Transcript May 2010 CE: Pediatric Focused Review

Pediatric Focused Review
Broselow Tape, Pediatric Codes,
After Action Report
Condell Medical Center EMS System
May 2010 CE
Objectives provided by: Mary Ann Zemla, RN
Packet prepared by: Sharon Hopkins, RN, BSN, EMT-P
Objectives
• Upon successful completion of this module, the
EMS provider will be able to:
• Define ages for the pediatric population
• Describe the Pediatric Assessment Triangle.
• Identify common age-related illnesses and
injuries in the pediatric population.
• Describe signs, symptoms, and management of
selected pediatric respiratory emergencies.
• Describe signs, symptoms, and management of
shock.
Objectives cont’d
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Describe management of the pediatric patient
with seizures.
Describe signs, symptoms, and management
of hypoglycemia in the pediatric patient.
Describe signs, symptoms, and management
of hyperglycemia in the pediatric patient.
Identify common causes of poisoning and toxic
exposure in the pediatric patient.
Identify injury prevention for infants and
children.
Objectives cont’d
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Describe the indication, dosage, route, and special
considerations for medication administration in infants
and children.
Identify when to complete an After Action Report and
how to forward it.
Actively participate in scenario discussion and practice.
Given a Broselow tape and the patient’s estimated
weight calculate the correct medication dose for a
pediatric patient.
Given a Broselow tape identify equipment used for a
specific patient.
Successfully complete the post quiz with a score of 80%
or better.
What is a Pediatric Patient?
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Newborn – first hours after birth
Neonate – birth to 1 month
Infant – 1 to 12 months
Toddler – 1 to 3 years old
Preschooler – 3 to 5 years old
School-age – 6 to 12 years old
Adolescent – 13 to 18 years old
Region X SOP
• Pediatric patient
– “considered under the age of 16”
– Patient is between the ages of 0 and 15
• Source: Follows guidelines of EMSC –
Emergency Medical Services for Children
Common Pediatric Fears
• Fear of
being separated from parents/caregivers
being removed from home and not returning
being hurt
being mutilated or disfigured
the unknown
Anatomical and Physiological
Differences – Peds vs Adult
• Tongue proportionately larger – may block
airway
• Smaller airway structures – more easily
blocked
• Abundant secretions – can block airway
• Baby teeth – easily dislodged, may block
airway
• Flat nose and face – difficult to get good
seal with face mask
Differences cont’d
• Heavy head with less developed neck
muscles to support head – head may be
propelled forward and cause more head
injuries
• Open fontanelles – bulging may indicate
increased ICP; shrunken may indicate
dehydration
• Thinner, softer brain tissue – increased
susceptibility to brain injuries
Differences cont’d
• Head larger in proportion to body – head tips
forward making neutral alignment difficult
• Shorter, narrower, more elastic trachea –
trachea can close with hyperextension
• Short neck – difficult to stabilize/immobilize
• Abdominal breather – difficult to evaluate
breathing
• Faster respiratory rate – fatigued muscles
leading to respiratory distress
Differences cont’d
• Obligate nasal breathers as newborns – may not
open mouth to breathe if nose is blocked
• Larger body surface area relative to body massprone to hypothermia
• Softer bones – more flexible, less easily
fractured, transmitted forces may injure internal
organs without rib fractures, lungs easily
damaged
• Spleen and liver more exposed- increased risk
of injury with significant force to abdomen
Initial Pediatric Assessment
• Active and alert child
– Can spend time slowly approaching patient
– Can spend time making patient more
comfortable
• Critically injured or ill child
– Requires quick assessment and quick
intervention
Pediatric Assessment Triangle
PAT
• Obtain information as you enter the area
and are walking towards the child
• Use to determine level of severity and
determine urgency of situation
• Based on visual observation and listening
skills
– Does not require equipment
PAT
• Evaluate:
Appearance
Work of breathing
Circulation to skin
• Information gained on:
• Underlying cardiopulmonary status
• Level of consciousness
• Is not a replacement but an addition to the
ABC assessment and vital signs
PAT - Appearance
• Appearance most important factor
• Reflects adequacy of
Oxygenation and ventilation
Perfusion
Homeostasis
CNS function
• Observe child while in caregiver’s lap
– Hands-on contact by caregiver may cause
agitation and crying; may complicate
assessment
PAT - Appearance
• Tone – good muscle tone or limp, listless?
