Caring for the Pediatric Patient

1
Caring for the Pediatric Patient

• Condell Medical Center EMS System
• Continuing Education
• February 2004
• Program prepared for CMC EMS by Sharon Hopkins,
  RN, BSN

2
Objectives

• Upon successful completion of this program, the
  participant will be able to
  
• assess the airway status and make appropriate
  intervention decisions
  
• recognize situations where the pediatric patient
  is hypoventilating and in need of intervention
  

3
Objectives

• assess identify the circulatory status of the
  pediatric patient and be able to determine when
  the pediatric patient is in need of
  interventions
• verbalize actions, indications,
  contraindications, dosing side effects of
  medications used in the pediatric situations

4
Objectives

• actively participate in review of the Condell
  Medical Center EMS System Standard Operating
  Guidelines (SOGs)
  
• participate in hands-on skill practice including
  intubation, Broselow tape, calculating drawing
  up medications, IO needle insertion, pediatric
  megacode

5
Is there a need for EMS to know how to take care
of the pediatric patient?How many pediatric
patients does EMS care for?
6
Children account for 5-10 of ambulance runs but
25-30 of ED visits.

• Most frequently seen are
• children
• for medical problems
• children 10 years
• old for trauma
• related problems

7
Medical problems most likely encountered

• respiratory problems
• stridor
• wheezing
• apnea
• seizures
• most commonly from febrile events

• altered mental status
• always check glucose levels
• abdominal pain
• pregnancy related problems
• pre-hospital births

8
What might that respiratory distress noise
indicate?

• If you hear stridor (inspiratory crowing-type of
  sound usually heard without a stethoscope), think
  an upper airway obstruction like
  
• croup
• epiglotitis
• foreign body

• If you hear wheezing (high pitched musical noises
  usually heard louder on exhalation), think lower
  airway involvement like
  
• acute bronchitis
• asthma
• chronic lung disease
• (yes, kids can have a chronic lung disease)

9
Trauma related problems most likely encountered

• MVC
• occupant
• pedestrian
• drownings
• ages 1-4 have the highest drowning death rate
• burns/inhalation injuries

• intoxication
• choking/suffocation
• penetrating trauma from firearms

10
Is there a difference between adults children
and how they present when theyre in trouble?
11
In adults

• ?sudden cardiac arrest is a primary event
• ?adults usually have underlying cardiac disease
• ?most commonly seen dysrhythmias are ventricular
  in nature

12
In children

• ?cardiac arrest is usually a secondary event
• ?usually involved is
• respiratory failure
• CNS insufficiency
• cardiovascular collapse with multiple etiologies
  
  
• ?most commonly seen dysrhythmia is asystole

13
Assessment-based, problem focused pediatric
patient care

• ?assess the patient
• ?find the problem
• ?provide intervention prioritizing care as
  emergent, urgent, non-urgent

14
Categorizing your patient?Emergent situations
immediately life threatening?Urgent
potentially life threatening or seriously
compromising?Non-urgent not life threatening
or compromising
15
Assessments should follow the ABC approach -
? airway ?
breathing ? circulation
16
Assessment of Airway Status

• Is the airway open?
• ?To open airways on infants, gently tip the head
  backwards
  
• ?To maintain an open airway, pad under the
  shoulders (pelvis due to large occiput)
  
• ?Too much head tilt on the infant will actually
  close off the airway

17
Assessment of Breathing

• ?Observe for chest abdominal movement and
  effort
  
• ?Infants young children use their diaphragmatic
  muscles to breath which makes the abdominal area
  (belly) move with respirations
  
• ?Is the rate depth age appropriate?

