Transcript Module III - The Pediatric Patient

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
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)
– Calculate medication dosages given the
patient’s weight
– Calculate the GCS given the pt’s 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
Pediatric Assessment
Triangle - PAT
• Establishes a level of severity
• Assists in determining urgency
for life support
• Identifies key physiological
problems using observational &
listening skills
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
PAT - Appearance
• Reflects adequacy of:
Oxygenation
Ventilation
Brain perfusion
Homeostasis
CNS function
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
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)
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
PAT - Circulation
• Reflects:
Adequacy of cardiac output
and perfusion of vital
organs (core perfusion)
Assessing Circulation
• Evaluate skin color:
Cyanosis reflects decreased
oxygen levels in arterial blood
Cyanosis indicates
vasoconstriction and respiratory
failure
Trunk mottling indicates
hypoxemia
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
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
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
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
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
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
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
Putting It All Together Mechanism of Injury
• Fall from height greater than 3 times
the toddler’s 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)
General Impression For This
2 year-old
• Category I trauma patient with head
& orthopedic injuries
• EMS Region X SOP’s 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
What’s 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
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
Respiratory Distress
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•
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•
•
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•
•
•
Stridor
Grunting
Gurgling
Audible wheezing
Tachypnea (increased respiratory rate)
Mild tachycardia
Head bobbing
Abdominal breathing (normal < 6-7 years-old)
Nasal flaring
Central cyanosis resolved with O2
Stridor
• Harsh, high-pitched sound
heard on inspiration
associated with upper airway
obstruction
• Sounds like high-pitched
crowing or “seal-bark” sound
on inspiration
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
Nasal Flaring
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
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
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
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
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)
EZ IO Landmarks
 Proximal medial tibia
• <39 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
Tibial
tuberosity
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
EMS Altered Level of
Consciousness SOP
• If blood glucose level is <60
– < 1 year old – Dextrose 12.5% 4 ml/kg
– > 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)
• 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
<20 kg = 0.1 mg/kg
IVP/IO/IM
>20 kg = 2 mg IVP/IO/IM
• Max total dose is 2 mg
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
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
other’s purses and have access to
the medicine cabinet & other
areas where drugs can be found
Calculation Practice
• Your 8 month-old patient weighs
17 pounds
• Which strength Dextrose should
this patient receive by EMS and
how much?
8 month-old
• < 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?
Drawing Up 12.5%
Dextrose From D25%
• Use 25% and dilute 1:1 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
Narcan Calculation
• Your patient weighs 19 pounds
• <20 kg the patient is to get
0.1 mg/kg
• How much Narcan would be
administered? Never give
more than the adult dose!
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
ml’s 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
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 ml’s to draw up into syringe
• Back of SOP’s has medical and cardiac
pediatric reference tables
– Includes mg and ml of medications
GCS For Pediatric
Patient
• Same tool used for the adult
population with minor changes to
accommodate the young nonverbal infant
• Most accommodations made in
the verbal section
• Makes sense if this is for the
non-verbal patient
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
GCS – Peds Verbal
Response
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•
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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
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
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
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
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
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
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
What Are the Risk Factors
That Expose Kids To
Seizures?
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•
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Fever – most common
Hypoxia
Infections
Electrolyte imbalance
Head trauma
Hypoglycemia
Toxic ingestions
Tumor
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
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
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!
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 ml’s to pull up
•
into the syringe?
Medication Resources
• Back of SOP’s (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
Possible Causes of
Critical Rhythms
• 6 H’s
– Hypovolemia – fluid challenge
– Hypoxia – supplemental O2
– Acidosis – ventilate to blow off CO2
– Hyper/hypokalema
– Hypothermia – warm core
– Hypoglycemia – check glucose level
• 5 T’s
– Tablets – drug overdose
– Tamponade – supportive care in
field
– Tension pneumothorax – needle
decompression
– Thrombosis, coronary or pulmonary
– Trauma
Peds VF or Pulseless VT
• After 2 minutes of CPR if unwitnessed,
defibrillate 2j/kg or equivalent biphasic
– AED can be used if >1 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
VF/VT Peds Region X SOP
Meds given during CPR:
• Epinephrine 1:10,000 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
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
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 1:10,000 0.01 mg /kg IVP/IO
– Repeat every 3-5 minutes
–
NO Atropine in SOP for peds!!!
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
Peds Symptomatic Brady
• Severe cardiorespiratory compromise
 Poor perfusion
 Bradycardia
 Weak, thready, absent pulse
 Hypotension
 Pallor
 Cyanosis
 Respiratory difficulty
Peds Brady EMS Region
X SOP
• Heart rate <60 & poor systemic perfusion
– perform CPR
• IV/IO access
• Epinephrine 1:10,000 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
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
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
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
Signs & Symptoms SVT
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•
•
•
•
•
Irritability
Poor feeding
JVD
Hepatomegaly – enlarged liver
Hypotension
Children can often tolerate the
rapid rate fairly well
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)
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
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
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
Allergic Reactions – Is
Response Life Saving or
A Killer?
• The body’s 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
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
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)
Why Epinephrine 1:1000 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)!
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
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
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)
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
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
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
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)
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
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)
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)
Scenarios
• Read the following case studies
• Determine your general impression
based on the pediatric assessment
triangle (PAT)
• Determine interventions appropriate
to the situation
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?
Case Study #1
• AED’s 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 30:2; 2 person is 15:2; once
intubated ventilations are delivered
once every 6-8 seconds
Case Study #1
• Attach a monitor as soon as possible
• Stop CPR (witnessed arrest) as soon
as monitor applied & ready
• What’s the rhythm & treatment?
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 <15)
– Repeat defibrillations at 4j/kg
– Epinephrine 1:10,000 0.01 mg/kg IV/IO
• Repeat every 3-5 minutes
•Choose one antidysrhythmic (Amiodarone
or Lidocaine; one dose)
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?
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
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
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 mother’s lap, anxious,
watches you and cries weakly when you
approach
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
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?
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
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!
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 child’s face
•
Helpful for croup & epiglottitis
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 patient’s
face if child too small to place lips
around mouthpiece or direct
mist near child’s face
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 caregiver’s lap
•Child is sleepy, no eye contact
or response to the exam
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
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?
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)
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 (won’t be able to
put mouth around mouthpiece)
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 < 1 & child < 8
– 1 breath every 3-5 seconds (12 –
20 breaths per minute)
– Give each breath over 1 second
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
Case Study #5
• What is your general
assessment?
• What is the GCS?
• What other assessments need to
be done?
• What interventions are needed?
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
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?
Case Study #5
• Check the back of the SOP’s
• 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
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:
–
–
What’s the rhythm?
What do you do?
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?
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 1:10,000 0.01 mg/kg IV/IO
– Repeated every 3-5 minutes
– Persistent , Medical
Control would need to order Atropine
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 SOP’s. Amended 1/08.
• www.peds.umn.edu/.../teaching/lung/
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