Transcript Pediatric Critical Medical Situations

Pediatric Medical Emergencies
Condell Medical Center
EMS System
August, 2007 CE
Site Code#10-7200E1207
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Objectives
Upon successful completion of this module,
the EMS provider should be able to:
• identify critical situations in the pediatric
population
• identify and appropriately state
interventions for a variety of EKG rhythms
• actively participate in a pediatric code
situation
• successfully complete the quiz with a score
of 80% or better
Children are
not small
adults!
Relationship of Head to Body
Changes
Pediatric Population Defined
• A patient under the age of 16 is considered
to be a pediatric patient
• This means the patient is 15 years of age or
less
• When medications are calculated based on
the pediatric patient weight, the dose is to
never exceed the amount that would be
administered to an adult!
Children and EMS
Adults may be glad to see EMS arrive
but
children are often frightened when EMS
comes to their rescue
Critical Determination
• Rapid assessment needs to be performed to
determine:
– Is this child sick or not?
– Any sick child needs immediate attention
and intervention
Pediatric Assessment Triangle
(PAT)
• Helps establish a general impression
• Used to:
establish a level of severity
determine urgency for life support
identify key physiological problems
• Provider to assess:
appearance
work of breathing
circulation to skin
Pediatric Assessment Triangle
(PAT)
Pediatric Assessment Triangle
(PAT)
•
•
•
•
Does not require any equipment to complete
Uses observational and listening skills
Can be completed in under 60 seconds
To be used as you “cross the room” to make
contact with the patient
Pediatric Assessment Triangle
(PAT)
• Evaluates underlying cardiopulmonary,
neurological, and metabolic states
• Can help identify the general physiological
problem for the child
• PAT does not replace vital signs and the
ABCDE’s but precedes & compliments them
Pediatric Assessment
• Scene size-up
• General assessment - pediatric assessment
triangle (PAT)
• Initial assessment
– ABCDE’s and transport decision
• Additional assessment
– focused history and physical exam; detailed
physical exam if trauma
• Ongoing assessment
Pediatric Assessment Triangle
Appearance
Reflects adequacy of:
oxygenation
ventilation
brain perfusion
homeostasis
CNS function
Assessing Appearance
Evaluate:
muscle tone
mental status/interactivity level
consolability
look or gaze
speech or cry
Pediatric Assessment Triangle
Breathing
Reflects:
adequacy of oxygen
oxygenation
ventilation
Assessing Breathing
Evaluate:
body position
visible movement of chest or abdomen
 <6-7 years old is primarily a
diaphragmatic breather (belly breather)
respiratory rate & effort
audible airway sounds
Pediatric Assessment Triangle
Circulation
Reflects:
adequacy of cardiac output and
perfusion of vital organs (core perfusion)
Assessing Circulation
Evaluate:
skin color
peripheral cyanosis refers to the extremities
central cyanosis is always pathological; evaluated
in the central part of the body: mucous
membranes of the mouth and trunk area
– reflects decreased oxygen in arterial blood
• Trunk mottling indicates hypoxemia
• Cyanosis indicates respiratory failure and
vasoconstriction
Principles of Infant Assessment
• Ask caregiver for patient’s name & use it
• To decrease the infant’s stress, perform
assessment in the following order:
observation
auscultation
palpation
• Approach infant slowly, calmly, and talk in
quiet voices; warm your hands before contact
• Try to be at patient’s eye level
Infant Assessment
• Observe interaction between caregiver and
infant
• Consider offering a toy as a distraction
• Perform assessment based on acuity level
if quiet & calm, obtain respiratory rate and breath
sounds
if critical, obtain most important information 1st
• Make non-threatening contact 1st
make 1st contact with extremity & can also obtain
capillary refill simultaneously
Principles of Toddler Assessment
• Beginning to assert independence but fearful of
separation from caregiver
• Approach slowly; keep contact to a minimum
• Be at eye level
• If possible, allow toddler to stay on caregiver’s
lap
• Introduce equipment slowly and use distraction
(ie: penlight, toy)
• A toddler is the center of his universe - ask
questions about them (ie: pets, clothing, events)
Toddler Assessment
• Keep choices limited (ie: “should I use the