18
Are signs of respiratory distress, failure or
arrest present?
19
Respiratory Distress

• compensation noted with ? respiratory ? heart
  rates
  
• normal or agitated mental status
• respiratory rate elevated
• bilaterally audible breath sounds

• minimal or lack of evidence of use of accessory
  muscles
  
• treatment geared to ?correcting hypoxia,
  ?observation of the condition, and
  ?investigation of the cause

20
Respiratory Failure

• decreased mental alertness (sleepy but arousable,
  possibly agitated)
  
• tachypnea, tachycardia, diaphoresis
• low pulse ox
• retractions

• use of accessory muscles
• nasal flaring
• see-saw respirations
• chest moves inward as abdomen moves outward
• head bobbing
• airway noises (ie grunting)

21
Respiratory Pre-arrestIncludes findings of
respiratory failure plus

• extreme tachypnea
• 60 breaths/minute
• or
• extreme bradypnea
• peripheral core cyanosis
• prominent use of accessory muscles or no muscle
  movement

• altered, depressed mental status
• diminished muscle tone
• bradycardia
• diminished peripheral perfusion
• prominent grunting on exhalation

22
Immediate aggressive care is needed now before
the patient progresses to the next step of
23
Respiratory ArrestCompensatory measures have
failed!

• unresponsive
• minimal or absent respirations
• flaccid muscles
• slow respiratory rate

• slow, weak, or absent peripheral pulses
• slow, weak, or absent central pulses
• hypoperfusion
• apnea

24
The time frame from decompensated respiratory
failure to respiratory arrest is rapid!Be
proactive prepared!
25
Goal of airway assessment

• Determine if
• the airway is patent/open
• the airway is likely to remain patent
• interventions are necessary to obtain and
  maintain airway patency

26
Airway interventions

• positioning - consider a small towel under
  shoulders. (to keep head neck aligned)
  
• clearing foreign bodies
• 1-8 years old - abdominal thrusts
• no finger sweeps on any peds patients
• suctioning - limit time to 5 seconds in peds

27
Airway interventions continued

• suctioning - avoid stimulating the pharynx (back
  of throat) to avoid stimulating gag reflex
  
• airway adjuncts
• oropharyngeal - measure central incisor to angle
  of jaw
  
• nasopharyngeal - size to little finger size
  length from nose to tragus (front part) of ear
  
• intubation - confirm tube placement with direct
  visualization, 3 point auscultation (stomach,
  midaxillary areas) watch for bilateral chest
  rise

28
Airway interventions continued

• additional clinical assessment confirmation of ET
  tube placement - improvement in heart rate, skin
  color, mental status, general condition
  
• if there might be a problem with ET tube
  placement, think through DOPE to trouble
  shoot
  
• D - displacement
• O - obstruction
• P - pneumothorax (from injury or rescuer
  created)
  
• E - equipment failure

29
What components need to be assessed to determine
the adequacy of pediatric circulation?
30
Determine pediatric circulatory adequacy by
evaluating

• Mental status changes
• AVPU category
• heart rate
• capillary refill
• urinary frequency
• blood pressure

31
Assessment of Pediatric Circulatory Adequacy

• ?Mental status changes
• how alert is the child to the environment?
• how does the child interact with the
  environment?
  
• does the child interact with the parents and
  respond to the parents?
  
• does the child recognize the presence of
  strangers (EMS) in the area?
  

32
Mental status evaluated using AVPU

• A - alert, responsive to their normal (need to
• ask parents/caregivers whats normal for
  
  
• this child)
• V - responds to verbal stimuli
• P - responds to painful/obnoxious stimuli
  which may be as simple as gentle shaking
  
• U - unresponsive, flaccid, no movement

33
Circulatory assessment using heart rate

• ? Heart rate
• central circulation assessment
• 1 year old - carotid or femoral
• peripheral circulation assessment
• 1 year old - radial pulse

34
Circulatory assessment using capillary refill

• ?Capillary refill
• normal response is for the area to refill in
  under 2 seconds
  
• any area of the body may be checked for capillary
  refill
  
• fingernail beds are useful available on older
  children
  
• on infants, squeeze the whole foot to check
  capillary refill
  
• more reliable in pediatric patients than adults

35
Circulation assessment using kidney function

• Urinary frequency
• ask the parents or caregiver if the frequency and
  weight of wet diapers has changed
  
• are the diapers even getting wet?

