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Pediatric Medical Emergencies

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Title: Pediatric Medical Emergencies


1
Pediatric Medical Emergencies
  • Condell Medical Center
  • EMS System
  • August, 2007 CE
  • Site Code10-7200E1207

Prepared by Sharon Hopkins, RN, BSN, EMT-P
2
Objectives
  • Upon successful completion of this module, the
    EMS provider should be able to
  • identify critical situations in the pediatric
    population
  • identify and appropriately state interventions
    for a variety of EKG rhythms
  • actively participate in a pediatric code
    situation
  • successfully complete the quiz with a score of
    80 or better

3
Children are not small adults!

4
Relationship of Head to Body Changes
5
Pediatric Population Defined
  • A patient under the age of 16 is considered to be
    a pediatric patient
  • This means the patient is 15 years of age or less
  • When medications are calculated based on the
    pediatric patient weight, the dose is to never
    exceed the amount that would be administered to
    an adult!

6
Children and EMS
  • Adults may be glad to see EMS arrive
  • but
  • children are often frightened when EMS comes to
    their rescue

7
Critical Determination
  • Rapid assessment needs to be performed to
    determine
  • Is this child sick or not?
  • Any sick child needs immediate attention and
    intervention

8
Pediatric Assessment Triangle(PAT)
  • Helps establish a general impression
  • Used to
  • establish a level of severity
  • determine urgency for life support
  • identify key physiological problems
  • Provider to assess
  • appearance
  • work of breathing
  • circulation to skin

9
Pediatric Assessment Triangle (PAT)
10
Pediatric Assessment Triangle (PAT)
  • Does not require any equipment to complete
  • Uses observational and listening skills
  • Can be completed in under 60 seconds
  • To be used as you cross the room to make
    contact with the patient

11
Pediatric Assessment Triangle (PAT)
  • Evaluates underlying cardiopulmonary,
    neurological, and metabolic states
  • Can help identify the general physiological
    problem for the child
  • PAT does not replace vital signs and the ABCDEs
    but precedes compliments them

12
Pediatric Assessment
  • Scene size-up
  • General assessment - pediatric assessment
    triangle (PAT)
  • Initial assessment
  • ABCDEs and transport decision
  • Additional assessment
  • focused history and physical exam detailed
    physical exam if trauma
  • Ongoing assessment

13
Pediatric Assessment Triangle Appearance
  • Reflects adequacy of
  • oxygenation
  • ventilation
  • brain perfusion
  • homeostasis
  • CNS function

14
Assessing Appearance
  • Evaluate
  • muscle tone
  • mental status/interactivity level
  • consolability
  • look or gaze
  • speech or cry

15
Pediatric Assessment TriangleBreathing
  • Reflects
  • adequacy of oxygen
  • oxygenation
  • ventilation

16
Assessing Breathing
  • Evaluate
  • body position
  • visible movement of chest or abdomen
  • lt6-7 years old is primarily a diaphragmatic
    breather (belly breather)
  • respiratory rate effort
  • audible airway sounds

17
Pediatric Assessment Triangle Circulation
  • Reflects
  • adequacy of cardiac output and perfusion of vital
    organs (core perfusion)

18
Assessing Circulation
  • Evaluate
  • skin color
  • peripheral cyanosis refers to the extremities
  • central cyanosis is always pathological
    evaluated in the central part of the body mucous
    membranes of the mouth and trunk area
  • reflects decreased oxygen in arterial blood
  • Trunk mottling indicates hypoxemia
  • Cyanosis indicates respiratory failure and
    vasoconstriction

19
Principles of Infant Assessment
  • Ask caregiver for patients name use it
  • To decrease the infants stress, perform
    assessment in the following order
  • observation
  • auscultation
  • palpation
  • Approach infant slowly, calmly, and talk in quiet
    voices warm your hands before contact
  • Try to be at patients eye level

20
Infant Assessment
  • Observe interaction between caregiver and infant
  • Consider offering a toy as a distraction
  • Perform assessment based on acuity level
  • if quiet calm, obtain respiratory rate and
    breath sounds
  • if critical, obtain most important information
    1st
  • Make non-threatening contact 1st
  • make 1st contact with extremity can also obtain
    capillary refill simultaneously

21
Principles of Toddler Assessment
  • Beginning to assert independence but fearful of
    separation from caregiver
  • Approach slowly keep contact to a minimum
  • Be at eye level
  • If possible, allow toddler to stay on caregivers
    lap
  • Introduce equipment slowly and use distraction
    (ie penlight, toy)
  • A toddler is the center of his universe - ask
    questions about them (ie pets, clothing, events)

