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Encountering The Pediatric Patient

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Encountering The Pediatric Patient Condell Medical Center EMS System November 2008 ECRN CE Module III Site Code #10-7200E1208 Prepared by: Sharon Hopkins, RN,BSN, EMT-P – PowerPoint PPT presentation

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Title: Encountering The Pediatric Patient


1
Encountering The Pediatric Patient
  • Condell Medical Center
  • EMS System
  • November 2008 ECRN CE
  • Module III
  • Site Code 10-7200E1208

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

3
  • Calculate medication dosages given the patients
    weight
  • Calculate the GCS given the pts responses
  • Identify and appropriately state interventions
    for a variety of EKG rhythms specific to the
    pediatric population (VF, SVT, bradycardia)
  • Successfully complete the 10 question
  • quiz with a score of 80 or better

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

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

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

7
Assessing Appearance
  • Evaluate as you cross the room and before you
    touch the child
  • Muscle tone can they sit up on own?
  • Mental status / interactivity level
  • Consolability
  • Eye contact or gaze do they
  • watch you?
  • Speech or cry

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

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

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

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

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

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

14
Additional Assessment
  • Includes
  • Focused history
  • Physical exam
  • Toe to head approach in the very young (infants,
    toddlers, preschoolers)
  • Head to toe in the older child
  • SAMPLE history

15
SAMPLE History
  • S signs symptoms
  • A allergies
  • M medications including herbal and over the
    counter (OTC)
  • P past pertinent medical history
  • L last oral intake (anything to eat or drink
    including water)
  • E events leading up to the incident

16
Assessment Interventions
  • Vital signs
  • Determine weight and age
  • SaO2 reading preferably before after O2
    administration
  • Cardiac monitor if applicable
  • Establish IV if indicated
  • Determine blood glucose if indicated
  • Reassess vital signs, SaO2, patient
  • condition

17
Detailed Physical Exam
  • Information gathered builds on the findings of
    the initial assessment and focused exam
  • Use the toe to head for infants, toddlers, and
    preschoolers

18
Putting It All Together
  • EMS is called to the scene for a 2 year-old
    who has fallen off the 2nd floor porch.
  • The toddler landed in the grass
  • The toddler is unresponsive upon EMS arrival
    there is a laceration to the right forehead and
    the right arm
  • is deformed

19
Putting It All Together - Mechanism of Injury
  • Fall from height greater than 3 times the
    toddlers height
  • For this 2 year-old, the mechanism of injury
    indicates a Category I trauma patient based on
    mechanism of injury (fall from height) and level
    of consciousness (unresponsiveness)

20
General Impression For This 2 year-old
  • Category I trauma patient with head orthopedic
    injuries
  • EMS Region X SOPs to follow
  • Spinal immobilization
  • Care of the airway with anticipation for need to
    be bagged or intubated
  • Hemorrhage control / interventions with IV/IO
    access needing to be obtained
  • Cardiac monitoring
  • Determining blood glucose level

21
Whats The Difference?
  • Respiratory distress
  • The patient exhibits increased work of breathing
    but the patient is able to compensate for
    themselves
  • Increased respiratory effort in child who is
    alert, irritable, anxious, and restless
  • Evident use of accessory muscles
  • Intercostal retractions
  • Seesaw respirations (abdominal breathing)
  • Neck muscles straining

22
  • Respiratory failure
  • Energy reserves have been exhausted and the
    patient cannot maintain adequate oxygenation and
    ventilation (breathing)
  • Sleepy, intermittently combative or agitated
    child
  • Heart rate usually bradycardic as a result of
    hypoxia

23
Respiratory Distress
  • Stridor
  • Grunting
  • Gurgling
  • Audible wheezing
  • Tachypnea (increased respiratory rate)
  • Mild tachycardia
  • Head bobbing
  • Abdominal breathing (normal lt 6-7 years-old)
  • Nasal flaring
  • Central cyanosis resolved with O2

24
Stridor
  • Harsh, high-pitched sound heard on inspiration
    associated with upper airway obstruction
  • Sounds like high-pitched crowing or seal-bark
    sound on inspiration