red or blue package”)
• Ask open ended questions; avoid yes/no
questions
• Praise toddler to get cooperation
• Use simple, concrete terms
• Perform most critical part of assessment 1st
moving in toe-to-head order
• Ask caregiver to assist (ie: removing
clothing, holding stethoscope)
• Toddlers do not sit still
Principles of Preschooler
Assessment
• Magical and illogical thinkers; fear loss of
control; short attention spans
• Use simple terms; explain procedures
immediately before performing
• Allow child to handle equipment
• It’s okay to set limits (ie: “you can cry but you
cannot kick”)
• Focus on one thing at a time
Principles of School-aged
Assessment
• Fear separation from caregiver; loss of
control, pain, & physical disability
• Speak directly to child, then to caregiver
• Respect privacy, these children are modest
• Don’t offer too much information; do use
terms the child can understand; explain
immediately before the procedure is done
School-Aged Assessment
• Don’t negotiate unless there really is a
choice (ie: IV in right or left hand, not if it
is okay to start the IV)
• Offer praise for cooperation
• Physical assessment okay to be performed
in head-to-toe format
Principles of Adolescent
Assessment
• Time for experimentation and risk-taking
behaviors
• Struggle with independence, loss of control,
body image, sexuality, and peer pressure
• Relying more on friends than family
• When ill or injured, often revert back to
lower maturity level
• Explain what you are going to do and why
Adolescent Assessment
• Encourage questions and involvement of the
adolescent
• Show respect; speak directly to teen
• Respect privacy and confidentiality
• Be honest and nonjudgmental
Pediatric Assessment - Appearance
• Provides most important look into the status of
the child - are they sick or not?
• Start observation as you 1st enter the scene and
while the child is still with the caregiver
– immediate hands-on may increase agitation,
crying and may interfere with a true picture
– immediate hands-on is necessary if the child
is unconscious or obviously critically ill
Normal/Abnormal Appearance
• Normal appearance
– good eye contact, has good muscle tone, and
good color
• Abnormal appearance
– poor eye contact, listless, and pale
Appearance doesn’t indicate the cause of
illness or injury but reflects that a problem
is going on
Normal Appearance In Setting Of
a Critical Situation
Maintain index of suspicion in children that look
okay initially but may soon become critically ill:
toxicological problems (overdoses)
blunt trauma
• powerful compensation abilities may fool
the examiner
• when the child “crashes” they will crash
quickly with rapid progression to
decompensated shock
Work of Breathing
• In the pediatric patient, evaluation of work of
breathing gives great insight into the pediatric
patient’s oxygenation & ventilation status’
• Listen for abnormal airway sounds
• snoring, muffled or hoarse speech, stridor, grunting,
wheezing
– Look for signs of increased breathing effort
• sniffing position, tripoding, refusing to lie down
• retractions (neck, intercostal, substernal muscles)
• nasal flaring
Tripod
Positioning
leaning
forward,
hands resting
on thighs
Costal
retractions &
use of
accessory
neck muscles
Abnormal Breath Sounds
Upper airway obstruction
– snoring, muffled, hoarse speech, stridor
• stridor - high-pitched inspiratory sound;
abnormal airflow across partially obstructed
upper airway
• Potential causes
–
–
–
–
–
croup
foreign body
aspiration
bacterial upper airway infection
bleeding, edema
Abnormal Breath Sounds
Grunting
–
–
–
–
–
exhaling against a partially closed glottis
keeps alveoli open for maximum gas exchange
sound heard best at end of exhalation
often present with moderate to severe hypoxia
reflects poor gas exchange due to fluid in lower
airways
• Potential causes
– pneumonia
– pulmonary contusion
– pulmonary edema
Abnormal Breath Sounds
Wheezing
–
–
–
–
continuous high-pitched musical sound; a whistle
movement of air across partially blocked small airways
in disease process heard earliest during exhalation
as obstruction increases, heard during inhalation and
exhalation
– with increased obstruction heard audibly
• Most common cause - asthma
• Other potential causes
– bronchiolitis
– lower airway foreign body aspiration
Abnormal Visual Signs Increased Work of Breathing
Providers must evaluate visually to determine