36
It is difficult to rely on pediatric blood
pressures

• ?Blood pressures are hard to obtain
• under age 3 usually rely on presence strength
  of central peripheral pulses instead
  
• size of the equipment needs to be accurate
• cuff should cover 2/3 the length of the upper
  arm
  
• just the act of taking the B/P can influence an
  increase in the pulse respiratory rates
  
• B/P changes are late markers of perfusion problems

37
If you want to remember a formula then

• B/P (2 x age in years) 70
• example normal B/P for 2 year old
• (2 x 2) 70
• 4 70 74 systolic

38
When circulation is poor in the pediatric patient
consider

• ? hypoxia
• ? hypovolemia

39
Cardiovascular compromise

• ?1st impressions that indicate a problem
• altered mental status - not alert, not
  interactive with caregivers, not looking around
  
• limp muscle tone
• weak respiratory effort
• paleness or cyanosis

40
The most common cause of hypoperfusion and
bradycardia in the pediatric patient is...

• RESPIRATORY
• FAILURE

41
Good patient outcome is dependent on early
recognition of shock /or inadequate perfusion
and timely interventions!
42
Whats the difference between compensated
decompensated shock?
43
Compensated shock

• irritability
• rapid heart rate
• tachypnea
• normal systolic B/P
• full central pulses, weak peripheral pulses
• delayed capillary refill
• decreased urine output
• cool, pale extremities

44
Weak peripheral pulses in compensated shock are

• ?radial pulses
• ? dorsal pedal pulses
• ?posterior tibial pulses

45
Decompensated shock

• decreased mental alertness
• very rapid or slowed heart rate
• very rapid or slowed respiratory rate
• low blood pressure
• absent peripheral pulses weak or absent central
  pulses
  
• markedly delayed or absent capillary refill
• markedly decreased or absent urine output
• dusky, mottled extremities

46
Weak central pulses in decompensated shock are
the

• ?brachial artery
• ? femoral artery
• ?carotid artery in
• older children

47
Causes of hypoperfusion

• vomiting diarrhea
• osmotic diuresis (ie diabetic ketoacidosis
  (DKA))
  
• blood loss (ie trauma including head injuries
  especially if fontanelles still open skull is
  not yet a closed box)
  
• plasma loss (ie burns)
• anaphylaxis - due to vasodilation
• generalized sepsis - massive infection
• spinal cord injury - due to vasodilation
  bradycardia
  
• cardiac failure (ie congenital heart disease
  respiratory failure from hypoxia acidosis)

48
What do I do if inadequate perfusion is present?

• Start CPR if
• pulse is absent altogether
• OR
• pulse is perfusion
  

49
Management of hypoperfusion

• prompt, aggressive management
• vascular access
• peripheral sites
• IO
• fluid resuscitation 20 ml/kg infused in under 20
  minutes reassess prepare to give another 20
  ml/kg
  
• frequent reassessment, rapid transport

50
Pediatric assessment triangle Another
assessment tool suggesting assessment of

Appearance mental status body position m
uscle tone
Breathing movement effort rate audibl
e
sounds
Circulation skin color
51
Appearance

• mental status - level of consciousness,
  interactions with parents, response to strangers
  (at 6-8 months the child should respond to
  their name being called)
• body positioning muscle tone - normally
  somewhat flexed extremities, symmetrical movement
  (at 4-6 months a child can sit up 8 months
  sits without assistance)
• ? PROBLEM floppy child or unusually stiff

52
Breathing

• visible movement, effort, rate, sounds need to
  be assessed
  
• children are normally abdominal breathers
• ? PROBLEM no visible movement of chest,
  struggling to breathe, rate too fast or too slow,
  grunting on exhalation, needs to maintain a
  specific position to breathe

53
Circulation

• skin color - if dark complexion, check lips,
  tongue, palms, sole of feet
  
• ? PROBLEM pale, bluish, mottled
• appearance
  
  

54
What are some other key differences between
adults children that impact our assessment
interventions?
55
Airway

• ?diameter is smaller
• ?tongue is proportionately larger - correct
  positioning is crucial
  
• ?epiglottis is floppier - use of the Miller or
  straight blade is easier preferred
  
• ?larynx is more anterior - visualization of
  anatomy is more difficult while intubating use
  of cricoid pressure could help

56
Airway continued

• ?to assist in intubation attempts increase
  visualization, have someone pull on the right
  corner of the patients mouth
  