22
Toddler Assessment
  • Keep choices limited (ie should I use the red
    or blue package)
  • Ask open ended questions avoid yes/no questions
  • Praise toddler to get cooperation
  • Use simple, concrete terms
  • Perform most critical part of assessment 1st
    moving in toe-to-head order
  • Ask caregiver to assist (ie removing clothing,
    holding stethoscope)
  • Toddlers do not sit still

23
Principles of Preschooler Assessment
  • Magical and illogical thinkers fear loss of
    control short attention spans
  • Use simple terms explain procedures immediately
    before performing
  • Allow child to handle equipment
  • Its okay to set limits (ie you can cry but you
    cannot kick)
  • Focus on one thing at a time

24
Principles of School-aged Assessment
  • Fear separation from caregiver loss of control,
    pain, physical disability
  • Speak directly to child, then to caregiver
  • Respect privacy, these children are modest
  • Dont offer too much information do use terms
    the child can understand explain immediately
    before the procedure is done

25
School-Aged Assessment
  • Dont negotiate unless there really is a choice
    (ie IV in right or left hand, not if it is okay
    to start the IV)
  • Offer praise for cooperation
  • Physical assessment okay to be performed in
    head-to-toe format

26
Principles of Adolescent Assessment
  • Time for experimentation and risk-taking
    behaviors
  • Struggle with independence, loss of control, body
    image, sexuality, and peer pressure
  • Relying more on friends than family
  • When ill or injured, often revert back to lower
    maturity level
  • Explain what you are going to do and why

27
Adolescent Assessment
  • Encourage questions and involvement of the
    adolescent
  • Show respect speak directly to teen
  • Respect privacy and confidentiality
  • Be honest and nonjudgmental

28
Pediatric Assessment - Appearance
  • Provides most important look into the status of
    the child - are they sick or not?
  • Start observation as you 1st enter the scene and
    while the child is still with the caregiver
  • immediate hands-on may increase agitation, crying
    and may interfere with a true picture
  • immediate hands-on is necessary if the child is
    unconscious or obviously critically ill

29
Normal/Abnormal Appearance
  • Normal appearance
  • good eye contact, has good muscle tone, and good
    color
  • Abnormal appearance
  • poor eye contact, listless, and pale
  • Appearance doesnt indicate the cause of
    illness or injury but reflects that a problem is
    going on

30
Normal Appearance In Setting Of a Critical
Situation
  • Maintain index of suspicion in children that look
    okay initially but may soon become critically
    ill
  • toxicological problems (overdoses)
  • blunt trauma
  • powerful compensation abilities may fool the
    examiner
  • when the child crashes they will crash quickly
    with rapid progression to decompensated shock

31
Work of Breathing
  • In the pediatric patient, evaluation of work of
    breathing gives great insight into the pediatric
    patients oxygenation ventilation status
  • Listen for abnormal airway sounds
  • snoring, muffled or hoarse speech, stridor,
    grunting, wheezing
  • Look for signs of increased breathing effort
  • sniffing position, tripoding, refusing to lie
    down
  • retractions (neck, intercostal, substernal
    muscles)
  • nasal flaring

32
Tripod Positioning-leaning forward, hands
resting on thighs
33
Costal retractions use of accessory neck muscles
34
Abnormal Breath Sounds
  • Upper airway obstruction
  • snoring, muffled, hoarse speech, stridor
  • stridor - high-pitched inspiratory sound
    abnormal airflow across partially obstructed
    upper airway
  • Potential causes
  • croup
  • foreign body
  • aspiration
  • bacterial upper airway infection
  • bleeding, edema

35
Abnormal Breath Sounds
  • Grunting
  • exhaling against a partially closed glottis
  • keeps alveoli open for maximum gas exchange
  • sound heard best at end of exhalation
  • often present with moderate to severe hypoxia
  • reflects poor gas exchange due to fluid in lower
    airways
  • Potential causes
  • pneumonia
  • pulmonary contusion
  • pulmonary edema

36
Abnormal Breath Sounds
  • Wheezing
  • continuous high-pitched musical sound a whistle
  • movement of air across partially blocked small
    airways
  • in disease process heard earliest during
    exhalation
  • as obstruction increases, heard during inhalation
    and exhalation
  • with increased obstruction heard audibly
  • Most common cause - asthma
  • Other potential causes
  • bronchiolitis
  • lower airway foreign body aspiration