evidence of increased work of breathing
– this means all patients need to be eventually
undressed for observation of the neck & chestwall
• Sniffing position - severe upper airway
obstruction; used as attempt to increase airflow
• Tripoding - refuses to lie down, leans forward
on outstretched arms; attempting to use
accessory muscles to breath
• Retractions - use of accessory muscles
to help breath; using extra muscle
power to move air into lungs; more
prominent in child than adult;
– includes head bobbing - use of neck
muscles during severe hypoxia
– includes nasal flaring - exaggerated
nostril opening during inspiration;
moderate to severe hypoxia
Respiratory Distress
Evaluating Respirations
• Respiratory rate
– Best to count for a minimum of 30 seconds due
to the natural irregularity of the pattern
• Breath sounds
– Place the stethoscope as lateral as possible
• Pulse oximetry
– Evaluate results along with work of breathing
– Readings above 94% indicates probably good
oxygenation
Normal Respiratory Rates By Age
•
•
•
•
•
Infant
Toddler
Preschooler
School-aged child
Adolescent
30-60 breaths/minute*
20-30 breaths/minute*
20-30 breaths/minute*
20-30 breaths/minute*
15-20 breaths/minute*
Trending more helpful than a single reading
*Values differ by source
Abnormal Visual Signs Poor Circulation to the Skin
• Cold environment may cause false skin
signs
• Inspect skin and mucous membranes
• Look at face, chest, abdomen,
extremities, and lips
• Dark complexion patients
– assess lips and mucous membranes
• Circulation to skin reflects overall
status of core circulation
– pallor - early sign; compensated
shock
– mottling - constriction of blood
vessels to the skin
– cyanosis - late finding of respiratory
failure or shock; critical finding that
indicates immediate resuscitative
action
Evaluating Circulation
• Heart rate - bradycardia is ominous sign
• Pulse quality
– Brachial is the peripheral site for a child under one
– Central pulse - femoral in infants and young children;
carotid in older child or adolescent
• Skin temperature and capillary refill
– Good locations are at the kneecap or the forearm
• Blood pressure
– Should make an attempt on children older than 3
– Cuff size should cover 2/3 the length of the upper arm
Normal Heart Rates by Age
•
•
•
•
•
Infant
100-160 beats per minute
Toddler
90-130 beats per minute
Preschooler
80-120 beats per minute
School-aged child 70-120 beats per minute
Adolescent
70-120 beats per minute
Bradycardia indicates critical hypoxia and/or
ischemia and indicates need for immediate
interventions
Region X
Pediatric SOP’s
Region X Routine Pediatric Care
SOP’s
• General patient assessment - pediatric
assessment triangle (PAT)
appearance
work of breathing
circulation to skin
• Initial assessment - ABCDE’s
• Identify priority patient and make transport
decision
• Additional assessment and interventions
–
–
–
–
–
vital signs
determine weight and age
pulse oximeter before & during O2
cardiac rhythm if applicable
IV/IO access (20 ml/kg administered under 20
minutes if fluid challenge is necessary)
– determine blood glucose if indicated
• altered level of consciousness
• unconscious, unknown reason
• known diabetic and related problem
– reassess previous assessments &
appropriateness of interventions performed
• Detailed physical exam
• Contact Medical Control
• Transport to closest most appropriate
hospital
Always remember to keep child
warm; hypothermia increases
the rate of complications and
negative outcome
Altered Level of Consciousness
• Dextrose
– Sugar to replace depleted stores
– Brain extremely sensitive to a drop in glucose
levels
– Dose if less than 1 year old
• 12.5% 4 ml/kg
– Dose for ages 1 - 15 (>1 - <16)
• 25% 2 ml/kg
– Dose for ages 16 and over
• 50%
Glucose Dosing
• To remember dosing schedule:
– D 12.5%
• 4 x 12.5 = 50 therefore D 12.5% is 4 ml/kg
– D 25%
• 2 x 25 = 50 therefore D 25% is 2 ml/kg
• Diluting D 25% to make D 12.5%
– Calculate total dose volume required
– Half the dose volume is D 25%; half the dose
volume is normal saline
– Mix 50/50 solution and administer slowly
Case Study
• A 12 year-old boy calls 911 for his
unconscious 4 year-old sister
• The brother reports a few minutes of full
body shaking by the sister; you are informed
that the patient was recently diagnosed as a
diabetic and she takes “shots”
• The patient is unresponsive, limp,
pulse rate 140; RR 30; B/P 98/68
• What is your impression?