• ?infants are obligate nose breathers - nasal
  secretions can obstruct the airway
  
• ?airway structures are more flexible - there is
  more expansion contraction with air movement

57
Breathing

• ?chest hyperresonnant - auscultation accuracy is
  difficult place stethoscope as far laterally as
  possible in axillary areas
  
• ?intercostal muscles not fully developed - these
  children tire easily from the work of breathing
  
• ?children are abdominal diaphragmatic breathers
  - compression of abdomen compromises breathing

58
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59
Breathing continued

• ?tachypnea used for compensation - but can only
  be sustained for short period of time
  
• ?tripod position assumed to assist in
  respirations - use of the upper arm muscles act
  as accessory muscles

60
Cardiovascular System

• Cardiac output heart rate x stroke volume
• CO HR x SV
• ?Children cannot ? SV to ? CO - due to
• immaturity of the heart to alter
  contractility
  
• ?Children can only ? CO by ? HR

61
Cardiovascular System continued

• ?Children compensate for hypoperfusion with ?
  systemic vascular resistance (remembering the
  mottling that shows up) and ? HR

62
Circulation

• ?total blood volume is much lower than an adults
  (80-90 ml/kg so 1 year old averages 800 cc total
  blood volume an adult has an average of 6000 cc
  total blood volume)
• ?vessels walls are healthier than adults -
  pediatric patients can rely on potent
  vasoconstriction to maintain the B/P you will
  see mottling due to vasoconstriction
• ?pediatric patients cannot ? cardiac
  contractility - cardiac output sustained mostly
  by ? the heart rate and creating potent
  vasoconstriction

63
Circulation continued

• ?compensation works well initially - then crashes
  when output can no longer meet requirements
  
• ?heart varies with respirations - sinus
  arrhythmia
  
• ?bradycardia is usually triggered by hypoxia -
  monitoring the heart rate is critical in the
  pediatric patient

64
Kids dont become hypotensive as quick as
adults!But, compensatory mechanisms have their
limits!!!

• B/P will drop rapidly after loss of approx 15 of
  circulating blood volume
  
• Total circulating blood volume is 80-90 ml/kg
  (ie 1 year old has

65
Trauma Considerations Related To Differences

• ?head - proportionately larger and heavier so
  more prone to head injuries when falling
  
• ?infant heads are expandable - anterior
  fontanelle (soft spot) open up to about 18 months
  of age so shock is possible from intracranial
  bleeding
• ?chest is mostly cartilage - blunt trauma is
  transmitted to thoracic organs without causing
  ribs to fracture

66
Trauma continued

• ?lower rib cage does not fully cover/protect
  abdominal organs - so liver spleen more easily
  injured
  
• ?bones flexible - bend easily without breaking
  most fractures are near the growth plates which
  could interfere with bone growth in the future

67
Changes in mental status can cause or be caused
by

• poor airway tone
• ? respiratory drive

68
Always be honest to the patient and family!!!

This builds trust!!!
69
Putting It All Together
Steps
in the
Assessment
Process
70
Scene size-up

• 1st impression (think peds triangle look at
  appearance, breathing, circulation (ABCs)
  
• Determine urgency rating do you consider this
  patient emergent, urgent, or non-urgent?
  
• Always keep the patient warm

71
Initial Assessment

• More detailed than 1st impression
• Builds on information already gathered
• Should attempt to be completed in less than 1
  minute

72
Steps in the Initial Assessment

• ?Mental status - AVPU
• A - patient awake
• V - patient responds to verbal stimuli name is
  called patient responds before they are
  touched
  
• P - some contact stimuli must be added to get the
  patient to respond
  
• U - the patient is flaccid unresponsive there
  is absolutely no movement

73
Initial Assessment continued

• ?Airway - open airway with gentle head tilt if
  necessary then look - listen - feel
  
• ?Breathing - ? adequacy of effort, breath sounds,
  coloring, pulse ox
  
• whats the resp rate depth?
• are there signs of ? effort like accessory muscle
  use, retractions, nasal flaring
  
• breath sounds - best to listen mid axillary to be
  as far away from opposite side as possible
  

