Transcript PAT - Advocatehealth.com

Pediatric
Population
May 2015 CE
Condell Medical Center
EMS System
Site Code: 107200E-1215
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Rev: 5.13.15
Objectives
Upon successful completion of this module,
the EMS provider will be able to:
1. Recall and be able to apply the components of the
Pediatric Assessment Triangle to determine if the
child is sick or not sick.
2. Distinguish between the patient in respiratory
distress versus respiratory failure.
3. Identify the components to tabulate for the GCS
in the pediatric population.
2
Objectives cont’d
4. Distinguish the stages of shock for the pediatric
population.
5. Identify what could constitute an episode of
apparent life-threatening event (ALTE).
6. Identify the pain management plan for the pediatric
patient and successfully calculate dosing.
7. Actively participate in review of selected Region
X SOP’s related to the topic presented.
8. Actively participate in review and correct
identification of a variety of EKG rhythms.
3
Objectives cont’d
9. Actively participate in case scenario and
group discussion at your respective licensed
level.
10. Actively participate in calculating and
drawing up pediatric doses of medications.
11. Successfully complete the post quiz with a
score of 80% or better.
4
Assessment Steps
Perform the scene size-up
◦ Safety threats
◦ Try to get your snapshot of what is going on
General & primary pediatric assessment
◦Determine life threats and need for immediate interventions
◦ Pediatric Assessment Triangle - PAT
◦ Hands-on airway, breathing, circulation, disability, and
exposure (ABCDE)
◦ Transport decision – stay or go
◦ If transporting, determine the most appropriate destination
within your transport area; inform parents of destination
5
Assessment Steps cont’d
History taking
◦SAMPLE, OPQRST
Secondary assessment
◦ Physical examination
◦ Toe to head approach up to approximately 3 years of age
◦ Starting around the face is more upsetting to the very young
◦ Monitoring devices
◦ Pulse oximetry
◦ Clip/wrap on a fingertip, toe, earlobe
◦ EKG monitor
Reassessment
◦An on-going process
6
Determining Sick From Not Sick
You may not know WHAT is wrong with your pediatric
patient
You need to identify that SOMETHING is wrong
Children have less energy reserves than the adult
◦ Children cannot compensate as long as adults
◦ When children collapse/decompensate, they do so
quickly
Don’t be the one that misses the signs and symptoms
being presented
7
A “Crashing” Patient
“They just suddenly deteriorate!”
This statement might mean that we missed the
signs and symptoms
Children can only compensate for a relatively short
time compared with adults
Maintain a high index of suspicion
Be prepared and be proactive
especially in children!
8
Pediatric Assessment Triangle PAT
To develop a first impression of the patient’s status
◦ Helps determine if the patient is sick or not sick
◦ Uses only visual and auditory clues without
assistance of any equipment beyond your
observational skills
Obtained on first look of the patient
Helps determine level of severity of the situation
Can determine the need for additional life support
9
PAT cont’d
Does NOT replace vital signs and the ABCDE’s hands-on
assessment
Will identify general physiological problems
Will identify urgency for treatment or transportation
Use this technique on all pediatric patients
◦ Will help determine a sick/not sick child
Most likely has been instinctively used by most care
providers for a long time without thinking of naming
the specific assessment process
10
Pediatric Assessment Triangle - PAT
11
PAT - Appearance
Tone
◦ Can they sit up on their own or are they flaccid?
Interactiveness
◦ How alert is the patient and interested in the
environment?
Consolable by caregiver?
Look – gaze
◦ Are they following activity in the room or not?
Speech/cry
◦ Strong, spontaneous or weak cry?
12
PAT – Work of Breathing
A great indicator in peds regarding oxygenation and
ventilation – more helpful than counting rates
Any abnormal sounds heard?
◦ Snoring, muffled or hoarse speech
Abnormal positioning noted?
◦ Sniffing position, tripoding,
unable to lie down?
Retractions evident?
Nasal flaring?
13
PAT – Circulation to Skin
White or pale?