• Interactive – how alert, looking around,
distracted, interested in playing?
• Consolable – able to be comforted by
caregiver?
• Eye contact/gaze – can gaze be fixed on
an object or is gaze glassy eyed?
• Speech/cry – strong, spontaneous or weak
and high-pitched?
What is
your
general
impression
PAT – Work of Breathing
• Indicator of
– Oxygenation
– Ventilation (breathing)
• More accurate than counting the
respiratory rate and auscultating breath
sounds
– These are more typically used in the adult
• Listen for abnormal sounds
• Observe for increased effort of breathing
PAT – Work of Breathing
• Abnormal positioning – sniffing position,
tripoding, refusing to lie down
• Abnormal airway sounds – snoring, stridor,
grunting, wheezing, hoarse
• Retractions – chest wall & neck muscles;
head bobbing in infants
• Flaring – of nares on inspiration
Tripod Position
• Leaning forward, hands placed on thighs
for support, expands the lungs
Abnormal Airway Sounds
• Snoring – blocked airway; usually tongue
• Stridor – partial airway obstruction; harsh
high-pitched sound on inspiration
• Grunting – Poor gas exchange; short, lowpitched sound at end of exhalation; helps
keep airway open
• Wheeze – whistling sound especially
during exhalation
Which infant is in more distress?
• Retractions noted
 Playful, interested
Positioning of Airway
• Rolled towels under the shoulders to
gently extend the neck of the infant
PAT – Circulation to Skin
• Important sign of core perfusion
– Skin and mucous membranes non-essential
and blood flow shunted away when cardiac
output is inadequate
• Expose long enough to determine
circulation status
– Avoid hypothermia
• In dark skinned children, evaluate lips,
mucous membranes, and nail beds
PAT – Circulation to Skin
• Pallor
– White or pale skin from inadequate blood flow
• Mottling
– Patchy skin discoloration due to
vasoconstriction/vasodilation
• Cyanosis
– Bluish discoloration of skin and mucous
membranes
– Late finding of respiratory failure or shock
Pediatric Emergencies
Are You Prepared?
• Airway
– Obstructions
– Infections
– Diseases
• Croup
• Epiglottitis
• Asthma
Signs & Symptoms
Respiratory Distress
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Irritable, anxious
Tachypnea
Retractions
Nasal flaring (infants)
Poor muscle tone as condition deteriorates
Tachycardia
Head bobbing
Grunting
Cyanosis that improves with oxygen
Signs & Symptoms
Respiratory Failure
• Mental status deteriorating to lethargic
• Marked tachypnea later deteriorating to
bradypnea
• Marked retractions deteriorating to agonal
respirations
• Poor muscle tone
• Marked tachycardia deteriorating to
bradycardia
• Central cyanosis
Pediatric Emergencies
Are You Prepared?