74
Initial Assessment continued

• Pulse ox - normal is 95 - 100
• mild hypoxia 91 - 95
• severe hypoxia
• ?Circulation - compare central pulses (carotid,
  brachial, femoral) to peripheral pulses (radial),
  ? color (? lips), temp, capillary refill (normal
  is 3 years old), cardiac
  rhythm

75
To check adequacy of circulation

• Rely on
• mental status changes
• heart rate
• capillary refill
• pulse character
• changes in urinary frequency
• The above information is easier to assess for
  than a B/P in the little ones

76
Normal pediatric vital signs

• Peds pulses 60-160 range
• formula for upper limit
• HR 150 - (5 x age in years)
• Estimated systolic upper limit formula
• SBP (2 x age in years) 90
• Estimated systolic lower limit formula
• SBP (2 x age in years) 70

77
Children are different

• Poor circulatory status in a child is rarely of
  primary cardiac origin.
  
• Consider possible causes of hypoxia and
  hypovolemia in a child with symptomatic
  bradycardia.

78
Ive done the ABCs, now what?
79
Focused History

• ?SAMPLE
• S - signs symptoms
• A - allergies (including iodine before IV start)
• M - current meds including vitamins and
• natural herbal medications
• P - past pertinent medical history including
• problems with birth
• L - last oral intake including liquid solids
• E - events leading up to the incident

80
Focused history continued

• ?Additional pertinent history
• any changes from normal (sleep habits, eating
  patterns)?
  
• neurological/developmental history
• recent trauma
• if falls, height, type of surface landed on
• if MVC - position in car, type of restraints
• if sports - use of helmet
• newborn history - any problems at birth

81
Physical Exam So, what is the purpose of the
physical exam?

• The physical exam is a head-to-toe or toe-to-head
  examination completed only if there is time
  during transport. The EMS provider uses this
  exam to gather more information to make effective
  clinical patient care decisions.

82
Components of a physical exam

• More interviewing history gathering
• Examination techniques
• inspection
• palpation
• percussion
• auscultation
• Vital signs
• Adjunctive equipment use (pulse ox, B/P cuff,
  stethoscope)

83
Physical Examination - begun during transport for
emergent urgent problems

• ?Toe to head or head to toe approach?
• Toe to head in younger ones to gain trust
• ?DCAP-BTLS on physical exam
• D - deformities (bones bend easily before
• breaking because theyre pliable)
• C - contusions -a bruise or birthmark?
• A - abrasions - is there a pattern?
• P - penetrations - immobilize as found

84
Physical exam continued

• B - burns - is there an identifiable pattern?
• T - tenderness to palpation
• L- lacerations - dont cut clothing through
  possible evidence
  
• S - swelling
• ?Fontanelles - remain open up to 18 months
• bulging with history of trauma think ?
  intracranial pressure
  

85
Physical exam continued

• Fontanelles
• bulging in presence of fever think meningitis
• sunken soft spot think dehydration
• ?GCS - use modified version usually up to 5
  years of age
  
• 13-15 - mild head trauma
• 9-12 - moderate head trauma
• 3-8 severe head trauma

86
Assessment tips!

• ?if possible, keep the child on the parents lap
• ?approach the infant with a smile offer a toy
  they can grasp
  
• ?sit or kneel at eye level
• ?speak quietly, simple words, avoid baby talk
• ?talk to children throughout exam, tell a story

87
Assessment Tips Continued

• ?ask questions about things child is interested
  in
  
• ?explain interventions immediately before
  performing them - dont want kids to have a lot
  of time to let their imaginations run wild with
  their interpretations
• ?dont ask permission of the child if the task
  has to be done anyway -do allow the child to make
  decisions where they can (ie B/P on right or
  left arm)
• ?allow parents to participate as much as possible

88
So, whats got to be done for a pediatric patient?

• use a length-based resuscitation or Broselow tape
  as guidelines
  
• another resource tool is protocol
• control the airway determine if intubation is
  necessary for this patient
  
• determine need for venous access - consider
  placement of an IO needle
  

89
Broselow Tape

• ?What is it?
• This tape is a device that lists proper pediatric
  equipment sizes and precalculated drug dosages
  based on the length of the child.
  