25
Grunting
  • Compensatory mechanism to help maintain patency
    of small airways
  • A short, low-pitched sound heard at the end of
    exhalation
  • Patient trying to generate positive
    end-expiratory pressure (PEEP) by exhaling
    against a closed glottis
  • Prolongs the period of oxygen and carbon dioxide
    exchange

26
Nasal Flaring
27
Retractions
  • A visible sign where the soft tissues sink in
    during inhalation
  • Most notable are in the areas above the sternum
    or clavicle, over the sternum, and between the
    rib spaces

28
Respiratory Failure
  • Decreased level of responsiveness or response to
    pain
  • Decreased muscle tone
  • Inadequate respiratory rate, effort, or chest
    excursion
  • Tachypnea with periods of bradypnea slowing to
    agonal breathing

29
IV Access
  • Peripheral access can be difficult to find in a
    child
  • More sub Q fat
  • Smaller targets
  • More fragile veins
  • Lack of our experience

30
Hint to Find Peds Veins
  • Hold your penlight across the skin to reflect the
    veins
  • Hold the penlight under the site to illuminate
    the veins

31
EMS IO Indications
  • Shock, arrest, or impending arrest
  • Unconscious/unresponsive to stimuli
  • 2 unsuccessful IV attempts or 90 second duration
  • Peds needle used for 3 39 kg (up to 88 lbs)
  • - Peds needle 15 G 5/8? (G same as adult,
    length is shorter)

32
EZ IO Landmarks
  • Proximal medial tibia
  • lt39 kg (child) tibial tuberosity often
    difficult to palpate if not palpated
  • Go 2 finger breadths below patella and then on
    flat aspect of medial tibia
  • 40 kg (88 pounds or more)
  • 1-2 finger breadths below patella (this is
    usually 1/2? (1 cm) distal to tibial tuberosity)
  • 1 finger breadth medially from the tibial
  • tuberosity

33
Tibial tuberosity
34
EZ IO Infusion
  • All patients need to have the IO flushed prior to
    connecting the IV solution
  • The primed extension tubing must be used with a
    syringe attached
  • Only the syringe is removed after flushing in
    preparation to attaching IV fluid
  • All IV bags need a pressure bag to
  • flow

35
EMS Altered Level of Consciousness SOP
  • If blood glucose level is lt60
  • lt 1 year old Dextrose 12.5 4 ml/kg
  • gt 1 -15 years old Dextrose 25 2 ml/kg
  • If no IV/IO access
  • Glucagon 0.1 mg/kg IM
  • Max dose up to 1 mg (max at adult dosage)

36
  • If you suspect narcotic influence or as a
    diagnostic tool if blood sugar is okay or patient
    does not respond to Dextrose
  • Narcan EMS dosing
  • lt20 kg 0.1 mg/kg IVP/IO/IM
  • gt20 kg 2 mg IVP/IO/IM
  • Max total dose is 2 mg

37
Dextrose
  • The brain is a very sensitive organ to inadequate
    levels of glucose
  • When the glucose levels drop the patient will
    have an altered level of consciousness
  • If glucose levels reach a critically low level,
    the patient may have a seizure

38
Narcan
  • Useful to reverse the effects of narcotics
    (respiratory depression and depression of the
    central nervous system)
  • Morphine, hydromorphine (Dilaudid), oxycodone,
    Demerol, heroin, codeine, percodan, fentanyl,
    darvon, methadone
  • Consider the children that get into
  • others purses and have access to
  • the medicine cabinet other
  • areas where drugs can be found

39
Calculation Practice
  • Your 8 month-old patient weighs 17 pounds
  • Which strength Dextrose should this patient
    receive by EMS and how much?

40
8 month-old
  • lt 1 year old receives Dextrose 12.5
  • More diluted form for smaller, more fragile veins
  • To receive 4 ml/kg
  • 17 pounds ? 2.2 7.7 kg (8kg)
  • Dextrose is 4 ml / kg
  • 4 ml x 8 kg 32 ml
  • How does EMS give 12.5 Dextrose
  • when they carry 25 as their
  • weakest dilution?