• Shock
– Inadequate tissue perfusion
– Dehydration – vomiting or diarrhea
– Infection – sepsis
– Trauma – especially abdominal
– Blood loss
Signs & Symptoms
Compensated Shock
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Irritability or anxiety
Tachycardia
Tachypnea
Weak peripheral pulses; full central pulses
Delayed capillary refill
Cool, pale extremities
Systolic B/P normal
Decreased urinary output
Decompensated Shock
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Lethargy or coma
Marked tachycardia or bradycardia
Absent peripheral pulses, weak central pulses
Markedly delayed capillary refill
Cool, pale, dusky, mottled extremities
Hypotension
Markedly decreased urinary output
Absence of tears
Signs & Symptoms
Mild Dehydration
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Alert
Skin normal and dry
Pulse normal
Respirations normal
Blood pressure normal
Capillary refill normal
Signs & Symptoms
Moderate Dehydration
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Irritable
Skin dry, ashen and very dry
Pulse increased
Respirations increased
Blood pressure normal
Capillary refill 2 – 3 seconds
Signs & Symptoms
Severe Dehydration
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Lethargic
Skin dry, cool, mottled, very dry, no tears
Pulse markedly increased
Respirations markedly increased
Blood pressure hypotensive
Capillary refill > 2 seconds
Pediatric Fluid Resuscitation
• Formula for all persons
– 20 ml/kg
– Calculate total amount based on weight
– Administer one full fluid challenge, volume
based on weight
• If total volume greater than 200 ml, assess at
every 200 ml increment
– Reassess to determine need for 2nd fluid
challenge
– Reassess after 2nd fluid challenge to
determine need for 3rd fluid challenge
Are You Prepared?
Neurological Emergencies
• Seizures
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Fever
Hypoxia
Infections - meningitis
Idiopathic epilepsy (unknown cause)
Electrolyte disturbance
Head trauma
Hypoglycemia
Toxic ingestions or exposure
Tumor
CNS malformations
Status Epilepticus
• Major emergency
• Involves prolonged periods of apnea
– Induces severe hypoxia
• Seizures may cause
– Respiratory arrest
– Severe metabolic and respiratory acidosis
– Increased intracranial pressure
– Elevations in body temperature
– Fractures of long bones and the spine
– Severe dehydration
Respirations and Status Epilepticus
• Patients in prolonged seizures must have
respirations supported via BVM
– Need to prevent hypoxia and acidosis
– Ventilate 1 breath every 3 seconds for
children
• Ventilate 1 breath every 5 – 6 seconds for
adults
• Patients not in status and breathing on their own
can be given a non-rebreather oxygen mask
Are You Prepared?
GI Emergencies
• Nausea
• Vomiting
• Diarrhea
• Biggest risk – dehydration and electrolyte
imbalance
Metabolic Emergencies
Mild Hypoglycemia
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Hunger
Weakness
Tachypnea
Tachycardia
Shakiness
Yawning
Pale skin
Dizziness
Metabolic Emergencies
Moderate Hypoglycemia
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Sweating
Tremors
Irritability
Vomiting
Mood swings
Blurred vision
Stomach ache
Headache
Dizziness
Slurred speech
Metabolic Emergencies
Severe Hypoglycemia
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Decreased level of consciousness
Seizures
Tachycardia
Hypoperfusion
Treatment Hypoglycemia
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Situation develops rapidly (ie: minutes)
Ages less than 1 – D 12.5% 4 ml/kg IVP/IO
Ages 1 -15 – D 25% 2 ml/kg IVP/IO
Ages 16 and older – D 50% 50 ml (25 Gms)
• Dextrose very irritating to veins
• Need diluted strength for the younger veins
• No IV access
– Glucagon 0.1mg/kg (max dose 1 mg)
Metabolic Emergencies
Early Hyperglycemia
• Increased thirst
• Increased urination
• Weight loss despite increased intake
• Stage in which many patients are
diagnosed due to the 3 P’s of signs and
symptoms: polyuria, polydipsia,
polyphagia
Metabolic Emergencies
Late Hyperglycemia
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Weakness
Abdominal pain
Generalized aches
Loss of appetite
Nausea, vomiting
Signs of dehydration but with  urine output
Fruity odor to breath
Tachypnea
Hyperventilation
Tachycardia
Metabolic Emergencies –
Hyperglycemia - Ketoacidosis
• Continued decrease in level of
consciousness progressing to coma
• Kussmaul’s respirations – deep, rapid,
becoming slow and gasping
– An attempt to exhale excess acids (ie: CO2)
produced during abnormal metabolism
• Signs of dehydration
– Sunken eyes
– Dry skin, tenting
– Tachycardia
Treatment Hyperglycemia
• Develops over time (ie: days or weeks)
• Patient prone to dehydration
– Needs fluid administration
• 20 ml/kg normal saline
– Monitor carefully for fluid overload
• Evaluate breath sounds frequently
when administering fluid challenge
Are You Prepared?