◦ Inadequate blood flow
Mottling
◦ Patchy/marbling skin discoloration
◦ Vasoconstriction or vasodilation
Cyanosis
◦ Bluish discoloration skin and mucous membranes
Note: Visual signs of poor
circulation may just be a “cold” child
14
Circulation in Dark Skinned
Populations
Assess areas where skin tone is lightest and pallor
and cyanosis is easiest to detect
◦ Lips
◦ Mucous membranes
◦ Nail beds
◦ Palms/soles
15
Preserving Body Temperature
Children can quickly become hypothermic
◦ Relative large body surface area and head
◦ Can lose heat via conduction, convection, radiation,
evaporation, and via respirations
Keep patient covered as much as possible
Consider turning up vehicle heat as needed
All patients can suffer cold stress
◦ Can increase metabolic demands; worsen effects of hypoxia
and hypoglycemia; reduce response to resuscitation
◦ Increases morbidity – medical problems related to the
situation
16
Hands-on ABCDE Assessment
Airway
◦ Open?
◦ Chest rising with each breath?
◦ If airway not open or compromised, what
intervention is necessary?
◦ Positioning? Suctioning? Other adjuncts?
Breathing
◦ Rate acceptable for the age of the patient?
◦ What are the breath sounds?
◦ Smaller the chest wall listen more in the axillary line
17
ABCDE cont’d
Circulation
◦ Heart rate normal range for the age of the patient?
◦ Pulse quality – weak or strong?
◦ Palpate in the brachial area especially under 1
◦ For central pulse
◦ Check femoral in infants and young children
◦ Check carotid pulse in older children
If pulse is absent or <60 with poor circulation,
begin CPR per AHA guidelines
18
ABCDE cont’d
Disability – neurological status
Want to check the cerebral cortex and brainstem
activity
Cerebral cortex
◦ Evaluate appearance - done during the PAT
◦ Assess level of consciousness via Alert, Voice, Pain, or
Unresponsive (AVPU) scale
Brainstem
◦ Evaluate pupillary reflex to light stimulus
◦ Cranial nerve III
◦ Evaluate motor activity – symmetrical movements?
19
AVPU
Standardized, reproducible tool to evaluate level of
consciousness
Results less accurate in restless or agitated states
A – alert, awake, responding
V – only responds after verbal stimuli provided
P – only responds after pain or tactile stimuli is
provided
◦ Note level of response: localizing, withdrawal, posturing
U – unresponsive and flaccid
20
Glasgow Coma Scale (GCS) for Peds
Involves memorization and a numeric table
Helpful to have reference table available
◦ See References in SOP page 91
May not be accurate in children with special health
care needs
Motor component results appears to be best
predictor of neurologic outcome
Peds component of GCS intended for non-verbal
young children; no specific age limit in applying
peds GCS
21
GCS – Best Eye Opening
Remains unchanged from adult assessment
4 – spontaneous
3 – after verbal stimuli used
2 – after pain or tactile stimuli applied
◦ Lids may just twitch and not fully open
1 – no eye opening;
no muscle twitching at all
22
GCS – Best Verbal Response
5 - Coos and babbles to their norm; more playful
4 – Irritable cry
3 – Cries to pain; may be high pitched; not
sustained
2 – Responds to pain but not any sustained crying
1 – no verbal response/noise at all
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GCS – Best Motor Response
Very similar to the adult response
6 – obeys commands – age appropriate
5 – Withdraws to touch
4 - Withdraws to pain
3 – Abnormal flexion/bending of extremities
2- Abnormal extension of extremities
◦ Back usually arches; wrists tend to curl inward
1 – no response; flaccid
24
ABCDE cont’d
Expose
◦ You can’t treat what you don’t see
◦ Minimally need to view the face, chest wall, and
enough skin to evaluate circulation
◦ Consider need for privacy dependent on age
◦ Be careful to avoid heat loss especially in infants
◦ Infants have a larger body surface to body weight ratio than
adults
◦ Greater risk than adults of cooling off rapidly
◦ “Mottling” may be response to cooler environment and not
from poor circulation
25
Changes to Body Proportions
26
Tips/Techniques – Obtaining
Vital Signs
Can be a challenge to the healthcare provider to obtain vital
signs and perform assessment on the very young
Use distraction to keep the child’s hands occupied
◦ Hand them something to hold – their toy or a tongue blade
Allow the caregiver to hold the child if possible