41
Drawing Up 12.5 Dextrose From D25
  • Use 25 and dilute 11 with sterile saline
  • Calculate the total dosage required (ie
    32 ml)
  • Half the syringe will be filled with 25 Dextrose
    and half the syringe will be filled with sterile
    saline
  • 16 ml 25 Dextrose mixed with 16 ml sterile
    normal saline
  • Administer in largest vein possible and at slowed
    rate
  • Extremely irritating to the veins

42
Narcan Calculation
  • Your patient weighs 19 pounds
  • lt20 kg the patient is to get 0.1 mg/kg
  • How much Narcan would be
  • administered? Never give
  • more than the adult dose!

43
Narcan for 19 Pound Infant
  • 19 pounds ? 2.2 kg 8.6 kg (9kg)
  • 9kg x 0.1 mg/kg 0.9 mg
  • (You still need to know how many mls to put into
    the syringe)
  • What type of syringe would you use?
  • Under 1 ml use a TB syringe
  • much more accurate to draw
  • up medications

44
Broselow Tape
  • Often gives mg but not always the ml to fill the
    syringe with
  • Mg helpful for accurate documentation
  • Holding a syringe, need to know how many mls to
    draw up into syringe
  • Back of SOPs has medical and cardiac pediatric
    reference tables
  • Includes mg and ml of medications

45
GCS For Pediatric Patient
  • Same tool used for the adult population with
    minor changes to accommodate the young non-verbal
    infant
  • Most accommodations made in the verbal section
  • Makes sense if this is for the non-verbal patient

46
GCS Eye Opening
  • Remains the same as the adult
  • 4 points if eyes open spontaneously with or
    without focus
  • 3 points if eyes open or flutter to command or
    noises/voice
  • 2 points if eyes open or eyelids flutter to touch
    or painful stimuli
  • 1 point if eyes do not open

47
GCS Peds Verbal Response
  • 5 points if oriented (coos, babbles)
  • 4 points if cry is irritable
  • 3 points if the patient cries to pain
  • 2 points if there is some noise response to pain
    (similar to moans groans in the adult)
  • 1 point if there is silence

48
GCS Peds Motor Response
  • 6 points if the patient moves appropriately
  • 5 points if the patient withdraws to touch
  • 4 points if the patient withdraws to pain
  • 3 points if there is abnormal flexion
  • 2 points if there is abnormal extension
  • 1 point if there is no movement/response
  • of any kind

49
Acute Asthma
  • Many patients will try to self medicate and may
    try for too long on their own before they call
    for help
  • The patient can deteriorate fast once they
    fatigue and their respiratory muscles are
    exhausted

50
Why Albuterol?
  • Albuterol is a bronchodilator
  • Receptors are in the lungs
  • Opens up constricted bronchiole passages
  • Albuterol also triggers receptors in the heart
    and you may see an increase in heart
  • rate

51
EMS Albuterol Dosing
  • 2.5 mg/3 ml for all patients
  • The drug will be more successful when the patient
    is coached through use of the nebulizer
  • The drug only works if it is inhaled deeply into
    the lungs
  • Short, shallow breaths will not help drug
    absorption

52
Nebulizer Delivery
  • This route is most effective if there is someone
    coaching the patient during use
  • Have someone talk the patient through the process
  • Verbal encouragement essential to success
  • Encourage slower breaths for a few ventilations
  • Then encourage the breaths to be a bit deeper
  • Then encourage the deeper breaths to be
  • held a bit longer to get the drug
  • down into the lungs

53
In-line Albuterol
  • Any patient no longer able to take a deep breath
    or remain conscious needs this drug forced into
    the lungs
  • The drug must be given in-line
  • Attach nebulizer to the BVM mask as you start
    bagging the patient to get some drug into the
    lungs
  • Once intubated, the ambu bag will continue to
    force the drug into the airway and down into the
    lungs

54
What Are the Risk Factors That Expose Kids To
Seizures?
  • Fever most common
  • Hypoxia
  • Infections
  • Electrolyte imbalance
  • Head trauma
  • Hypoglycemia
  • Toxic ingestions
  • Tumor

55
Status Epilepticus
  • A series of one or more generalized seizures
    without any periods of consciousness
  • Concern is with periods of prolonged apnea that
    can lead to hypoxia

56
Assessment of Seizures
  • ALWAYS obtain a glucose level if level of
    consciousness is altered
  • Ask if there is a history of recent illness
  • Ask for description of the seizure activity
  • Jerking of both sides of the body, jerking
    limited to a particular part of the body, eye
    blinking, staring, lip smacking

57
EMS Seizure Intervention
  • Support the airway
  • Consider BVM if active seizure
  • To terminate current seizure
  • Valium 0.2 mg/kg IVP
  • No IV access, Valium rectally 0.5 mg/kg
  • Max total rectally 10 mg
  • Remove extra clothing if febrile
  • Cool cloths over patient, fan patient
  • Shivering will increase body temp!