Evaluating for Poisoning
• Possible indicators of ingested poisoning
– Previous history of swallowing a poison
– Change in level of consciousness
– Vital sign alterations
– Pupils – size and reaction
– Skin and mucosa findings
– Observation of mouth signs & odor
– Abdominal complaints – nausea, vomiting,
diarrhea
Toxicological Exposures
• Carbon monoxide
– Who else is ill?
– Headache, nausea, vomiting, sleepiness
• Cardiac medications
– Nausea and vomiting
– Headache, dizziness, confusion,
dysrhythmias, bradycardia
• Caustic substances (Drano, liquid
plumber)
– Burns, drooling, hoarseness
Toxicology cont’d
• Salicylates (Aspirin toxic at 300 mg/kg)
– Rapid resp, hyperthemia, altered level of
consciousness, abdominal pain
• Acetominophen (Tylenol toxic at 150 mg/kg)
– Nausea, vomiting, weakness, abdominal pain,
liver disorder, liver failure
• Alcohol
– CNS depression, impaired judgement
• Marijuana
– Euphoria, dilated pupils, altered sensation
Toxicology cont’d
• Cocaine (crack, rock)
– Euphoria, dilated pupils, anxiety, hypertension,
tachycardia, seizures, chest pain
• Narcotics (Heroin, codeine, morphine)
– CNS depression, constricted pupils,
hypotension, bradycardia, coma, death
• Amphetamines (Ritalin, speed)
– Hyperactivity, dilated pupils, hypertension
Injury Prevention
• Far better to prevent the initial traumatic or
medical insult than to try to treat the
results
– Proper immobilization in vehicles
– Use of protective gear in sports
– Keeping harmful products non-accessible
• Children naturally inquisitive
– Being diligent in watching children
Case Studies
• How do you perform your initial
assessment?
• What is your general impression?
• What is your initial action?
• What your other interventions?
• How would you reassess this situation?
Case Study #1
• You are dispatched to a local school for a 7 year
old with difficulty breathing
• The child is sitting upright, leaning forward
• States trouble breathing started in gym, she
forgot her meds at home
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Anxious, restless
Talking with frequent stops to take in a breath
Respiratory rate increased, labored
Skin pale, warm, dry
Lips dry
Unproductive cough
Case Study #1
• General impression?
– Asthma
• Initial actions?
– Finish hands on assessment
• Vital signs (96/56-130-30-SpO2 91% room air)
• Breath sounds – bilateral wheezing – barely audible
• Signs of respiratory distress
– OPQRST to obtain information on medical calls
– SAMPLE history
Case Study #1
• Initial interventions
– Supplemental oxygen
• What route would you use?
– Does the patient require IV access?
– Monitoring equipment to apply
• Pulse oximetry
• Cardiac monitor
• Blood pressure cuff
• Medications indicated
– Albuterol 2.5 mg/3ml via nebulizer
Case Study #1
• Reassessment
– Airway
• Does it remain open?
– Breathing
• What is the rate, quality, and rhythm of breathing
• What are the breath sounds now?
– Circulation
• What is the rate, quality and rhythm of the pulse?
• What does the cardiac monitor show?
– Response to intervention
• What would you monitor specifically for asthma?
Case Study #1
• Reassessment
– Patient is developing increased respiratory
distress, labored breathing, barely able to
auscultate bilateral wheezing, decreasing level
of consciousness
– RR – 38 and shallow dropping to 8; SpO2 86%
• What action is necessary?
– Support ventilations via BVM with Albuterol inline
– Prepare for intubation
Case Study #1 – In-line Albuterol
• Begin bagging via BVM with nebulizer kit
• After intubation is accomplished, take off
BVM mask and connect to ETT with adaptor
Case Study #2
• You are responding to a home for a 7 month-old
with vomiting and diarrhea.