• What is your approach/intervention?
Case Study
• This child is most likely hypoglycemic
• Sugar stores are quickly used and the brain is
the most sensitive organ to  glucose levels
• Protect the airway (positioning, have suction
available)
• Obtain IV access and evaluate the glucose level
(this patient’s blood sugar is 40)
• This patient needs dextrose (glucagon if no IV)
– >1 years old = D25% (2 ml/kg)
– Patient weighs 25 pounds
Practice Math - How much
Dextrose does this patient receive?
• 25 pounds  2.2 kg = ? kg
2.2 25 (move decimal to right in both
numbers)
22 250 = 11 kg
• D 25% formula: 2 ml/kg
· 2(ml) x 11(kg) = 22 ml D25%
• Administer slowly through largest vein
available (irritating to veins)
Altered Level of Consciousness
• Glucagon
–
–
–
–
In the absence of IV access
0.1 mg/kg (max dose 1 mg (1 unit))
Must be reconstituted
May be followed by Dextrose if IV access
obtained & no improvement in LOC
• Narcan
– Known or suspected acute narcotic overdose
– < 20kg = 0.1 mg/kg IVP/IO/IM (max dose 2mg)
– >20 kg (approx 4 year-old) = 2 mg IVP/IO/IM
Protecting The Airway
• Positioning
– side lying
– securely strapped to the backboard with sufficient
head/spine immobilization in case of need to rapidly
turn the backboard onto its side
• Suctioning
– anticipate the need, unit turned on and ready to be
used
– minimize time suction applied while removing
catheter
• adults 10-15 seconds; children < 5 seconds
• Anticipate supplemental O2 - poss via BVM
Pediatric Acute Asthma
• Albuterol
– Bronchodilator with some cardiac side effects (HR &
 strength of contractions (“pounding heart”))
– 2.5 mg / 3ml in nebulizer
– May need to use nebulizer mask in place of mouthpiece
– Encourage deep & slow breaths
– May need to administer Albuterol in-line
• Set up nebulizer equipment and start administering
while bagging the patient even prior to intubation
– getting some drug into the lungs may prove
helpful
Nebulizer Mask - when the patient
can’t tolerate the mouthpiece
Acute Asthma
• Earliest in disease will auscultate bilateral
wheezing breath sounds heard first on exhalation
• Eventually will hear audible wheezing standing
next to the patient
• A silent chest (no breath sounds can be heard with
a stethoscope) is a critical (deadly) situation in any
patient
• Patients in an acute asthma attack are dry (lose
moisture from the increased respiratory rate) and
are potentially hypoxic
Patient Treatment
• Prior to any treatment, assessment must be
done
• EMS needs to obtain a general impression
– this drives the decision regarding which
SOP to work from
• EMS needs to think “cause” of the situation
which can also drive a decision on which
SOP to use
Possible Causes of Critical Cardiac
Situations - 6 H’s & 5 T’s
Hypovolemia
Hypoxia
Hydrogen ion acidosis
Hyper/hypokalemia
Hypothermia
Hypoglycemia
Tablets
Tamponade, cardiac
Tension pneumothorax
Thrombosis, coronary
(ACS)
Thrombosis, pulmonary
(embolism)
Trauma
Pediatric Ventricular Fibrillation
• 2 minutes of CPR if arrest unwitnessed or >4-5 min
• Single defibrillation attempts for all persons
– Initial pediatric defibrillation - 2 j/kg
– 2nd & subsequent defibrillation attempts - 4 j/k
• Immediately after defibrillation attempts, CPR
resumed for all persons
– 30:2 for single rescuer on all patients
– 15:2 for 2 person with child & infant CPR
• IV access