37
Abnormal Visual Signs - Increased Work of
Breathing
  • Providers must evaluate visually to determine
    evidence of increased work of breathing
  • this means all patients need to be eventually
    undressed for observation of the neck chestwall
  • Sniffing position - severe upper airway
    obstruction used as attempt to increase airflow
  • Tripoding - refuses to lie down, leans forward on
    outstretched arms attempting to use accessory
    muscles to breath

38
  • Retractions - use of accessory muscles to help
    breath using extra muscle power to move air into
    lungs more prominent in child than adult
  • includes head bobbing - use of neck muscles
    during severe hypoxia
  • includes nasal flaring - exaggerated nostril
    opening during inspiration moderate to severe
    hypoxia

39
Respiratory Distress
40
Evaluating Respirations
  • Respiratory rate
  • Best to count for a minimum of 30 seconds due to
    the natural irregularity of the pattern
  • Breath sounds
  • Place the stethoscope as lateral as possible
  • Pulse oximetry
  • Evaluate results along with work of breathing
  • Readings above 94 indicates probably good
    oxygenation

41
Normal Respiratory Rates By Age
  • Infant 30-60 breaths/minute
  • Toddler 20-30 breaths/minute
  • Preschooler 20-30 breaths/minute
  • School-aged child 20-30 breaths/minute
  • Adolescent 15-20 breaths/minute
  • Trending more helpful than a single reading
  • Values differ by source

42
Abnormal Visual Signs - Poor Circulation to the
Skin
  • Cold environment may cause false skin signs
  • Inspect skin and mucous membranes
  • Look at face, chest, abdomen, extremities, and
    lips
  • Dark complexion patients
  • assess lips and mucous membranes

43
  • Circulation to skin reflects overall status of
    core circulation
  • pallor - early sign compensated shock
  • mottling - constriction of blood vessels to the
    skin
  • cyanosis - late finding of respiratory failure or
    shock critical finding that indicates immediate
    resuscitative action

44
Evaluating Circulation
  • Heart rate - bradycardia is ominous sign
  • Pulse quality
  • Brachial is the peripheral site for a child under
    one
  • Central pulse - femoral in infants and young
    children carotid in older child or adolescent
  • Skin temperature and capillary refill
  • Good locations are at the kneecap or the forearm
  • Blood pressure
  • Should make an attempt on children older than 3
  • Cuff size should cover 2/3 the length of the
    upper arm

45
Normal Heart Rates by Age
  • Infant 100-160 beats per minute
  • Toddler 90-130 beats per minute
  • Preschooler 80-120 beats per minute
  • School-aged child 70-120 beats per minute
  • Adolescent 70-120 beats per minute
  • Bradycardia indicates critical hypoxia and/or
    ischemia and indicates need for immediate
    interventions

46
Region X Pediatric SOPs
47
Region X Routine Pediatric Care SOPs
  • General patient assessment - pediatric assessment
    triangle (PAT)
  • appearance
  • work of breathing
  • circulation to skin
  • Initial assessment - ABCDEs
  • Identify priority patient and make transport
    decision

48
  • Additional assessment and interventions
  • vital signs
  • determine weight and age
  • pulse oximeter before during O2
  • cardiac rhythm if applicable
  • IV/IO access (20 ml/kg administered under 20
    minutes if fluid challenge is necessary)
  • determine blood glucose if indicated
  • altered level of consciousness
  • unconscious, unknown reason
  • known diabetic and related problem
  • reassess previous assessments appropriateness
    of interventions performed

49
  • Detailed physical exam
  • Contact Medical Control
  • Transport to closest most appropriate hospital
  • Always remember to keep child warm
    hypothermia increases the rate of complications
    and negative outcome

50
Altered Level of Consciousness
  • Dextrose
  • Sugar to replace depleted stores
  • Brain extremely sensitive to a drop in glucose
    levels
  • Dose if less than 1 year old
  • 12.5 4 ml/kg
  • Dose for ages 1 - 15 (gt1 - lt16)
  • 25 2 ml/kg
  • Dose for ages 16 and over
  • 50

51
Glucose Dosing
  • To remember dosing schedule
  • D 12.5
  • 4 x 12.5 50 therefore D 12.5 is 4 ml/kg
  • D 25
  • 2 x 25 50 therefore D 25 is 2 ml/kg
  • Diluting D 25 to make D 12.5
  • Calculate total dose volume required
  • Half the dose volume is D 25 half the dose
    volume is normal saline
  • Mix 50/50 solution and administer slowly

52
Case Study
  • A 12 year-old boy calls 911 for his unconscious 4
    year-old sister
  • The brother reports a few minutes of full body
    shaking by the sister you are informed that the
    patient was recently diagnosed as a diabetic and
    she takes shots
  • The patient is unresponsive, limp,
    pulse rate 140 RR 30 B/P 98/68
  • What is your impression?
  • What is your approach/intervention?