• The mother states her child became ill this
morning with several episodes of vomiting and
diarrhea.
• The child is listless laying in the crib
• Child has a weak, whiny cry
• Airway is open with rapid and unlabored
respirations
• Patient is pale, dry mouth, no tears are present
Case Study #2
• Check PAT upon entering the room
– Appearance
– Work of breathing
– Circulation
Case Study #2
• General impression?
– Dehydrated patient
• Initial actions?
– Finish hands-on assessment
• Warm/hot to the touch (T – 101.50F)
• No B/P obtained; capillary refill 4 seconds
• P – 190, weak radial, strong brachial
• RR – 50; SpO2 96%
• Poor skin turgor
• Abdomen soft, does not cry when palpated
– OPQRST
– SAMPLE history
Case Study #2
• Severe dehydration with signs of
compensated shock
– Listless
– Tachypnea
– Tachycardia
– Weak peripheral (radial) pulse; strong central
(brachial) pulse
– Cool, pale extremities
– Delayed capillary refill
Signs of Dehydration - Tenting
Case Study #2
• Cardiac rhythm observed:
• Does the cardiac rhythm match the
presentation?
– In infants, tachycardia <220 almost always
sinus tach especially in presence of fever,
pain, hypovolemia, or hypoxia
Case Study #2
• Interventions
– Supportive oxygen therapy
• BVM not required at this point
• Try NRB or blow-by if too agitated
– Agitation would be a good sign that the child is
relating to stimuli
– IV access
• Check peripheral sites
– Hands, AC, ankle, feet
• Consider IO –proximal tibial area
– Contact and discuss with Medical Control
• Formula is 20 ml/kg
– Reevaluate as you are passing every 200 ml
volume
Case Study #2
• IO insertion
– Do not place hand behind
the site
– Stop placement when a
“pop” or lack of resistance is
felt
Case Study #2
• Rapid transport with early communication
• This infant is critically ill
– Shock develops much more rapidly in infants
and children compared to adults
• Relatively small fluid reserves
• In compensated shock, peripheral blood
flow is being shunted to the core of the
body
• Decompensated shock will quickly follow
unless the patient is treated promptly
–Cardiovascular collapse and death
Case Study #3
• 911 call from a frantic mother screaming her
4 year-old son is not breathing
• Upon arrival, the child is laying on the living
room floor unresponsive
• Mother states the child stuck a pin in the
electrical outlet
• The child is no longer in contact with the outlet
– The scene is safe
– Small arc-burn wound noted to left hand
Case Study #3
• Initial assessment
– Spinal motion restriction (SMR)
• Is c-spine control necessary?
– Level of consciousness
– Airway
• Open with head tilt chin lift? or
• Open with modified jaw thrust?
– Breathing
• Look, listen, and feel
• If not breathing, administer 2 breaths
– Circulation
• Where do you feel for a pulse on 4 year-old?
– Check the carotid area after the age of one
Case Study #3
• Patient assessment
– Patient is unresponsive, not breathing, no pulse
• Next action?
– CPR for 2 minutes
• Witnessed arrest by mother but now over
4 - 5 minutes
• Preparation during CPR
–Apply monitor pads
–Run through IV tubing
–Use Broselow tape to prepare
medications
Case Study #3
• Electrode placement
– Anterior/anterior
Make sure
electrodes
do not touch
– Anterior/posterior
Case Study #3
Broselow Tape
• How do you measure the Broselow tape?
– From top of head to heel (not end of toes)
• Information on both sides of tape
– Equipment and medication
Case #3
• 2 minutes of CPR done
• What is the patient’s rhythm?
– Ventricular fibrillation
• What is the next appropriate step?
– Interrupt CPR for no longer than 10 seconds
– Defibrillate at 2 joules per kg
• Patient weighs 40 pounds
– Immediately resume CPR
Case #3
• What is the order of care to deliver?