– Peripheral or IO routes attempted
– Flush all drugs with 5 ml NS to enhance delivery
Pediatric VF
Meds
• Vasopressor – Epinephrine (primary action in arrest is to
constrict blood vessels to support perfusion)
– 1:10,000 - 0.01 mg/kg IVP/IO
– repeated every 3-5 minutes for duration of arrest
• Antidysrhythmic
– Amiodarone 5 mg/kg IVP/IO; 5 ml NS flush
OR
– Lidocaine 1 mg/kg IVP/IO; 5 ml NS flush
Antidysrhythmic Medications
• Do not mix administration of Amiodarone
and Lidocaine
– The heart becomes more irritable when these
drugs are administered simultaneously to
patients during the same acute process
• IV drips
– Only establish a drip for the same drug
administered IVP
• Lidocaine drip follows Lidocaine bolus
• Amiodarone drip follows Amiodarone bolus
(usually hung at the hospital)
Pediatric Asystole, PEA, Pulseless
Idioventricular Rhythms
• CPR - push hard, push fast
• IV/IO fluid challenge
– 20ml/kg formula for all persons/all ages
– reassess as every 200 ml has been administered to
the patient moving towards a total infusion amount
– monitor breath sounds on all patients receiving fluids
• Vasopressor drug
– Epinephrine 1:10,000
– 0.01 mg/kg IVP/IO; followed by 5 ml NS flush
– Repeat every 3-5 minutes
What Is This Rhythm?
• Sinus Bradycardia
• What is the significance in the pediatric population?
Pediatric Bradycardia
• In pediatric patients, bradycardia almost
always represents hypoxia
• Evaluate airway, airway, airway
• Ventilate, ventilate, ventilate (BVM)
• Vasopressor drug
– Epinephrine 1:10,000 0.01 mg/kg IVP/IO
– Repeat every 3-5 minutes
• Atropine - only helpful in pediatrics if the
bradycardia is related to a vagal cause
(more common in the adult)
What Is The Significance of This
Rhythm In a Newborn?
• This patient was born 5 days ago; this rate is too slow
• A normal heart rate range in newborns should be 100-160
• This patient is ill & needs immediate ventilation & support
Practice Math - Epinephrine
• Your patient weighs 26 kg
• Epinephrine 1:10,000 dose is 0.01 mg/kg
• 0.01 (mg) x 26 (kg) = ? mg
0.01
x 26
6
2
0 .26 (mg)
Formula #1 - To Determine ml Of
Epinephrine To Give
mg on hand =
ml on hand
1 mg =
10 ml
(cross multiply) 1 x X =
1X =
(get X by itself) 1X1 =
X
desired mg
X ml
0.26mg
X ml
0.26 x 10
2.6
2.6  1 (1 2.6 )
= 2.6 ml
Formula #2 - To Determine ml of
Epinephrine To Give
Xml= desired dose x vol on hand
dose on hand
X ml = 0.26 (mg) x 10 (ml)
1 (mg)
X ml = 0.26 x 10
1
X ml = 2.6 (1 2.6 )
1
X ml = 2.6 ml IVP flushed with 5 ml NS
Pediatric Shock
• Hypovolemic
– Hemorrhage, diarrhea, vomiting,  fluid intake
– Fluid challenge 20 ml/kg; repeated twice more (60ml/kg)
• Reassess as every 200 ml is being administered
• Cardiogenic
– Usually congenital; no fluid challenge to be given!
• Distributive
– Sepsis (massive infection), anaphylaxis
– Fluid challenge 20 ml/kg; repeated twice more
• Reassess as every 200 ml is being administered
– If allergic response, add that protocol
Case Study
• You have been called to the home for a
6-month-old vomiting for 24 hours.
• The infant is lying still with poor muscle
tone; irritable if touched; weak cry.
• No abnormal airway sounds, retractions, or
nasal flaring.
• Skin is cool, pale, mottled, with 4 second
capillary refill time, weak brachial pulse.
• Heart rate 180; RR 30; breath sounds clear.
• Abdomen is distended.
• Impression? Intervention needed?