53
Case Study
  • This child is most likely hypoglycemic
  • Sugar stores are quickly used and the brain is
    the most sensitive organ to ? glucose levels
  • Protect the airway (positioning, have suction
    available)
  • Obtain IV access and evaluate the glucose level
    (this patients blood sugar is 40)
  • This patient needs dextrose (glucagon if no IV)
  • gt1 years old D25 (2 ml/kg)
  • Patient weighs 25 pounds

54
Practice Math - How much Dextrose does this
patient receive?
  • 25 pounds ? 2.2 kg ? kg
  • 2.2 25 (move decimal to right in both
    numbers)
  • 22 250 11 kg
  • D 25 formula 2 ml/kg
  • 2(ml) x 11(kg) 22 ml D25
  • Administer slowly through largest vein available
    (irritating to veins)

55
Altered Level of Consciousness
  • Glucagon
  • In the absence of IV access
  • 0.1 mg/kg (max dose 1 mg (1 unit))
  • Must be reconstituted
  • May be followed by Dextrose if IV access obtained
    no improvement in LOC
  • Narcan
  • Known or suspected acute narcotic overdose
  • lt 20kg 0.1 mg/kg IVP/IO/IM (max dose 2mg)
  • gt20 kg (approx 4 year-old) 2 mg IVP/IO/IM

56
Protecting The Airway
  • Positioning
  • side lying
  • securely strapped to the backboard with
    sufficient head/spine immobilization in case of
    need to rapidly turn the backboard onto its side
  • Suctioning
  • anticipate the need, unit turned on and ready to
    be used
  • minimize time suction applied while removing
    catheter
  • adults 10-15 seconds children lt 5 seconds
  • Anticipate supplemental O2 - poss via BVM

57
Pediatric Acute Asthma
  • Albuterol
  • Bronchodilator with some cardiac side effects
    (?HR ? strength of contractions (pounding
    heart))
  • 2.5 mg / 3ml in nebulizer
  • May need to use nebulizer mask in place of
    mouthpiece
  • Encourage deep slow breaths
  • May need to administer Albuterol in-line
  • Set up nebulizer equipment and start
    administering while bagging the patient even
    prior to intubation
  • getting some drug into the lungs may prove
    helpful

58
Nebulizer Mask - when the patient cant tolerate
the mouthpiece
59
Acute Asthma
  • Earliest in disease will auscultate bilateral
    wheezing breath sounds heard first on exhalation
  • Eventually will hear audible wheezing standing
    next to the patient
  • A silent chest (no breath sounds can be heard
    with a stethoscope) is a critical (deadly)
    situation in any patient
  • Patients in an acute asthma attack are dry (lose
    moisture from the increased respiratory rate) and
    are potentially hypoxic

60
Patient Treatment
  • Prior to any treatment, assessment must be done
  • EMS needs to obtain a general impression
  • this drives the decision regarding which SOP to
    work from
  • EMS needs to think cause of the situation which
    can also drive a decision on which SOP to use

61
Possible Causes of Critical Cardiac Situations -
6 Hs 5 Ts
  • Hypovolemia
  • Hypoxia
  • Hydrogen ion - acidosis
  • Hyper/hypokalemia
  • Hypothermia
  • Hypoglycemia
  • Tablets
  • Tamponade, cardiac
  • Tension pneumothorax
  • Thrombosis, coronary (ACS)
  • Thrombosis, pulmonary (embolism)
  • Trauma

62
Pediatric Ventricular Fibrillation
  • 2 minutes of CPR if arrest unwitnessed or gt4-5
    min
  • Single defibrillation attempts for all persons
  • Initial pediatric defibrillation - 2 j/kg
  • 2nd subsequent defibrillation attempts - 4 j/k
  • Immediately after defibrillation attempts, CPR
    resumed for all persons
  • 302 for single rescuer on all patients
  • 152 for 2 person with child infant CPR
  • IV access
  • Peripheral or IO routes attempted
  • Flush all drugs with 5 ml NS to enhance delivery