Allow the caregiver to hold stethoscope over the anatomical
area being examined
Speak in a quiet, calm, even tone
Get on eye level with the patient if possible
Watch and interpret trends more than any one reading
27
Obtaining vital signs
Pulse rate
◦ Try the apical approach
◦
◦
◦
◦
Listen over the heart with a stethoscope
Tricky to listen to the “lub” or “dub” but accurate
Listen now to all kids you have access to for practice
Parent can be the one to hold the stethoscope over the heart
Respiratory rate
◦ Note that the younger patient breaths uneven with
short periods of apnea – this is normal
◦ Younger patients have more abdominal breathing
◦ Count for a minimum of 30 seconds and multiply by 2
28
Vital signs cont’d
Signs of circulation
◦ Evaluate skin temperature, capillary refill time and
pulse quality
◦ B/P is difficult to obtain - may need to rely on above
parameters alone especially under 3 years of age
Blood pressure
◦ Can be difficult to obtain
◦ Lack of patient cooperation, inappropriate cuff size
◦ Minimal systolic >1 years old = 70 + (2 times the age)
29
Blood Pressure Cuffs
Cuff size is
appropriate
when the
height
covers 2/3 of
the upper
arm
30
Respiratory Distress
Patient able to compensate and maintain adequate
oxygenation and ventilation
Appearance relatively normal
◦ Requires tremendous amount of energy and internal
resources to compensate
Increased work of breathing
Increased respiratory rate
Use of accessory muscles
Nasal flaring
31
Respiratory Failure
Energy reserves have been exhausted
Patient unable to maintain adequate oxygenation and
ventilation
Altered level of consciousness
Respiratory rate slowed
Respiratory effort decreased
Bradycardia usually present
Agitation, exhaustion, lethargy with cyanosis may be
present
32
Point of Discussion
EMS is called to the scene for a one year old
choking
Upon arrival child is in highchair eating lunch
◦ PAT?
◦ Impression?
◦ Interventions?
33
Point of Discussion
PAT –
◦ Appearance – normal
◦ Work of breathing – effortless
◦ Circulation – normal
Impression
◦ Resolved choking issue
Interventions
◦ Still perform detailed respiratory assessment
◦ Slight wheezing heard on right, left lungs clear
◦ Child may have aspirated FB – encourage transport
for evaluation
34
Assessing Shock in Peds
Decreased circulation will show signs of poor brain
perfusion
Use multiple assessment techniques to determine
child’s status and determine type of physiological
problem and presence or absence of abnormal
perfusion
PAT
Hands-on ABCDE’s
35
Abnormal Appearance Due To
Shock
Lethargic or listless
Decreased motor activity
Less interactivity with caregiver or others
Inconsolable
Poor eye contact
Weak cry; lack of tears if crying
Sunken fontanels – anterior (last to close) closes in most
by 2½ years
36
Work of Breathing in Presence
of Poor Perfusion
Decreased perfusion leads to metabolic acidosis
Child may increase respiratory rate without
increasing work of breathing just to “blow off”
excess CO2 – an acidotic by-product
Signs of increased work of breathing usually
indicate presence of a respiratory problem
Can indicate poor gas exchange and hypoxia
37
Abnormal Circulation to Skin
If environmental temperature is low, signs may be
inaccurate
◦ Vasoconstriction is a reflex to preserve body heat
Look for evidence of peripheral vasoconstriction evidence of maintaining core circulation versus
poor skin perfusion
◦ Mottling
◦ Pallor / paleness
◦ Cyanosis
If above present with abnormal appearance in a
warm environment, consider presence of shock
38
Shock
Inadequate tissue perfusion
Insufficient oxygen delivery to maintain normal
cellular function
Cardiovascular function relies on a network
◦ Oxygenation and ventilation
◦ Heart rate
◦ Intravascular volume
◦ Myocardial function
◦ Vascular stability
39
Shock in a Child
Same physiological components as the adult
Vasoconstriction and tachycardia very efficient in
the child as compensatory mechanisms
Absence of sweating until adolescence
◦ Children have cool, dry skin in shock
Infants in particular have high glucose needs with
low energy stores
◦ Use up stores of glucose very quickly and often become
hypoglycemic
◦ Check glucose levels in children under stress and
with altered mental status
40
Point of Discussion
How would you check the blood glucose level for
any patient?