58
Valium Calculation
  • Patient with active seizure
  • Patient weighs 26 pounds
  • 26 ? 2.2 11.8 KG (12 KG)
  • Valium is 0.2 mg/kg
  • 12kg x 0.2 2.4 mg
  • Where are your resources to use to check how many
    mls to pull up
  • into the syringe?

59
Medication Resources
  • Back of SOPs (Medical Cardiac Pages)
  • Meds by mg for documentation and by ml to draw up
    into the syringe
  • Broselow tape 2007 Edition B
  • Legend gives the formula
  • Valium (diazepam) exact mg given under each
    respective weight category
  • Careful!!! Diazepam broken down by IV AND
    rectal so read columns carefully

60
Possible Causes of Critical Rhythms
  • 6 Hs
  • Hypovolemia fluid challenge
  • Hypoxia supplemental O2
  • Acidosis ventilate to blow off CO2
  • Hyper/hypokalema
  • Hypothermia warm core
  • Hypoglycemia check glucose level

61
  • 5 Ts
  • Tablets drug overdose
  • Tamponade supportive care in field
  • Tension pneumothorax needle decompression
  • Thrombosis, coronary or pulmonary
  • Trauma

62
Peds VF or Pulseless VT
  • After 2 minutes of CPR if unwitnessed,
    defibrillate 2j/kg or equivalent biphasic
  • AED can be used if gt1 years old
  • Immediately resume CPR for 2
    minutes / 5 cycles
  • Rhythm checks after 2 minutes CPR
  • Repeat defibrillate is at 4j/kg or equivalent
    biphasic
  • Resume CPR after defibrillation
  • Establish IV/IO

63
VF/VT Peds Region X SOP
  • Meds given during CPR
  • Epinephrine 110,000 0.01 mg/kg IVP/IO
  • Repeat every 3-5 minutes
  • Choose one antidysrhythmic to alternate with Epi
  • Amiodarone 5 mg/kg IVP/IO
  • Lidocaine 1 mg/kg IVP/IO
  • Repeat doses per Medical Control order

64
Why Epinephrine?
  • Epinephrine is a catecholamine and stimulant
  • Epinephrine is a vasoconstrictor to improve blood
    flow
  • Before drug therapy, always assess/evaluate the
    status of oxygen delivery and effectiveness of
    ventilation

65
PEA/Asystole Peds Region X SOP
  • Start CPR and run thru the H T checklist
  • Secure airway
  • Establish IV/IO
  • Fluid challenge 20 ml/kg
  • Epinephrine 110,000 0.01 mg /kg IVP/IO
  • Repeat every 3-5 minutes
  • NO Atropine in SOP for peds!!!

66
Why No Atropine in Peds PEA, Asystole, or Brady?
  • Atropine will probably not help unless the
    patient has primary AV block and that is not
    likely in a young and healthy heart
  • Improving oxygenation and ventilation are the
    primary treatments for pediatric bradycardia

67
Peds Symptomatic Brady
  • Severe cardiorespiratory compromise
  • Poor perfusion
  • Bradycardia
  • Weak, thready, absent pulse
  • Hypotension
  • Pallor
  • Cyanosis
  • Respiratory difficulty

68
Peds Brady EMS Region X SOP
  • Heart rate lt60 poor systemic perfusion
    perform CPR
  • IV/IO access
  • Epinephrine 110,000 0.01 mg/kg IVP/IO
  • Repeat every 3-5 minutes
  • If persistent brady, contact Medical control for
    order of Atropine
  • Atropine if ordered 0.02 mg/kg (minimum dose to
    give 0.1 mg) IVP/IO
  • May repeat Atropine x1
  • Max dose 1 mg
  • Consider pacing