63
Pediatric VF
  • Meds
  • Vasopressor -
  • Epinephrine (primary action in arrest is to
    constrict blood vessels to support perfusion)
  • 110,000 - 0.01 mg/kg IVP/IO
  • repeated every 3-5 minutes for duration of arrest
  • Antidysrhythmic
  • Amiodarone 5 mg/kg IVP/IO 5 ml NS flush
  • OR
  • Lidocaine 1 mg/kg IVP/IO 5 ml NS flush

64
Antidysrhythmic Medications
  • Do not mix administration of Amiodarone and
    Lidocaine
  • The heart becomes more irritable when these drugs
    are administered simultaneously to patients
    during the same acute process
  • IV drips
  • Only establish a drip for the same drug
    administered IVP
  • Lidocaine drip follows Lidocaine bolus
  • Amiodarone drip follows Amiodarone bolus (usually
    hung at the hospital)

65
Pediatric Asystole, PEA, Pulseless
Idioventricular Rhythms
  • CPR - push hard, push fast
  • IV/IO fluid challenge
  • 20ml/kg formula for all persons/all ages
  • reassess as every 200 ml has been administered to
    the patient moving towards a total infusion
    amount
  • monitor breath sounds on all patients receiving
    fluids
  • Vasopressor drug
  • Epinephrine 110,000
  • 0.01 mg/kg IVP/IO followed by 5 ml NS flush
  • Repeat every 3-5 minutes

66
What Is This Rhythm?
  • Sinus Bradycardia
  • What is the significance in the pediatric
    population?

67
Pediatric Bradycardia
  • In pediatric patients, bradycardia almost always
    represents hypoxia
  • Evaluate airway, airway, airway
  • Ventilate, ventilate, ventilate (BVM)
  • Vasopressor drug
  • Epinephrine 110,000 0.01 mg/kg IVP/IO
  • Repeat every 3-5 minutes
  • Atropine - only helpful in pediatrics if the
    bradycardia is related to a vagal cause (more
    common in the adult)

68
What Is The Significance of This Rhythm In a
Newborn?
  • This patient was born 5 days ago this rate is
    too slow
  • A normal heart rate range in newborns should be
    100-160
  • This patient is ill needs immediate ventilation
    support

69
Practice Math - Epinephrine
  • Your patient weighs 26 kg
  • Epinephrine 110,000 dose is 0.01 mg/kg
  • 0.01 (mg) x 26 (kg) ? mg
  • 0.01
  • x 26
  • 6
  • 2
  • 0 .26 (mg)

70
Formula 1 - To Determine ml Of Epinephrine To
Give
  • mg on hand desired mg
  • ml on hand X ml
  • 1 mg 0.26mg
  • 10 ml X
    ml
  • (cross multiply) 1 x X 0.26 x 10
  • 1X
    2.6
  • (get X by itself) 1X?1 2.6 ? 1 (1 2.6 )
  • X
    2.6 ml

71
Formula 2 - To Determine ml of Epinephrine To
Give
  • Xml desired dose x vol on hand
  • dose on hand
  • X ml 0.26 (mg) x 10 (ml)
  • 1 (mg)
  • X ml 0.26 x 10
  • 1
  • X ml 2.6 (1 2.6 )
  • 1
  • X ml 2.6 ml IVP flushed with 5 ml NS

72
Pediatric Shock
  • Hypovolemic
  • Hemorrhage, diarrhea, vomiting, ? fluid intake
  • Fluid challenge 20 ml/kg repeated twice more
    (60ml/kg)
  • Reassess as every 200 ml is being administered
  • Cardiogenic
  • Usually congenital no fluid challenge to be
    given!
  • Distributive
  • Sepsis (massive infection), anaphylaxis
  • Fluid challenge 20 ml/kg repeated twice more
  • Reassess as every 200 ml is being administered
  • If allergic response, add that protocol

73
Case Study
  • You have been called to the home for a
    6-month-old vomiting for 24 hours.
  • The infant is lying still with poor muscle tone
    irritable if touched weak cry.
  • No abnormal airway sounds, retractions, or nasal
    flaring.
  • Skin is cool, pale, mottled, with 4 second
    capillary refill time, weak brachial pulse.
  • Heart rate 180 RR 30 breath sounds clear.
  • Abdomen is distended.
  • Impression? Intervention needed?