◦ You should be performing a “finger stick” for a
capillary sample
◦ Obtaining a blood sample from an IV start has been
discouraged – this is a venous sample
◦ The design of protected IV catheters does not allow
easily obtaining a sample from the used IV catheter
41
Clinical Signs of Decreased
Perfusion
Altered mental status
Tachycardia as compensation
◦ Very effective in a child
Changes in skin color and temperature due to
vasoconstriction
Skin remains dry (no sweating until adolescence)
Note: Adult can compensate with increased cardiac
contractility; children do not. Pulse strength does
not change like the adult.
42
General Classes of Shock
Hypovolemic
◦ Volume loss
Distributive
◦ Decreased vascular tone with problems distributing
blood volume usually related to peripheral vasodilation
Cardiogenic
◦ Heart failure – usually in child with congenital problem
Obstructive
◦ Physical obstruction to blood flow
43
Etiology Pediatric Shock
Hypovolemic
◦ Vomiting – most common
◦ Diarrhea – most common
◦ Blunt trauma
◦ Excessive blood loss
Distributive
◦ Sepsis – massive infection most common in 2-3 years old
◦ Anaphylaxis – multisystem response to an antigen
◦ Unintentional drug overdoses – B-blockers, barbiturates
◦ Neurogenic shock - spinal cord injury with interruption of
sympathetic nerves - particularly above T6 level
44
Etiology Shock cont’d
Cardiogenic
◦ Uncommon in children
◦ Usually a congenital condition
Obstructive shock
◦ Pericardial tamponade
◦ Tension pneumothorax
◦ More common in children with cystic fibrosis
◦ A bleb may rupture spontaneously and turn into tension
pneumothorax
45
Point of Discussion
You are unable to establish a peripheral IV in a child
who needs IV access
What do you do?
◦ Establish an IO
◦ Palpate the site to determine the length of needle used
◦ If you can feel the bone (similar to over your radial area) then use
the pink shortest needle (15 G 15mm)
◦ If the site feels fleshy use the blue medium needle (15G 25mm)
◦ Reserve the yellow needle (15G 45mm) for extremely obese sites
and the humeral insertion (Medical Control permission for this site
in peds)
46
Point of Discussion
What are the landmarks for the proximal tibial site?
◦ Leg needs to be straight
◦ Palpate 2 fingers below bottom edge (distal) of patella
◦ May not palpate the tibial tuberosity in the very young
◦ Identify site 1 finger width in from tibial tuberosity (medial)
MUST stay away from growth plate
◦ Needle insertion into the growth
plate could stunt future growth
of the extremity
47
Point of Discussion
How do you know your IO needle insertion is
successful?
◦ Feel the pop through to the marrow
◦ Needle stands up on its own
◦ Able to aspirate bone marrow – doesn’t always
happen
◦ Line flushes easily
◦ Line runs with pressure bag applied to IV bag
48
Point of Discussion
Your peds patient is unconscious
You have successfully inserted an IO needle
How would you know the infusion is causing pain?
◦ Agitation, restlessness, trying to move extremity
◦ Facial grimacing, moaning
◦ Increased heart rate, respiratory rate, B/P
What would your response be?
◦ Lidocaine 1 mg/kg IO over 60 seconds, wait 60
seconds then restart infusion
49
Point of Discussion – Lidocaine
Dose For IO Pain Control
Patient weighs 88 pounds (formula 1 mg/kg)
◦ Check the SOP reference charts
◦ Notice the dosage in the heading is for 1.5 mg/kg
◦ This is the dose used for drug assisted intubation
◦ This patient should get 40mg (they are 40 kg (882.2))
Patient weighs 130 pounds (formula 1 mg/kg)
◦ 1302.2 = 59 kg
◦ Max adult dose is 50 mg!