• ?How do I use the tape?
• place the tape alongside the supine child with
  the red end even with the top of the head.
  Measure to the heel of the child.

90
News on Revised Broselow Tape

• ?updated/revised Broselow tape out (2002
  edition)
  
• ?Region X SOP will update peds medication dosages
  to match the Broselow tape (until then, follow
  current SOP for drug dosages if there is a
  conflict of dosage guidelines)
• ?color categories remain consistent
• ?medications printed in new lay-out format

91
Revisions to Broselow tape continued

• ?IV drips are the only meds listed now that have
  a range for dosing (ie IV Diazepam for a 10 kg
  patient was 1.0 - 3.0 mg revised tape IV
  Diazepam is 2 mg)
• ?Children are grouped into color-coded zones
  rather than individual kilogram weights
  
• ?Epi listed as 1st dose and high dose/ET dose
  (TT) (follow 1st dose schedule for all IVP epi
  doses)

92
Intubation Techniques For Our Smaller Patients

• ?Intubation
• ventilate with 100 O2 for 1 minute
• apply cardiac monitor - watch for bradycardia
• assemble check equipment
• use Broselow tape protocol for sizing
  guidelines
  
• stylets, if used, are not to extend beyond the
  tip
  
• uncuffed ET up to size 6 (approx 8 years of age)
  
  
• suction to be turned down to 100 mmHg suction
  time limited to

93
Intubation continued

• positioning infant or child
• gentle head extension/sniffing position helpful
  to put a towel roll under the shoulders
  
• provide blow-by oxygen when not bagging
• use a straight blade (preferred due to floppy
  epiglottis large tongue) lift the epiglottis
  
• if using a curved blade, slip tip into the
  valeculla and lift upward
  
• DO NOT ROCK THE HANDLE !!!

94
Intubation continued

• ?place the ET tube only until the dark vocal cord
  guide ring near the distal tip of the tube is at
  the level of the vocal cords (this puts the
  distal tip of the ET tube halfway between the
  vocal cords carina)
• ?never let go of the ET tube until secured

95
Primary confirmation of ET tube placement

• ?visualization of the vocal cords
• ?auscultation of epigastric sounds - expecting to
  hear none
  
• ?auscultation for bilateral breath sounds - place
  stethoscope in axillary areas
  
• ?watching for bilateral equal chest expansion

96
Additional helpful tools to ? ET tube placement

• ?positive findings with the ETCO2 - yellow color
  after several ventilations with BVM (not reliable
  in poor cardiac output states)
  
• ?improvement in heart rate skin color
• ?no gastric distension with ventilation
• ?improvement in pulse ox readings -
• normal is 95
• ?condensation in the tube during exhalation

97
Not helpful in confirmation of ET tube placement
in pediatrics

• ?EDD - esophageal detector device
• If the ET tube is in the esophagus, the pressure
  exerted by the EDD may be too high and could
  damage the lining of the esophagus in the
  pediatric patient
• ?Adult ETCO2 will not function reliably in
  smaller children because gas flow is minimal

98
How often should the ET tube placement be
reconfirmed?

• ?Every time the patient is moved the ET tube
  placement should be rechecked.
  
• ?This includes
• ? after each defibrillation
• ? after each transfer from cot-to-cot
• ? anytime the ET placement is questioned
• ?Consider c-spine immobilization (ie towel
  rolls) to help immobilize
  

99
What else about intubating a pediatric patient?

• As a reminder, the landmarks are very small
• The presence of any swelling will greatly reduce
  the glottic opening
  
• Swelling may increase due to the trauma of being
  intubated
  
• Make your first attempt your best attempt - it
  may be your only attempt!

100
Intraosseous NeedlesThe IO

• IO access allows the administration of fluids and
  drugs directly into the bone marrow.
  
• Blood from the marrow space drains into the
  central circulation
  
• If the fluid or drug can be given IV it can
  usually go IO also.