69
Peds Shock EMS Region X SOP
  • Hypovolemic or distributive shock
  • IV fluid challenge 20 ml/kg
  • If no response repeat 20 ml/kg up to 60 ml/kg
    (ie total 3 challenges)
  • No fluid challenge for peds in cardiogenic shock

70
Peds Tachycardia
  • Bradydysrhythmias are more common in peds
    patients than tachycardias
  • Sinus Tachycardia
  • Heart rates in infants are under 220 and in
    children under 180
  • No drug therapy indicated
  • Search for possible causes

71
Probable Supraventricular Tachycardia
  • Narrow complex tachycardia greater than 220 in
    infants and greater than 180 in a child
  • Typically due to a problem in the cardiac
    conduction system
  • Rapid heart rates prevent adequate ventricular
    filling that can lead to
  • CHF and cardiogenic shock

72
Signs Symptoms SVT
  • Irritability
  • Poor feeding
  • JVD
  • Hepatomegaly enlarged liver
  • Hypotension
  • Children can often tolerate the rapid rate fairly
    well

73
EMS Treatment SVT with Adequate OR Poor Perfusion
  • Vagal maneuvers
  • If a straw is available, have child blow thru one
  • Adenosine 0.1 mg/kg rapid IVP followed by 5 ml
    rapid saline flush
  • Max 1st dose is 6 mg (max at adult dose)
  • Repeat dose if needed is 0.2 mg/kg with
  • 5 ml saline flush
  • Max 2nd dose is 12 mg (adult dose)

74
Cardioversion for No Response to Adenosine or For
Probable VT
  • Sedate with Versed 0.1 mg/kg IVP slowly over 2
    minutes
  • Cardioversion at 1 j/kg
  • If no response, cardiovert at 2 j/kg

75
Why Versed?
  • Amnesic
  • Relaxes patient
  • Shorter acting than Valium
  • Does NOT take away pain!
  • Can cause respiratory depression
  • Have BVM reached ready whenever Versed or
    Valium are given in case the patient needs
    ventilation support

76
Probable VT with Poor Perfusion
  • No time to allow drugs to work to slow or convert
    rhythm
  • Need to be more aggressive
  • Cardiovert the patient
  • 1st attempt 1 j/kg
  • 2nd attempt if needed 2 j/kg
  • If no response to cardioversion, contact Medical
    Control for possible
  • Amiodarone or Lidocaine order

77
Allergic Reactions Is Response Life Saving or
A Killer?
  • The bodys immune response to an antigen tries to
    eliminate the antigen (foreign material) from the
    body
  • Bronchospasm so no more offending antigen can
    enter the respiratory tract
  • Coughing to expel the antigen
  • Leaky capillaries remove antigen from the blood
    stream and place it into the interstitial tissue
    for removal via lymph
  • system
  • Vomiting diarrhea remove antigen from GI tract

78
Antigen Exposure Histamine Release
  • Increased capillary permeability
  • 3rd spacing (intravascular fluid into
    interstitial space)
  • Edema
  • Relative hypovolemia
  • Peripheral vasodilation
  • ? peripheral vascular resistance (? B/P)
  • Smooth muscle constriction
  • Abdominal cramps, vomiting, diarrhea
  • Bronchoconstriction laryngeal edema

79
Is it an Allergic Reaction or Anaphylaxis?
  • Anaphylaxis is the more severe response of the
    two
  • Usually occurs when a patient is exposed to a
    specific allergen, especially injected directly
    into the circulation
  • Anaphylaxis principally affects the
    cardiovascular, respiratory, GI systems and the
    skin
  • Faster the reaction, usually the more severe the
    reaction is
  • In anaphylaxis, the patient will be
  • hypotensive (ominous sign)

80
Why Epinephrine 11000 For An Immune Response?
  • Stimulates certain receptors in the body (alpha
    beta receptors)
  • Constricts blood vessels to help counter
    vasodilation effects of anaphylaxis (alpha
    affect)
  • Opens up airways by reversing bronchospasm of
    anaphylaxis (beta affect)
  • Max dose calculated at adult dose (0.3ml)!