74
Case Study
  • This infant is severely ill - in shock
  • Poor appearance, diminished tone, poor
    interactiveness, weak cry
  • Requires resuscitation rapid transport
  • Vital signs are deceptive
  • Need to be correlated with pediatric assessment
    triangle full assessment
  • Immediate airway support (possible BVM support)
  • IV/IO access - fluid challenge 20 ml/kg

75
Do The Math - How Much Fluid?
  • The patient weighs 15.5 pounds.
  • What is the amount of the fluid challenge that
    needs to be administered?
  • How is the fluid challenge to be administered?
  • 15.5 ? 2.2 ? 2.2 15.5 (move decimal point
    over to the right one space in each number)
  • 22 155 7 kg
  • 7 kg x 20 ml 140 ml fluid challenge NS
  • Administer in under 20 minutes reevaluate

76
Pediatric Tachycardia
  • Children compensate by increasing heart rate more
    than increasing contractility
  • Sustained high respiratory rates and heart rates
    indicate a vascular problem
  • Low respiratory rate, heart rate, and blood
    pressure indicate a serious problem with
    oxygenation, ventilation, and/or perfusion
  • Trends in vital signs more important than taking
    one reading

77
Probable Sinus Tachycardia
  • Most common tachycardia in pediatrics
  • Rates can be higher than expected compared to the
    adult population
  • Infants usually lt 220 beats per minute
  • Child usually lt180 beats per minute
  • Most common approach is symptomatic treatment

78
Pediatric Tachycardia
  • May be a nonspecific sign not representing
    anything serious
  • fear
  • anxiety
  • pain
  • fever
  • May be indicating a life-threatening problem such
    as hypoxia or hypovolemia
  • Evaluate heart rate and QRS width

79
What Is This Rhythm?
  • Probably sinus tachycardia in a pediatric patient
  • Appearance is altered from typical adult rhythm
    pattern
  • Treatment is geared to determining the underlying
    reason

80
Probable Supraventricular Tachycardia
  • QRS narrow
  • Rate can be higher than expected
  • Infants usually 220 beats per minute
  • Child usually 180 beats per minute
  • Vagal maneuvers
  • Have child hold their breath or have child blow
    hard through a straw
  • Adenosine 0.1 mg/kg rapid IVP with flush
  • Repeat Adenosine 0.2 mg/kg rapid IVP with flush

81
What is this rhythm?
  • 9 wk old infant presents listless,
  • sweaty, short of breath

Probably SVT
82
Pediatric Ventricular Tachycardia with Poor
Perfusion
  • Severe systemic insult that must be reversed as
    soon as possible
  • Electrical countershock - cardioversion
  • Pre-medicate Versed 0.1 mg/kg IVP slowly over 2
    minutes, titrate to sedation
  • Cardiovert 1 j/kg observing safety precautions
    (look call all clear)
  • If repeat cardioversion required, 2 j/kg
    observing safety precautions

83
Pediatric Ventricular Tachycardia with Adequate
Perfusion
  • You have time to attempt drug therapy
  • Amiodarone 5 mg/kg IVPB
  • Dose diluted in 100 ml D5W
  • Pediatric drip rate at 30 mcgtt/10 seconds
  • OR
  • Lidocaine 1 mg/kg IVP
  • Cardioversion after versed sedation if no
    response to drug therapy

84
Do The Math - Amiodarone
  • Your 4 year-old patient weighs 40 pounds and will
    need Amiodarone 5 mg/kg
  • Amiodarone in the arrested state is to be given
    as a diluted rapid IVP bolus (stable patients
    receive the drug slow IVPB)
  • Calculate pounds to kilograms
  • 40 (pounds) ? 2.2 (kg) ? Kg
  • 2.2 40 (move the decimal to the right and
    need to move decimal space behind 40)
  • 22 400 18 kg

85
  • Calculate dosage of drug to administer
  • 18 (kg) x 5 (mg/kg) 90 mg (of Amiodarone)
  • Calculate volume of medication to administer
  • Amiodarone packaged 50 mg/ml need to administer
    90 mg
  • Formula 1 mg on hand desired mg
  • ml on hand X ml
  • Formula 2 Xmldesired dose x vol on hand
  • dose on hand