– Secure airway
– Work on IV access
– Repeat defibrillation after every 2 minutes of
CPR
• Initially 2 j/kg; then 4 j/kg
– Alternate medications during CPR
• Epinephrine 0.01 mg/kg 1:10,000 IVP/IO
–Repeat every 3-5 minutes
• Amiodarone 5 mg/kg IVP/IO OR
• Lidocaine 1 mg/kg IVP/IO
Case Study #3
• How do you evaluate ETT placement?
– Direct visualization during placement
• Apply cricoid pressure to control vomitus
• Do not let go until the cuff is inflated
– Observation of bilateral rise and fall of chest
– 5 point auscultation
• Over the epigastric area
• Upper lobes and midaxillary approximately
4th-5th intercostal space
Case Study #3
• Peds patient positioning for ETT
– Need to place a small
towel under the occiput
to obtain neutral position
• ETT confirmation with ETCO2
– Observe for yellow color
– Color can change back
and forth reflecting status
Case #3
• After several rounds of medication and several
defibrillation attempts next rhythm check:
• What do you need to do now?
– Check for pulse now that you observe a rhythm that
should generate a pulse
– What is the perfusion status of the patient with this
rhythm (sinus rhythm with PVC’s)?
Case #4
• You are responding to a call for a 3 year
old with a seizure
• Your patient is sitting in mom’s lap crying
and clinging to mom
• Patient has been “ill” for the past 12 hours
• Respirations are increased and unlabored
• Patient is flushed
Case #4
• General impression
– Febrile seizure
– Avoid tunnel vision; get history
• Recent head trauma
• Medical history
– Initial actions
• Finish hands-on assessment
– Skin hot and dry
– Radial pulse rapid & regular
– Capillary refill 2 seconds
– VS: B/P 80/50, P – 140; RR - 40
Case #4
• While transporting to the ED, the child
begins to have a seizure
• What are your interventions?
– Protect the airway
• Turn the child onto their side
• Turn on suction
– Administer blow-by oxygen
• If the seizure lasts for any length of time you will
need to bag the patient to oxygenate and ventilate
them
Case #4
• SOP for seizures
– Obtain blood glucose level
• If result < 60, administer Dextrose
–<1y/o – D 12.5% 4 ml/kg
–1-15 y/o – D 25% 2 ml/kg
– Current, active seizure
• Valium 0.2 mg/kg IVP titrated to seizure
activity
• No IV access – Valium 0.5 mg/kg rectally
(max 10 mg)
Case Study #5
• Called to the scene for a 6 year-old struck by a
car while riding his bike
• Scene is safe
• Child flickers eyelids to pain, is occasionally
moaning, and withdraws to pain
• Blood flowing from mouth
• Respirations rapid, gurgling, irregular
• Radial pulse slow, bounding
• Skin warm and dry
Case Study #5
• Rapid trauma assessment
– Hematoma right side of head with abrasions
– Trachea midline, no JVD, c-spine normal
– Abrasions to left lateral chest, chest wall stable
& symmetrical
– Breath sounds clear bilaterally
– Abdomen soft & nondistended; pelvis stable
– Closed fx left femur; abrasions upper extremities
– No signs of trauma when rolled over
Case Study #5
• Baseline vital signs and SAMPLE
– VS: 140/90; P -66; RR – 36 and shallow;
SpO2 91%
– SAMPLE – unknown
– History of events – child ran out in front of car
• What interventions need to be performed?
• What category trauma is this?
• Where is this patient transported to?