Patient weighs 50 pounds (formula 1 mg/kg)
◦ 50  2.2 = 23 kg (kg will equal mg to give)
50
Compensatory (“Early”) Shock
Signs and symptoms begin to show at fluid loss
equal to 5% of body weight
Goal compensated shock
◦ To sustain cardiac output to maintain adequate
perfusion to core organs
◦ Supported via stimulation of sympathetic nervous
system
Compensatory mechanisms most evident in peds
◦ Vasoconstriction
◦ Increased heart rate
51
Compensatory Shock
Effects of vasoconstriction
◦ Delayed capillary refill time > 2seconds
◦ Poor skin color – pale or mottling
◦ Dry, cool skin
◦ Systolic B/P NORMAL
◦ Minimal systolic over 1 year old = 70 + 2 times the age
◦ Appearance normal or slightly agitated
52
Decompensated Shock
Compensatory mechanisms of vasoconstriction and
increased heart rate unable to maintain adequate
perfusion to core organs
Blood pressure drops with approximate 25% loss of
intravascular (blood) volume
Hypotension is hallmark sign of decompensated
shock
53
Decompensated Shock
Appearance is abnormal – inadequate brain perfusion
◦ FYI - may still be assigned “A” under AVPU
Restless, agitated
Poorly responsive
Hypotension
Tachypnea
Extreme tachycardia with weak palpable pulse
Pale, mottling, or cyanosis with cold skin
54
Cardiac Failure
Develops when decompensated shock is not
reversed
◦ Bradycardia
◦ Respiratory failure
◦ Cardiac arrest
55
Interventions For Shock
Determine type of shock patient is exhibiting
Begin routine pediatric care
Establish IV/IO access with normal saline
◦ The use of minidrip tubing allows for better control
of fluid volume infused
◦ Avoids inadvertent over-hydration of patient
Formula is 20 ml/kg
◦ May be repeated to a total volume of 60 ml/kg
◦ Allows for total of 3 fluid challenges for the peds patient
56
Point of Discussion – Comparing
Fluid Challenges
Your 200# adult patient requires a fluid challenge
How will you deliver this?
◦ Administer in 200 ml increments
◦ Formula is 20 ml/kg for all persons
◦ Total for this patient would be 1820 ml (91 kg x 20 ml/kg)
◦ Do not stop infusion but as you pass each 200 ml
increment, you would reassess patient
Level of consciousness
Skin parameters
Lung sounds
57
Point of Discussion
Your 60 pound peds patient requires a fluid challenge
How will you deliver this?
Resources
◦ Do the math: 60#  2.2 = 27 kg; 27kg x 20 ml = 540ml
◦ Check the back of the SOP’s
◦ Choose closest and next less weight 57# = 520 ml
How are you going to administer this volume?
Child requires their total calculated volume
◦ Administer as close to 20 minute time frame as possible
◦ Assess as you pass a reasonable volume of fluid
58
Apparent Life Threatening
Event - ALTE
Defined as an episode involving significant
behavioral or physical changes in a child
Often witnessed by the parents only
◦ Usually resolved prior to arrival of healthcare
provider
Involves some combination
Apnea
Color change
Marked change in muscle tone
Choking or gagging
59
ALTE
If child appears “normal” upon exam, encourage
transport in case of occult or hidden illness
If child is symptomatic, perform appropriate
intervention for the physiological or anatomical
problem
Most cases are limited to transport only
◦ Continue reassessments watching for a change in the
patient
◦ Don’t be lulled into a false sense of security
Expect the worse, hope for the best!!!
60
ALTE
Use scene size-up to obtain any clues
Perform ABCDE assessment
◦ Airway unobstructed?
◦ Breathing rate, depth, and quality?
◦ Circulation status?
◦ Pulse rate, regularity, and quality?
◦ Capillary refill; skin color and temperature?
Thorough history
◦ SAMPLE, OPQRST
Vital signs – B/P, P, R, pulse ox, pain scale, glucose
Hands-on toe-to-head or head-to-toe assessment
61
OPQRST Assessment
O – what where you doing at the onset?
P – what makes it better/worse (palliation/provocation)?
Q – in patient’s words, what is the quality?
R – does the pain radiate?
S – on the appropriate pain scale, what is the severity?
T – what time did this start?
62
ALTE
Possible problem list
Sepsis
Congenital heart disease
Metabolic abnormality
Seizure
Gastroesophageal reflux
Brain injury
63
Pain Management in Peds
Contact Medical Control for patients under 2
Pain often under-recognized in the peds population
◦ Therefore, often undertreated in this population
Indications a person may be experiencing pain
◦ Verbalizes – only if old enough to do so!
◦ Use age appropriate assessment tool (0-10 pain scale, WongBaker FACES, FLACC pain scale)
◦ Increased pulse rate
◦ Increased agitation, restlessness, moaning
◦ Sweating – usually not present until adolescence
64
Pediatric Pain Management
Pain and anxiety can both be present
Need to identify one from the other
◦ Interventions are different
Morphine – opioid
◦ Can cause vasodilation and a drop in blood pressure
◦ Indicated for control of pain related to burns
Fentanyl – synthetic opioid
◦ Faster acting and shorter duration than morphine
◦ Does not affect cardiovascular status (B/P)
65
Pediatric Pain Management
Fentanyl 0.5 mcg/kg IVP/IN/IO
May repeat in 5 minutes – same dose
Reminder: adult max total dosing is 200 mcg
◦ 220 pound patient would get 100 mcg with one dose
Watch for respiratory depression
What should you do if respiratory depression is
noted?