81
What Does Epinephrine Do?
  • Primary drug used in reactions
  • Increases heart rate
  • Increases strength of cardiac contractions
  • Causes peripheral vasoconstriction
  • Can reverse bronchospasm
  • Can reverse capillary permeability
  • Effects short term

82
Why Benadryl For Immune Response?
  • Antihistamines are the 2nd line agents to give in
    reactions
  • Antihistamines block the effects of histamine
    released in the body by blocking histamine
    receptors
  • Duration of action is 6-12 hours so anticipate
    rebound if the patient has not filled a
    prescription to continue
  • taking the antihistamine
  • Max dose given is at adult dosing

83
EMS Benadryl Dosing
  • Epinephrine is 1st line drug if applicable
  • Stable allergic reaction no airway involvement
  • Benadryl 1 mg/kg slow IVP or IM
  • Max 25 mg (adult dose)
  • Stable allergic reaction with airway involvement
  • Benadryl 1 mg/kg slow IVP
  • Max 50 mg (adult dose)
  • Anaphylactic shock
  • - Benadryl 1 mg/kg slow IVP
  • - Max 50 mg (adult dose)

84
Practice Calculating the GCS
  • Remember to use the PEDS alternative values
    when the patient is non-verbal
  • If the patient is old enough to talk, follow the
    adult prompts to calculate the GCS

85
GCS Calculation 1
  • Patient is 7 months old
  • Eyes are open but do not focus or follow
    activities
  • The infant has an irritable cry
  • The infant pulls their arms in when the IV stick
    is attempted

86
GCS Calculation 2
  • Patient is 3 years-old
  • Eyes flutter open when the patient is yelled at
  • The toddler cries after the injured extremity is
    manipulated
  • The toddler pulls back when the injured extremity
    is manipulated

87
GCS Calculation 3
  • Patient is 5 months-old
  • Eyes flutter open when the deformed extremity is
    manipulated
  • The patient moans when the injured extremity is
    manipulated
  • The patient pulls up their
  • extremities tightly into their
  • chest when touched (flexion)

88
GCS Calculation 4
  • Patient is 5 years-old
  • Patient is watching your movement
  • Patient is using repetitive words and is confused
  • Patient pushes your hands away
  • when you touch them

89
GCS Calculation Answers 1 2
  • Pt 1 GCS 12
  • Eye opening 4 (spontaneous)
  • Verbal 4 (irritable cry)
  • Motor 4 (withdraws to pain)
  • Pt 2 GCS 10
  • Eye opening -3 (eyes open to voice)
  • ?Verbal 3 (cries to pain)
  • ?Motor 4 (withdraws to pain)

90
GCS Calculation Answers 3 4
  • Pt 3 7
  • Eye opening 2 (eyes flutter to pain)
  • Verbal 2 (moaning is an incomprehensible
    word/sound)
  • Motor 3 (flexes extremities into chest)
  • Pt 4 13
  • Eye opening 4 (spontaneous)
  • Verbal 4 (repetitive words / confused)
  • Motor 5 ( pushes hands away/purposeful)

91
Scenarios
  • Read the following case studies
  • Determine your general impression based on the
    pediatric assessment triangle (PAT)
  • Determine interventions appropriate to the
    situation

92
Case Study 1
  • EMS is at a local high school track meet when a
    12 year-old boy collapses while running the
    100-yard dash. Initial assessment reveals the
    child is apneic and pulseless. CPR is started
    immediately
  • What are the next appropriate steps to take?
  • Can an AED be used on a 12 year-old?

93
Case Study 1
  • AEDs can be used in patients over
    1 years-old
  • Use the child pads for 1 8 year olds
  • If no child pads available, use adult pads
  • Cannot use child pads though on the adult
  • CPR for 12 year-old is adult standards
  • CPR 1 person infant child (1-8 years-old per
    AHA) is 302 2 person is 152 once
  • intubated ventilations are delivered
  • once every 6-8 seconds

94
Case Study 1
  • Attach a monitor as soon as possible
  • Stop CPR (witnessed arrest) as soon as monitor
    applied ready
  • Whats the rhythm treatment?