Case Study #5
Interventions
• Spinal motion restriction (SMR) – c-spine
control
• Supportive ventilations with oxygenation
– Ventilate at 20 breaths per minute
• 60 (seconds)  20 (breaths/minute) = 1 breath
every 3 seconds
– Suctioning is limited to 10 seconds alternated
with 2 minutes of ventilation
• Think: IV – O2 - monitor
Case Study #5
• Typical injury pattern for child versus auto
– Waddell’s triad
• Initial impact blunt abdominal trauma, pelvic
fractures and/or femur fractures (bumper)
• Seconds impact thoracic trauma (grill or hood of
car)
• Third impact closed head trauma (thrown from car
to ground)
• Brain injury associated with highest
mortality rates
Case Study #5
• Category trauma patient
– Category I
• Transport decision
– Highest level within 25 minutes
• Closely monitor ventilations
– Ventilation rate for head injury if needed:
• Adult 10 breaths per minute (if deteriorated 20/min)
• Children 20 breaths per minute (if deteriorated 30/min)
• Infants 25 breaths per minute (if deteriorated 35/min)
Case Study #5
Fluid Resuscitation
• Formula 20 ml/kg all patients
– Monitor vital signs and breath sounds closely
– Administer in 200 ml increments reassessing
as you pass each 200 ml mark
– Goal to get B/P to 90 systolic
– Max fluid challenge for peds is 60ml/kg
• 3 separate fluid challenges (each dose 20 ml/kg)
Case Study #5
• Why the abnormal vital signs for this patient?
– Increased intracranial pressure due to closed head
trauma and cerebral edema
• Acute rise in systolic B/P
• Reflex bradycardia (from parasympathetic tone)
• Abnormal respiratory pattern based on pressure in
various levels in the brain stem
– Inadequate ventilatory volume requiring
ventilatory support
• Cushing’s triad -  B/P, bradycardia, abnormal
respirations
Case #6
• You respond to a local food establishment
for a child (7 year old) choking
• Child was eating a piece of candy running
around the store
• Child conscious, panicked, weak audible
cough
• Perioral cyanosis, radial pulse present
• What is your immediate response?
Case Study #6
• Immediate intervention
– Abdominal thrusts
• Continue until object expelled or child passes out
• Equipment to prepare
– Intubation equipment
– Magill forceps
– Suction
– Broselow tape in case of medication dosing
Case Study #6
• Clinical findings of inadequate airway or
poor air exchange:
Weak, ineffective audible cough
Faint inspiratory stridor
Perioral cyanosis
Minimal to no air movement via nose or
mouth
No audible sounds, unable to talk
Case Study #6
Abdominal Thrusts
Case Study #6
• If failed abdominal thrust and person
collapses, begin steps of CPR
– Open airway
– Look in mouth
– If you see the object, pull it out
– No blind finger sweeps
– Have Magill forceps ready to
retrieve object
Case Study #6
• Continue normal steps of CPR if
obstructed airway
– Before attempting 2 ventilations, open airway
and look into mouth and remove object if
visualized
• CPR 1 man for child and infant
– 30 compressions to 2 ventilations
• CPR 2 man for child and infant
– 15 compressions to 2 ventilations
Case Study #6
• You are able to remove an object with the
Magill forceps
• Now what?
– Open airway
– Look, listen, feel for breathing
– If not breathing, administer 2 ventilations
– Check 5 – 10 seconds for pulse
– If no pulse, begin chest compressions
Case Study #7
• You have responded to the scene for a 6
year-old with an altered mental status
• Child is unconscious and breathing rapid
and deep
• Skin is pale
• Radial pulse present, rapid and weak
Case Study #7
• What could cause an altered mental status
in a 6 year-old?
• What else would you need to obtain for
your baseline assessment?
• What interventions are required?
Case Study #7
• Most likely causes of altered mental status
in the pediatric patient
– Alcohol (regardless of age)
– Endocrine (Diabetic), electrolytes
– Opiates/narcotics
– Trauma
– Intracranial problems, infection (meningitis)
– Poisoning, psychiatric
– Seizures
Case Study #7
• Further assessment
– VS: 88/56; P – 130; RR – 10; SpO2 – 94%
– Monitor – Sinus Tachycardia
– SAMPLE history
• Any reason for the altered mental status?
• Any recent trauma?
• Any evidence around the environment for
poisonings?