◦ Reverse the response with Narcan
◦ Consider need to support ventilations via BVM
66
Pediatric Medication
Medication is based on patient weight in kilograms
Parents will often provide information in pounds
What are your resources for dosing calculations?
◦ The Region X SOP for calculation formula
◦ Back of the SOP’s for dosing charts
◦ Check “how supplied” for equivalency of calculation
Precaution
◦ Broselow tape may not follow same formula calculation
as Region X SOP’s
◦ Many drugs listed as total mg, not ml to put into syringe
67
Case Scenario Discussion
Review the following cases
Discuss as a group
Information gathered from the PAT
General impression formed
Necessary interventions to perform
What you will do for reassessment
68
Case Scenario #1
EMS is called for a 13 year old who was injured at school
A non-parental adult has volunteered to drive him to the
hospital
How would you respond to this suggestion?
◦ Only the patient’s parents/legal guardians can authorize a
medical release or alternative transportation
◦ An authorized school representative can authorize a
medical release into the school representative’s custody
◦ Encourage ambulance transport if appropriate
69
Case Scenario #1
PAT
◦ Patient is sitting up, in obvious pain
◦ Respiratory rate is slightly elevated ; in no distress
◦ Skin is pale (what might this mean???)
VS: B/P 122/78; P – 98; R – 16; pain 9/10
Deformity present to right leg; no other injuries
What is the mechanism of injury (MOI)?
What is your priority of care?
What interventions will you provide?
70
Case Scenario #1
Perform full head to toe assessment
◦ One injury is obvious; don’t want to miss another one
Immobilize injured extremity
◦ Splint includes joint above and below the injured site
◦ Assess CMS/PMS before and after splinting
Address pain intervention
◦ Splinting (rest), elevation if able
◦ Ice applied indirectly to site
◦ Pain medication for 132 pound patient
◦ Fentanyl 0.5 mcg/kg IVP/IN/IO
71
Case Scenario #1
How much Fentanyl would you give?
◦ 132#  2.2 kg = 60 kg
◦ 60 kg x 0.5 mg/kg = 30 mcg
◦ 30 mcg = 0.6 ml Formula #1
30 mcg = 100 mcg
X ml
2 ml
100 X = 30 x 2
100 X =
60
100
100
X = 60  100
X = 0.6 ml
Formula #2
X ml = Vol x desired dose
Dose on hand (mg)
Xml = 2 ml x 30 mcg
100 mcg
X ml = 60
100
X ml = 60  100
X ml = 0.6 ml
72
Case Scenario #2
A 3 year-old patient was found drinking a caustic
product
Upon your arrival, you notice the child is not interactive
You hear stridor
You notice tissue damage around lips
PAT?
Impression?
Product involved?
Intervention?
73
Case Scenario #2
PAT – sick child
Impression – airway compromise
Intervention
◦ Secure airway
◦ How would you do this?
◦ Positioning
◦ Intubation; Quick trach (size 2mm for 22-77# or 10-35 KG)
◦ Consider need for oxygen support
◦ How would you administer blow-by oxygen?
◦ Hold oxygen source so O2 blows across mouth area
74
Case Scenario #3
You arrive on the scene for a patient who is less
responsive
Mother reports 35 pounds
PAT
◦ Child is limp, not interactive
◦ Respiratory rate is shallow and rapid
◦ No noises are heard
◦ Circumoral cyanosis – cyanosis around mouth
Impression?
Is this a respiratory or cardiac problem?
75
Case Scenario #3
Impression
◦ Sick child
◦ Needs rapid intervention and transport
Consider IV – O2 – monitor
How fast should you bag the infant & child?
◦ Check the SOP’s
◦ 1 breath every 3 - 5 seconds (12-20/minute) (up to puberty)
◦ Adult over puberty – 1 breath every 5-6 seconds (10-12 per minute)
How much Lidocaine would be indicated if necessary
after IO insertion?