86
Formula 1 - Desired Dose 90 mg
  • mg on hand desired mg
  • ml on hand X ml
  • 50mg
    90mg
  • 1 ml
    X ml
  • (cross multiply) 50 x X 90 x 1
  • 50X 90
  • (get X by itself) 50X?50 90 ? 50 (50
    90)
  • X
    1.8 ml

87
Formula 2 Desired Dose 90 mg
  • Xml desired dose x vol on hand
  • dose on hand
  • X ml 90 (mg) x 1 (ml)
  • 50 (mg)
  • X ml 90 x 1
  • 50
  • X ml 90 (50 90 )
  • 50
  • X ml 1.8 ml

88
Administering Amiodarone IVPB
  • Add dose to 100 ml bag D5W (90 mg (1.8ml))
  • Gently mix the contents label the bag
  • Spike the bag with minidrip tubing run thru the
    tubing
  • Wipe off the port with alcohol and attach
    piggyback line into main IV line
  • Infuse the drip
  • over 20 minutes for pediatric patient
    (lt16 years)
  • run the piggyback at 30 minidrips/10 seconds

89
Pediatric Croup
  • Viral infant/toddler population low grade
    fever barking cough
  • Humidified O2
  • 6 ml NS in nebulizer, place mask near childs
    face
  • If wheezing, Albuterol 2.5 mg (may repeat once)
  • If no improvement, Epinephrine 11000 1ml mixed
    with 2 ml NS in nebulizer (may repeat once)
  • If unstable (cyanotic, respiratory distress),
    begin BVM ventilations, be prepared to intubate

90
Pediatric Epiglottits
  • Bacterial usually 4 year-old and upward in age
    (no upper age limit) high fever drooling
    stridor
  • Humidified O2
  • 6 ml NS in nebulizer, place mask near childs
    face
  • If patient deteriorates, ventilation via BVM be
    prepared to intubate (one attempt)
  • True emergency requiring gentle handling,
    avoidance of agitating the patient, and rapid
    transport

91
Case Study
  • You are called to the scene of a 23-month-old
    child for trouble breathing.
  • Upon arrival the child is sitting on the mothers
    lap starts to cry when they see you.
  • He has audible wheezing you observe intercostal
    retractions. Skin is pink.
  • Mother states runny nose for 2 days.
  • The child starts hitting you when you approach.
  • What is your impression?
  • What is your approach?

92
Case Study
  • A normal toddler is afraid of strangers (hitting
    and kicking is not unusual).
  • A quiet cooperative toddler is of more concern!
  • Impression croup
  • Approach get on the childs eye level
  • Ask the parent to remove the shirt to observe
    breathing
  • Start physical contact at the toes progress up
  • Praise cooperative behavior
  • Have caregiver hold nebulizer kit for the patient

93
Pediatric Seizures
  • Remember to check glucose levels
  • check on all altered/abnormal level of
    consciousness patients known diabetics with
    diabetic related problem
  • To treat current seizure activity
  • Valium 0.2 mg/kg IVP titrated to control seizure
    activity
  • In absence of IV, administer Valium 0.5 mg/kg
    rectally
  • Valium/Diazepam will only stop the current
    seizure activity does not prevent future ones

94
Rectal Administration of Medication
  • Rectum highly vascular
  • Medication absorption fairly quick thru lining or
    mucosa of rectum (IVP is quicker)
  • Calculate Valium dosage
  • Draw up dosage into TB or 3-5 ml syringe
  • If syringe larger than TB, attach the plastic
    catheter from an IV catheter (14-20 G) to tip
  • Lubricate tip of syringe or catheter
  • Carefully introduce 2? into rectum inject
  • Hold buttocks closed for 10 seconds

95
Rectal Medication
Draw up dosage
Gently administer dosage aspiration is
not necessary
96
Allergic Reactions
  • There is exposure to an antigen and the
    response is to form antibodies
  • Immune response activated
  • Antihistamines (ie Benadryl) given to stop
    histamines from their normal action/response
  • conjunctivitis - inflammation of the eye
  • rhinitis - inflammation of nasal mucous membranes
  • angioedema - localized edema in tissues
  • urticaria - itchy skin rash
  • contact dermatitis - inflammation of skin

97
  • Vasopressors (Epinephrine) given in the presence
    of airway swelling, difficulty breathing, or
    clinical signs of shock
  • Reverses bronchoconstriction to improve the
    respiratory status
  • Supports a falling blood pressure
  • In shock, IM a more predictable absorption than
    SQ route