101
Region X SOP IO Indications

• ?Children
• ?Presence of shock, cardiac arrest, or
  unresponsiveness
  
• ?2 unsuccessful peripheral attempts or 90
  seconds in time to insert a peripheral line
  

102
IO Contraindications

• ?recent fracture of the bone being considered for
  the site
  
• ?recent previous IO attempt in that same bone
• ?osteogenesis imperfecta - congenital disorder of
  the bone bones are brittle
  

103
IO Procedure

• ?reach equipment antiseptic, IO needle,
• 10 ml syringe filled with 5 ml 0.9 NS
• ?prep IV tubing with NS IV bag
• ?prepare anterior surface of leg below the tibial
  tuberosity with antiseptic solution
  
• ?insert needle in a twisting fashion 1-3 cm below
  tibial tuberosity perpendicular to skin

104
IO procedure continued

• ?confirm IO needle placement
• lack of resistance or pop sensation when marrow
  entered
  
• needle stands up without support
• bone marrow aspirated (this does not always
  happen)
  
• IO easily flushed with NS syringe
• attached IV bag flows freely (may have to help
  start the flow by squeezing on the bag initially)

105
Review of more commonly used pediatric
medicationsAlbuterolGlucagonD25Valium
106
Albuterol

• Bronchodilator
• Useful in asthma, croup, allergic reactions,
  anaphylaxis
  
• Dosage 2.5 mg (3 ml) (same as adults)
• To be successful, need to coach patient thru
  treatment encourage slower deeper breathes
  eventually holding the deep breath slightly.
  
• Consider use of neb mask if necessary

107
Glucagon

• Hormone and antihypoglycemic
• Causes a breakdown of stored glycogen, from the
  liver, into glucose
  
• Only effective if there are sufficient stores of
  glycogen in the liver
  
• Must be reconstituted
• Takes time to work if IV gets established after
  a dose of glucagon is given, recheck sugar
  levels. If blood sugar is low pt still has ?
  LOC, give D25

108
D25

• A carbohydrate to rapidly elevate the blood
  glucose level
  
• Rapid action necessary in hypoglycemia to prevent
  serious brain injury
  
• All patients with an altered LOC must have
  glucose levels checked
  
• Administer as slow IVP in decent sized vein - can
  be very irritating to injection site
  
• Infiltration of IV site could cause necrosis

109
Valium

• Benzodiazepine used as an anticonvulsant
• Works on stopping the current seizure activity,
  does not prevent future seizures
  
• Relatively short acting - watch for return of
  seizure activity
  
• Manage respiratory depression by bagging the
  patient to support respirations
  
• Relatively rapid onset when given rectally

110
Review on drug calculations

• Formula 1
• X desired dose x volume on hand
• dose on hand
• Formula 2
• mg on hand mg ordered
• ml on hand X ml to be
  given

111
Case Scenario 1

• You respond to the scene of a 12 year old girl
  who has passed out. Upon arrival, scene is safe,
  BSIs are on. The girl is found unresponsive on
  the bathroom floor with several girlfriends
  standing around.
• What do you do next?

112
Initial Patient Assessment - ABCs LOC - Case 1

• patient is unresponsive on the floor in a side
  lying position.
  
• how would you open the airway?
• what would you look for to evaluate for adequacy
  of breathing?
  
• where is it appropriate to check for pulses?

113
ABCs LOC continued - Case 1

• consider the possibility of trauma and protect
  the c-spine when opening the airway
  
• evaluate skin color, chest expansion, rate
  depth of breathing, pulse ox
  
• consider applying oxygen
• as a 12 year old, you may check for peripheral
  pulses in the radial area
  

114
Initial Assessment FindingsCase 1

• airway is open, she moans to her name
• patient is breathing 16 times/minute
• skin color is warm, dry, pink
• pulse ox is 95
• radial pulse is strong at 120/minute
• do you deem your patient stable or unstable?
  Emergent, urgent, or non-urgent?

115
Focused History Physical Exam - Case 1

• care initiated
• c-spine control
• oxygen therapy
• blood glucose level (110)
• SAMPLE - no allergies, no meds, no hx, girls
  skipped school admit to drinking vodka shots
  over last couple of hours
  
• detailed physical exam
• age appropriate for head-to-toe

116
Physical Exam continued - Case 1

• DCAP-BTLS - no injuries found, assisted to floor
  by friends
  
• GCS - eye opening (to voice) - 3
• verbal response (moans) - 2
• motor response (pushes you away) -
  5
  
• Other interventions necessary?