– Neurological assessment
Case Study #7
• Neurological assessment
– Level of consciousness
• AVPU
• GCS
– Pupils
• Pinpoint
– CMS
• Circulation – peripheral and distal
• Motion – if able, ask patient to wiggle fingers/toes
• Sensation – can patient feel a finger or toe being
touched or do you get a response when
extremities pinched?
Case Study #7
• Interventions
– IV-O2-monitor
• Support respirations via BVM
– 1 breath every 3-5 seconds
» 12 – 20 breaths per minute
– Check blood glucose level
• Onset of diabetes often presents with increased
thirst (polydipsia), increased urination (polyuria),
and increased hunger (polyphagia)
– Consider Narcan for potential narcotics
Case Study #7
• Narcan
– Narcotic antagonist
– Evidence of narcotic overdose
• Pinpoint pupils
• Slurred speech
• Uneven gait
• Depressed respirations
– < 20 kg – 0.1 mg/kg IVP/IO/IM
– >20 kg – 2 mg IVP/IO/IM
• Maximum calculated dose 2 mg (adult
dose)
After Action Report
• Completed individually or as a group at the
completion of all multiple patient incidents
– Provides an opportunity for critique of the
incident
• Return form to the EMS Resource Hospital
as soon as possible
• To be used as a learning tool
Name:
FD or Hosp:
REGION X
MULTIPLE PATIENT MANAGEMENT PLAN
AFTER-ACTION REPORT
Date of Incident: ________ Time of Incident: ________ Primary Fire/Rescue Agency: ___________________
Description of Incident: ______________________________________________________________________
Check One:
CLASS 1 : Total # patients: ____ (Specific # Trauma: Cat I___ Cat II___ Cat III___ Medical: Cat I___ Cat II ___ Cat III ___)
/
CLASS 2 
CLASS 3 : Total # patients: _____ (Specific #: Red _____ Yellow _____ Green _____ Deceased _____)
Please answer the following questions. Use the reverse side for additional comments (take note when faxing form).
Which hospital was first contacted by field personnel?______________________________________________
Mode of communication between field and hospital: Cell phone  Telemetry  MERCI  Other:_______
Any difficulties with initial communication? No 
Yes:__________________________________________
Was it difficult to determine the ‘Class’ of the incident? No

Yes:________________________________
Any difficulties with triage? No 
Yes:_______________________________________________________
Receiving Hospitals / # pts to each hospital: ______________________________________________________
Any difficulties with patient disbursement? No

Yes:___________________________________________

Any difficulties with ambulance to hospital communication (Class 1 only): No
Yes:_________________
Was the two-sided Multiple Patient Management Plan REFERENCE CARD used? Yes
If yes, was it helpful? Yes

No


No

Comments: _________________________________________
Was a Region X Multiple Patient Management Plan LOG FORM used? Yes

No

If yes, was it helpful? Yes  No  Comments: _________________________________________
Overall, how effective was Region X Multiple Patient Management Plan in successfully disbursing patients from the scene to
area-wide hospitals?
Very Effective 
Effective 
Ineffective 
Very Ineffective 
The success of the plan depends on your detailed comments. Please provide us with any additional information that may be
helpful:
_________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Hospital Personnel – Submit this form and Emergency Department Log form to your hospital EMS Coordinator.
Field Personnel – Fax this form and Field Provider Log Form to the Resource Hospital EMS Office.
Bibliography
• American Academy of Pediatrics. Pediatric Education for
Prehospital Professionals. 2nd edition. Jones & Bartlett.
2006.
• Bledsoe, B., Porter, R., Cherry, R. Paramedic Care
Principles and Practices. 3rd Edition. Brady. 2009.
• Dietrich, A., Shaner, S., Ohio Chapter ACEP. Pediatric
Trauma Life Support. 3rd Edition. ITLS. 2009.
• Rahm, S. Pediatric Case Studies for the Paramedic.
AAOS. 2006.
• Region X SOP’s, March 2007, Amended version
implemented May 1, 2008.