98
Pediatric Allergic ReactionStable
  • Patient alert, skin warm dry
  • Irritating signs and symptoms
  • hives, itching, rash
  • GI distress
  • Benadryl
  • 1 mg/kg slow (over 2 minutes) IVP or IM
  • maximum 25 mg (equivalent to adult dose)

99
Practice Math
  • Your pediatric patient presents with an allergic
    reaction with hives, no airway involvement.
  • They weigh 75 pounds (34 kg)
  • How much Benadryl do they get?
  • Formula 1mg/kg patient weighs 34 kg
  • Calculation 34kg x 1mg 34 mg (of Benadryl)
  • Note Do not give a pediatric patient a higher
    dosage than what the adult would receive
  • Administration 25 mg Benadryl slow IV or IM

100
Pediatric Allergic Reaction Stable with Airway
Involvement
  • Patient alert skin warm dry
  • Has external signs symptoms now with itchy or
    scratchy throat, hoarseness, wheezing
  • Epinephrine 11000 SQ
  • 0.01 mg/kg (maximum 0.3 ml/dose)
  • May repeat every 15 minutes
  • Benadryl
  • 1 mg/kg IVP slow(over 2 minutes) IVP (max 50 mg)
  • Albuterol 2.5 mg nebulizer (may repeat)

101
Pediatric Allergic Reaction Anaphylactic Shock
  • Patient with altered mental status
  • THEY ARE IN SHOCK!!!
  • Epinephrine 11000 IM 0.01 mg/kg (max 0.3
    ml/dose) may repeat every 15 minutes
  • Benadryl 1 mg/kg IVP slowly over 2 minutes (max
    50 mg)
  • IV fluid challenge 20 ml/kg (max 60 ml/kg)
  • Albuterol 2.5 mg nebulizer

102
Self-Administered Epi-pens
  • Packaging
  • Epi-pen (adult) - 0.3mg/0.3ml
  • Epi-pen Jr (pediatrics) 0.15 mg/0.3ml
  • Expiration dates need to be evaluated

103
Epi-Pens
  • EMT-Basic
  • Epi-pens are taught as a patient assist device
  • The epi-pen must belong to the patient
  • The EMT-B may assist the patient in administering
    their own epi-pen
  • Paramedic
  • If medication is required, the paramedic will use
    their own supply of medications
  • If the patient has injected their own epi-pen,
    you might need to contact Medical Control to
    determine if your Epinephrine should be held

104
  • To use an Epi-pen
  • Form fist around unit
  • Remove black tip - keep fingers away from opening
  • Pull off gray safety release
  • Jab black tip firmly into outer thigh 900 angle
    (perpendicular)
  • Hold firmly for 10 seconds then remove
  • Massage site for 10 seconds
  • Dispose of unit
  • Patients may have been instructed to replace unit
    into carrier and return to prescribing MD for new
    prescription

105
Can go through clothing
106
Broselow Tape
  • Patient length used as a valid marker of size
    specific equipment and medication dosing
  • Measure the childs length from the top of head
    to the heel (not the toe)

Measure top of head
to the heel
107
Broselow Tape
  • Colored sections display a range of weights
  • Medications, defibrillation and cardioversion
    joules listed on one side
  • Medications, fluid challenge amounts, and
    equipment sizing listed on the reverse side
  • Medications are printed in mg and need to be
    calculated into ml to determine quantity of
    medication to deliver
  • Region X SOPs match the Broselow tape
    calculations

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Calculating Medication Dosage
  • 2 page reference printed in the SOPs
  • one page for medical medications
  • one page for cardiac medications
  • Document dosage in mg (obtain from Broselow or
    SOP reference)
  • Need ml to know what quantity of medication to
    put into the syringe

113
Patient Deterioration
  • Always be assessing for changes in patient status
  • Key information that points to a patient change
  • watch for rapid decrease in appearance especially
    interactiveness
  • watch heart rate especially if the rate begins to
    drop
  • watch for irregularity of the respiratory pattern

114
Bibliography
  • American Academy of Pediatrics. Pediatric
  • Education for Prehospital Professioinals.
  • Jones Bartlett. 2000.
  • Bledsoe, B., Porter, R., Cherry, R. Paramedic
    Care Principles Practices 2nd Edition. Brady.
    2006.
  • Region X SOPs, March 1, 2007.
  • Sanders, M. Paramedic Textbook, Second
  • Edition. Mosby. 2007
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