95
Case Study 1
  • Rhythm Torsades
  • Most likely this young athlete has long QT
    syndrome (conduction defect) that makes them
    prone to arrest during physical exertion
  • Treat like VF (follow Region x SOP for EMS)
  • Defibrillate 1st at 2j/kg (peds pt lt15)
  • Repeat defibrillations at 4j/kg
  • Epinephrine 110,000 0.01 mg/kg IV/IO
  • Repeat every 3-5 minutes
  • Choose one antidysrhythmic (Amiodarone or
    Lidocaine one dose)

96
Case Study 2
  • A 2 year-old at preschool fell from a sitting
    position and the teacher witnessed jerking of the
    arms and legs that lasted for 1-2 minutes. Parent
    told teacher the child was not feeling well
    during the night.
  • On arrival, the child is drowsy, will open their
    eyes to voice but does not answer questions,
    moans withdraws when touched.
  • VS B/P 110/58 HR 100 RR 30 skin warm to the
    touch
  • What is your impression based on the assessment
    triangle?
  • What is the GCS?

97
Case Study 2
  • Patient appears physiologically stable
  • Drowsy, no extra effort or noise for breathing,
    skin pink and warm
  • GCS 10 (3, 2, 5) (currently post-ictal)
  • Initial impression is febrile seizure (no history
    trauma, history of being ill last night, feels
    warms to touch)
  • Field treatment limited to cooling measures
  • Remove extra clothing, cool cloths on
    forehead
  • Reevaluate GCS watching for improvement
  • as level of consciousness improves

98
Case Study 2 - Is Valium Indicated
Now?
  • No active seizure currently, so no drug
  • Valium stops the current seizure but does not
    prevent future seizures
  • Valium indicated if multiple seizures occur or
    seizure lasts longer than a few minutes
  • Long lasting seizure can cause hypoxia
  • Side effects of valium are
  • respiratory depression

99
Case Study 3
  • You are on the scene for an 18 month-old child
    who is having difficult breathing
  • The mother states a 2 day hx of slight fever and
    wheezing esp when crying
  • Pt suddenly woke tonight short of breath with
    loud noises on inhalation
  • Child sitting on mothers lap, anxious, watches
    you and cries weakly when you
  • approach

100
Case Study 3
  • Color pink, has retractions with nasal flaring
  • HR 180 RR 42
  • Strong pulses, cap refill 2 seconds
  • Loud, harsh breath sounds bilaterally

101
Case Study 3
  • How sick is this child?
  • PAT (pediatric assessment triangle)
  • Evaluate appearance, work of breathing,
    circulation to skin
  • What is your general impression?
  • Do you think this is an upper or lower airway
    problem?
  • How should you care for this
  • child in the field?

102
Case Study 3
  • PAT makes eye contact cries when EMS
    approaches exhibiting stridor increased work
    of breathing skin pink warm
  • This child is in respiratory distress, not
    failure, with an upper airway problem
  • Stridor indicates upper airway obstruction and
    history of a few days
  • of respiratory infection is
  • consistent with croup

103
Case Study 3
  • Management upper airway obstruction based on
    severity of symptoms
  • Position of comfort usually best to leave child
    sitting upright
  • O2 best if humidified
  • Can humidified O2 be given in the field? Yes!

104
Humidified Oxygenation in the Field
  • Place 6 ml normal saline into the nebulizer
  • Finish assembling the nebulizer
  • Connect tubing to the O2 source
  • Turn up the liter flow to generate a flow of
    mist
  • Aim the mist near the childs face
  • Helpful for croup epiglottitis

105
Case Study 3
  • If wheezing, EMS gives Albuterol 2.5 mg
  • Used as bronchodilator
  • FYI Research indicates Albuterol does not have
    much affect in croup
  • Place Albuterol into nebulizer
  • Place nebulizer mask over patients face if child
    too small to place lips
  • around mouthpiece or direct
  • mist near childs face

106
Case Study 4
  • 911 called to the scene for a 3-month old
    who has had 3 days of cough, runny nose
    low-grade fever.
  • Caregiver concerned because the child is working
    harder to breathe and having hard time feeding
  • Child is in caregivers lap
  • Child is sleepy, no eye contact
  • or response to the exam

107
Case Study 4
  • Child limp, audible wheezing, deep retractions,
    nasal flaring, skin mottled, diaphoretic
  • VS HR 180 RR 70 SaO2 on room air 74
  • Breath sounds tight with only fair air movement
    with high-pitched inspiratory expiratory
    wheezes

108
Case Study 4
  • Is this child in respiratory distress or
    respiratory failure?
  • What is your general impression?
  • What do you need to do to manage this patient?