◦ 35# = 16 kg = 16 mg = 0.8 ml
76
Case Scenario #3
How do pediatric patients compensate?
◦ Tachycardia and vasoconstriction are the most powerful
responses a peds patient can have to support perfusion
◦ Peds patients do not increase cardiac contraction strength like
adults do for compensation
◦ Vasoconstriction will change skin parameters to cool and
pale
◦ Often see definite line of demarcation of coloring and mottling
◦ Sweating does not usually occur until adolescence
◦ Most children in shock have cool, dry skin
77
Case Scenario #4
The mother states the child hasn’t been eating well
for the past 2 days
Child has been vomiting
PAT?
Impression?
Interventions?
78
Case Scenario #4
Child is awake, does not object to you approaching
them, weak cry
Respirations non-labored, no noises
Skin dry
Impression?
◦ Sick
◦ Looks emaciated and dehydrated
◦ This looks like it has been a longer term problem
What would you do if you suspect child neglect?
79
Case Scenario #4
Consider need for IV access
Need cardiac monitoring
If you suspect child abuse/neglect
◦ Objectively document findings
◦ Report verbally your suspicions to ED staff
◦ Report to DCFS 24/7 via hot line 1-800-252-2873
◦ Follow-up phone report with written report filed
with DCFS within 48 hours
80
Small Group Practice
Small groups are to respond to the “call”
Perform as realistically as possible
Perform your assessments – PAT, ABCDE, OPQRST,
SAMPLE
Form a general impression
Determine interventions required
Perform skills as you would in the field
81
Group Practice #1
13 year-old patient (90 pounds) found unresponsive
with shallow breathing at a rate of 4 per minute
Weak radial pulse
Pinpoint pupils
History of insulin dependent diabetes
Perform as a small group
with this scenario
82
Group Practice #1 Skills
Positioning
Airway control
IV/IO access
Blood glucose monitoring
Medication calculation
◦ Narcan
◦ Dextrose 25%
◦ Lidocaine for drug assisted intubation
◦ Lidocaine for pain control of IV infusion
83
Group Practice #2
5 year-old (45 pounds) with persistent vomiting
Listless
No eye contact
Sunken eyes
Tachypnea, tachycardia
Cool, dry skin
Perform as a small group with this scenario
84
Group Practice #2 Skills
Positioning
Airway control
◦ BVM 1 breath every 3-5 seconds (12-20 per minute)
◦ Advanced procedures
IV/IO access
◦ Calculating fluid challenge 20 ml/kg
Blood glucose monitoring
Medication
◦ Lidocaine for pain control of IO infusion
85
Group Practice #3
2 year-old unresponsive; 23 pounds
Limp
Shallow, slow respiratory rate
Circumoral cyanosis
No radial pulse; slow, weak carotid
86
Group Practice #3 Skills
Positioning
Airway control – BVM, advanced airway device
IV/IO access
◦ Fluid challenge 20 ml/kg
Cardiac monitoring
CPR for child
Medications
◦ Epinephrine 1:10,000
◦ Drug assisted intubation: Atropine, Etomidate, Versed
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Group Practice #4
8 year-old (60 pounds) with a severe asthma attack
Agitated; having hard time sitting up
Pale, diaphoretic
Looks exhausted, minimal accessory muscle use
SpO2 92%
Lung sounds: diminished and hard to hear
88
Group Practice #4 Skills
Positioning
Airway control – O2, BVM assist
Medications
◦ Duoneb via nebulizer
◦ Duoneb via in-line set-up
IV/IO access
89
Group Practice #5
15 year-old patient (128 pounds) found
unresponsive
Diaphoretic; shallow, snoring respirations
Weak, rapid pulse
Medic alert tag - diabetic
90
Group Practice #5 Skills
Positioning
Airway control – BVM, oro/nasopharyngeal airway
IV access
Medications
◦ Glucagon IM/IN
◦ Dextrose 25%
◦ Calculated from 25% and 50% concentrations
◦ Narcan considered
91
Bibliography
American Academy of Pediatrics. Pediatric Education for Prehospital
Professionals 3rd Edition. Jones and Bartlett. 2014
Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices,
4th edition. Brady. 2013.
Mistovich, J., Karren, K. Prehospital Emergency Care 9th Edition. Brady.
2010.
Region X SOP’s; IDPH Approved April 10, 2014.
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