Case Study
• This infant is severely ill - in shock
– Poor appearance, diminished tone, poor
interactiveness, weak cry
– Requires resuscitation & rapid transport
• Vital signs are deceptive
– Need to be correlated with pediatric assessment
triangle & full assessment
• Immediate airway support (possible BVM
support)
• IV/IO access - fluid challenge 20 ml/kg
Do The Math - How Much Fluid?
• The patient weighs 15.5 pounds.
• What is the amount of the fluid challenge that
needs to be administered?
• How is the fluid challenge to be administered?
• 15.5  2.2  2.2 15.5 (move decimal point
over to the right one space in each number)
• 22 155 = 7 kg
• 7 kg x 20 ml = 140 ml fluid challenge NS
• Administer in under 20 minutes; reevaluate
Pediatric Tachycardia
• Children compensate by increasing heart
rate more than increasing contractility
• Sustained high respiratory rates and heart
rates indicate a vascular problem
• Low respiratory rate, heart rate, and blood
pressure indicate a serious problem with
oxygenation, ventilation, and/or perfusion
• Trends in vital signs more important than
taking one reading
Probable Sinus Tachycardia
• Most common tachycardia in pediatrics
• Rates can be higher than expected
compared to the adult population
– Infants usually < 220 beats per minute
– Child usually <180 beats per minute
• Most common approach is symptomatic
treatment
Pediatric Tachycardia
• May be a nonspecific sign not representing
anything serious:
• fear
• anxiety
• pain
• fever
• May be indicating a life-threatening
problem such as hypoxia or hypovolemia
– Evaluate heart rate and QRS width
What Is This Rhythm?
• Probably sinus tachycardia in a pediatric patient
• Appearance is altered from typical adult rhythm pattern
• Treatment is geared to determining the underlying reason
Probable Supraventricular
Tachycardia
• QRS narrow
• Rate can be higher than expected
– Infants usually 220 beats per minute
– Child usually 180 beats per minute
• Vagal maneuvers
– Have child hold their breath or have child blow hard
through a straw
• Adenosine 0.1 mg/kg rapid IVP with flush
• Repeat Adenosine 0.2 mg/kg rapid IVP with flush
What is this rhythm?
9 wk old
infant
presents
listless,
sweaty,
short of
breath
Probably
SVT
Pediatric Ventricular Tachycardia
with Poor Perfusion
• Severe systemic insult that must be reversed as
soon as possible
• Electrical countershock - cardioversion
– Pre-medicate Versed 0.1 mg/kg IVP slowly
over 2 minutes, titrate to sedation
– Cardiovert 1 j/kg observing safety
precautions (look & call “all clear”)
– If repeat cardioversion required, 2 j/kg
observing safety precautions
Pediatric Ventricular Tachycardia
with Adequate Perfusion
• You have time to attempt drug therapy
– Amiodarone 5 mg/kg IVPB
– Dose diluted in 100 ml D5W
– Pediatric drip rate at 30 mcgtt/10 seconds
OR
– Lidocaine 1 mg/kg IVP
• Cardioversion after versed sedation if no
response to drug therapy
Do The Math - Amiodarone
• Your 4 year-old patient weighs 40 pounds and
will need Amiodarone 5 mg/kg
• Amiodarone in the arrested state is to be given
as a diluted rapid IVP bolus; (stable patients
receive the drug slow IVPB)
• Calculate pounds to kilograms:
40 (pounds)  2.2 (kg) = ? Kg
2.2 40 = (move the decimal to the right and
need to move decimal space behind “40”)
22 400 = 18 kg
• Calculate dosage of drug to administer:
18 (kg) x 5 (mg/kg) = 90 mg (of
Amiodarone)
• Calculate volume of medication to administer:
• Amiodarone packaged 50 mg/ml; need to
administer 90 mg
• Formula #1: mg on hand = desired mg
ml on hand
X ml
• Formula #2: Xml=desired dose x vol on hand
dose on hand
Formula #1 - Desired Dose 90 mg
mg on hand = desired mg
ml on hand
X ml
(cross multiply)
(get X by itself)
50mg
1 ml
50 x X
50X
50X50
X
=
90mg
X ml
= 90 x 1
= 90
= 90  50 (50 90)
= 1.8 ml
Formula #2 Desired Dose 90 mg
