
  • Bilateral equal breath sounds - auscultate in
    axillary areas
  • Absence of epigastric sounds
  • Improvement in patient condition
  • Improved heart rate
  • Improved skin color
  • Improved mental status

Confirm every time the patient is moved!!!
IV Access - Intraosseous Insertion
  • Allows administration of drugs, fluids, and blood
    products directly into the bone marrow
  • Indications for Region X
  • child under 6 years of age
  • presence of shock or cardiac arrest
  • 2 failed attempts at peripheral IV insertion or
    90 second time limit
  • Contraindication - fracture in same bone

Intraosseous Equipment
  • IO needle - can usually adjust length to less
    than diameter of childs leg
  • 10 ml syringe filled with 5ml 0.9 NS
  • Skin prep material
  • Primed IV bag
  • with tubing

Intraosseous NeedleInsertion Technique
  • Select site
  • proximal tibia just below knee
  • flat bone area 1-2 cm (3/8 - 3/4?) distal to
    slightly medial to tibial tuberosity (1? 2.5
  • Prep area
  • Apply constant pressure with palm and use
    twisting motion to push thru cortex to enter
    marrow - avoid growth plate
  • Use slight angle towards feet or 900 angle

Confirming Intraosseous Placement
  • Feel pop or note lack of resistance
  • Needle stands on own
  • With inner trochar removed, connect syringe with
    saline to IO and aspirate watching for bone
  • Line flushes easily
  • Observe for extravasation
  • Consider use of pressure
  • bag to maintain fluid flow or at least
    initially be prepared to squeeze IV bag

Securing IO Needle
  • Secure with gauze dressing and tape
  • Can use arm board to support leg
  • Document site and size needle
  • used

Pediatric Patients AEDs
  • If an AED is to be used, the pediatric patient
    should receive one minute of CPR prior to
    analyzing with the AED.
  • It is preferable to use pediatric pads but in the
    absence of peds pads, use adult pads placing them
    in the anterior/posterior positions.
  • Doing something is better than nothing!
  • Developed by EMSC Prehospital Committee May,
    2005. Accepted into Region X practice.

ABCs of Infant Child CPR
  • Airway -gentle head tilt, chin lift
  • Breathing
  • once every 3 seconds (20/minute)
  • enough to make the chest gently rise
  • Circulation / Compressions
  • child 1-8 heel of one hand lower half of sternum
  • infant or thumbs around the chest wall
  • 51 for 1 and 2 man CPR
  • compression rate of 100/minute minimum

Pediatric Case Scenarios
  • Michael is 9 months old. Mom states she had a
    difficult time waking him up today.
  • Assessment
  • eyes open but seems unaware of environment
  • increased work of breathing
  • color pale
  • history of failure to thrive, no other history
  • the child is small for his age (15 pounds)
  • VS HR 160 RR 16 weak peripheral pulses
  • Cardiac monitor - sinus tachycardia

Case Scenario 1
  • Interventions started
  • assess ABCs
  • apply supportive oxygen
  • check glucose level (altered LOC!)
  • Glucose level 38
  • administer D12.5 4ml / kg
  • How many kilograms is Michael (15 pounds)?
  • How much glucose does he get and which dilution?

Case Scenario 1
  • 15 pounds 2.2 6.8 kg 7kg
  • Give 4ml/kg of D12.5
  • 4ml x 7kg 28 ml of D 12.5
  • 28 ml total solution volume is to be made as a
    11 dilution of D25
  • draw up 14 ml D25 and mix with 14 ml of normal
  • administer slowly due to vein irritation
  • Reassessment Michael is more responsive after D

Case Scenario 2
  • Justin is a 3 year old who fell from playground
    equipment. He didnt move for several minutes
    and now is sleepy and is currently lying quietly
    in moms arms. Dried blood noted on face.
  • Assessment
  • unresponsive to pain
  • breathing decreased from your first visual
    contact with the patient
  • color pale with bluish tint around mouth
  • VS HR 160 RR 20 B/P 98/58

Case Scenario 2
  • Interventions necessary
  • ABCs
  • IV-O2-Monitor-C-spine control
  • Watch vital sign trends
  • Child becoming less responsive, more cyanotic,
    heart rate dropping, unable to get peripheral IV
  • consider bagging, potential intubation
  • prepare for IO insertion
  • Resource for equipment sizing
  • Broselow tape measured top of head to heel

Drug Calculation Practice 1
  • Your 3 year old patient who weighs 30 pounds
    needs rectal valium. The dosage is 0.5 mg/kg.
    The valium syringe reads 10 mg/2ml
  • a. how much does the child weigh?
  • ____kg
  • b. how much drug should the child
  • receive? ____mg
  • c. how many ml needs to be drawn up?
  • ____ml

Drug Calculation Practice 2
  • Your two year old patient weighs 25 pounds.
    Their symptomatic bradycardia requires
    Epinephrine 110,000 at 0.01 mg/kg IVP or IO.
    Epinephrine is packaged as 1 mg/10ml.
  • a. how much does the child weigh?
  • ____kg
  • b. how much drug should the child
  • receive? ____mg
  • c. how many ml needs to be drawn up?
  • ____ml

Drug Calculation Practice 3
  • Your 31/2 year old patient weighs 35 pounds.
    They went into grandmas purse and now need to
    receive narcan at 0.1 mg/kg. The narcan syringe
    reads 2 mg/2ml.
  • a. how much does the child weigh?
  • ____kg
  • b. how much drug should the child
  • receive? ____mg
  • c. how many ml needs to be drawn up?
  • ____ml

Drug Calculation Answer Key
  • ? 30 13.6 kg rounded to14 kg
  • 14 x 0.5 mg/kg 7 mg
  • 7 mg 1.4 ml
  • ? 25 11.3 kg rounded to 11 kg
  • 11x 0.01 mg/kg 0.11 mg
  • 0.11 mg 1.1 ml
  • ? 35 15.9 kg rounded to 16 kg
  • 16 x 0.1 mg/kg 1.6 mg
  • 1.6 mg 1.6 ml

  • NIMSCA contribution for packet by Valued
    Gateway Client
  • Additions/revisions made by
  • Sharon Hopkins, RN, BSN
  • Region X SOPs effective March 2005
  • CMC EMS System SOGs

Pediatrics October 2005
Questions ??