117
Patient 1 Outcome

• Patient outcome
• patient had elevated ETOH levels. Needed fluid
  hydration. Remained hospitalized overnight until
  LOC ETOH levels had improved

118
Case Scenario 2

• You are responding to a call for a 15 month old
  male having a seizure.
  
• Scene is safe, many family members in the house
  most non-English speaking.
  
• BSIs are on.
• Initial impression?

119
Initial Patient AssessmentABCs LOC- Case 2

• airway breathing are hard to evaluate as the
  child is actively seizing
  
• so, how would you evaluate airway breathing?
• circulation - the patient has a carotid radial
  pulse which are rapid skin warm/hot pale
  
• is this patient stable or unstable? Emergent,
  urgent, or non-urgent?

120
Focused History Physical Exam - Case 2

• Care initiated start BVM support because this
  long lasting active seizure disrupts the patient
  from breathing effectively
  
• Pulse ox initially went from 95 RA to 99 with
  BVM support
  
• SAMPLE - no allergies, started an antibiotic
  yesterday for ear infections, no other hx,
  nibbled on breakfast today

121
Detailed Physical ExamCase 2

• DCAP-BTLS - no unusual findings
• GCS - eye opening (none) - 1
• verbal response (moans) - 2
• motor response (withdraws) - 4
• Glucose level - 72
• Other interventions necessary?

122
Patient 2 Outcome

• This patient presented with bacterial spinal
  meningitis. The patient received IV antibiotics
  and recovered. All EMS members listed on the EMS
  run report were contacted for prophylactic
  antibiotic therapy. No one else contracted
  bacterial meningitis traced to this patient.

123
Case Scenario 3

• You are called to the scene for a 2 year old with
  noisy respirations for the past 5 hours. You
  arrive to find a pale 2 year old patient sitting
  in moms lap appearing tired is clingy to mom,
  using accessory muscles with an increased
  respiratory
• rate
• What do you think is going
• on what should you do next?

124
Initial AssessmentABCs LOC - Case 3

• airway is open
• the pt is using accessory muscles, retractions
  evident, prolonged exhalation times, audible
  wheezing, mucous membranes dry.
  
• the radial pulse is present rapid
• is this patient stable or unstable? Emergent,
  urgent, or non-urgent?

125
Focused History Physical Exam - Case 3

• Care initiated
• pulse ox (89 RA, 98 on O2)
• supplemental oxygen therapy - what device would
  you use?
  
• SAMPLE - no allergies, meds are atrovent, hx
  asthma, sipping juice today
  

126
Physical Exam continued Case 3

• Detailed physical exam
• DCAP-BTLS - no injuries noted
• GCS - eye opening (open) - 4
• verbal response (normal) - 5
• motor responses (moves all
  spontaneously)
  
• 
  - 6
  
• Other interventions necessary?

127
Patient 3 Outcome

• This patient had an acute onset of asthma. They
  continued to deteriorate in the ED and pulse ox
  remained low with increasing respiratory work
  efforts. The patient was intubated and
  transferred to a pediatric center. They
  gradually improved, were extubated and returned
  home.

128
Nobody wants a bad outcome
129
With preparation practice you can improve your
odds on a good outcome
130
Our goal is for a good outcome!
131
Now skill practice time!
132
References

• American Academy of Pediatrics Neonatal
  Resuscitation 2000.
  
• Bezyack, M. E. Respiratory Distress - Making the
  Diagnosis in Kids
  
• Bledsoe, B., Clayden, D., Papa, F. Prehospital
  Emergency
  
• Pharmacology 5th Edition. Brady. 2001.
• Broselow Tape. 2002 Edition.
• Markenson. Pediatric Prehospital Care. Brady.
  2002.
  
• Region X SOP 2001 Implementation.
• Sanders, M. Paramedic Textbook Revised Second
  Edition. Mosby.
  
• 2001.