109
Case Study 4
  • You note increased work of breathing, abnormal
    appearance, and poor circulation
  • This patient is in respiratory failure
  • With the wheezing, the problem is most likely a
    lower airway obstruction
  • Most likely bronchiolitis (inflammation of the
    bronchioles often caused by RSV a viral
    infection)

110
Case Study 4
  • Rapid and urgent transport
  • This patient most likely does not have an easily
    reversible respiratory problem and is likely to
    deteriorate further
  • Enroute EMS to administer a bronchodilator
    (Albuterol) via nebulizer via mask (wont be able
    to
  • put mouth around mouthpiece)

111
Case Study 4
  • Respiratory status monitored closely
  • If decreased respiratory effort or slowing of the
    rate, support with BVM considered using a slow
    rate and long expiratory time
  • AHA ventilatory rate for rescue breathing infant
    lt 1 child lt 8
  • 1 breath every 3-5 seconds (12 20 breaths per
    minute)
  • Give each breath over 1 second

112
Case Study 5
  • EMS is called to the scene for an unresponsive 3
    year-old child
  • There are no abnormal airway sounds
  • Patient is pale slightly diaphoretic
  • VS B/P 80/60 HR 160 RR 20
  • Pupils small, slow to react
  • Withdraws from pain moans
  • Was playful before his nap and
  • appeared healthy

113
Case Study 5
  • What is your general assessment?
  • What is the GCS?
  • What other assessments need to be done?
  • What interventions are needed?

114
Case Study 5
  • This patient is critical unresponsive, no
    abnormal appearance for work of breathing, pale
    diaphoretic tachycardic
  • GCS - 7
  • Eye opening 1 (none)
  • Verbal response 2 (moans)
  • Motor response 4 (withdraws)
  • Need to obtain glucose level (40)
  • Keep airway open, supplemental O2,
  • establish IV access
  • Needs D25 2 ml/kg slow IVP

115
Case Study 5
  • Calculating administrating Dextrose
  • D25 ages 1 15 is 2 ml/kg
  • This 3 year-old weighs 29 pounds
  • How much D25 do you administer?
  • Where are your resources to
  • find the information?

116
Case Study 5
  • Check the back of the SOPs
  • Check the Broselow tape
  • Divide pounds by 2.2 to determine kg
  • 29 ? 2.2 13 kg
  • Multiply kg by the formula (2 ml/kg)
  • 13 kg x 2 ml/kg 26 ml D25
  • D25 is packaged in 10 ml prefilled syringe
  • Administer IV dose slowly to
  • minimize vein irritation from the med

117
Case Study 6
  • You run the call
  • EMS has a 6 year-old who was found listless with
    a GCS of 9
  • The monitor shows
  • Whats the rhythm?
  • What do you do?

118
Case Study 7
  • Pediatric bradycardia is a hypoxia problem until
    proven otherwise
  • CPR started with attention to ventilation
  • IV or IO access established
  • What drug therapy is necessary for
  • the pediatric symptomatic bradycardia?

119
Case Study 7
  • EZ IO landmarks
  • 2 fingerbreadths down from patella over tibial
    tuberosity
  • 1 fingerbreadth toward medial surface away from
    tibial tuberosity
  • Peds bradycardia treatment
  • Epinephrine 110,000 0.01 mg/kg IV/IO
  • Repeated every 3-5 minutes
  • Persistent , Medical
  • Control would need to order Atropine

120
Bibliography
  • Aehlert, B. PALS Study Guide. Elsevier. 2007.
  • American Academy of Pediatrics. Pediatric
    Education for Prehospital Professionals. 2nd
    edition. Jones Bartlett. 2006.
  • Rahm, S. Pediatric Case Studies for the
    Paramedic. AAOS. 2006.
  • Region X SOPs. Amended 1/08.
  • www.peds.umn.edu/.../teaching/lung/
  • stridor.jpg
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