Xml= desired dose x vol on hand
dose on hand
X ml = 90 (mg) x 1 (ml)
50 (mg)
X ml = 90 x 1
50
X ml = 90 (50 90 )
50
X ml = 1.8 ml
Administering Amiodarone IVPB
• Add dose to 100 ml bag D5W (90 mg (1.8ml))
• Gently mix the contents; label the bag
• Spike the bag with minidrip tubing & run thru
the tubing
• Wipe off the port with alcohol and attach
piggyback line into main IV line
• Infuse the drip
– over 20 minutes for pediatric patient
(<16 years)
– run the piggyback at 30 minidrips/10 seconds
Pediatric Croup
• Viral; infant/toddler population; low grade fever;
barking cough
– Humidified O2
• 6 ml NS in nebulizer, place mask near child’s face
– If wheezing, Albuterol 2.5 mg (may repeat once)
– If no improvement, Epinephrine 1:1000 1ml mixed
with 2 ml NS in nebulizer (may repeat once)
– If unstable (cyanotic, respiratory distress), begin
BVM ventilations, be prepared to intubate
Pediatric Epiglottits
• Bacterial; usually 4 year-old and upward in age
(no upper age limit); high fever; drooling; stridor
– Humidified O2
• 6 ml NS in nebulizer, place mask near child’s face
– If patient deteriorates, ventilation via BVM; be
prepared to intubate (one attempt)
True emergency requiring gentle handling,
avoidance of agitating the patient, and rapid
transport
Case Study
• You are called to the scene of a 23-month-old
child for trouble breathing.
• Upon arrival the child is sitting on the mother’s
lap & starts to cry when they see you.
• He has audible wheezing & you observe
intercostal retractions. Skin is pink.
• Mother states runny nose for 2 days.
• The child starts hitting you when you approach.
• What is your impression?
• What is your approach?
Case Study
• A normal toddler is afraid of strangers
(hitting and kicking is not unusual).
• A quiet & cooperative toddler is of more
concern!
• Impression: croup
• Approach: get on the child’s eye level
– Ask the parent to remove the shirt to observe
breathing
– Start physical contact at the toes & progress up
– Praise cooperative behavior
– Have caregiver hold nebulizer kit for the patient
Pediatric Seizures
• Remember to check glucose levels
– check on all altered/abnormal level of
consciousness patients & known diabetics with
diabetic related problem
• To treat current seizure activity
– Valium 0.2 mg/kg IVP titrated to control seizure
activity
• In absence of IV, administer Valium 0.5 mg/kg
rectally
• Valium/Diazepam will only stop the current
seizure activity; does not prevent future ones
Rectal Administration of Medication
• Rectum highly vascular
• Medication absorption fairly quick thru lining
or mucosa of rectum (IVP is quicker)
• Calculate Valium dosage
• Draw up dosage into TB or 3-5 ml syringe
• If syringe larger than TB, attach the plastic
catheter from an IV catheter (14-20 G) to tip
• Lubricate tip of syringe or catheter
• Carefully introduce 2 into rectum; inject
• Hold buttocks closed for 10 seconds
Draw up dosage
Gently administer
dosage;
aspiration is not
necessary
Rectal
Medication
Allergic Reactions
• There is exposure to an antigen and the
response is to form antibodies
• Immune response activated
• Antihistamines (ie: Benadryl) given to stop
histamines from their normal action/response
–
–
–
–
–
conjunctivitis - inflammation of the eye
rhinitis - inflammation of nasal mucous membranes
angioedema - localized edema in tissues
urticaria - itchy skin rash
contact dermatitis - inflammation of skin
• Vasopressors (Epinephrine) given in the
presence of airway swelling, difficulty
breathing, or clinical signs of shock
– Reverses bronchoconstriction to improve
the respiratory status
– Supports a falling blood pressure
– In shock, IM a more predictable
absorption than SQ route
Pediatric Allergic Reaction
Stable
• Patient alert, skin warm & dry
• Irritating signs and symptoms
– hives, itching, rash
– GI distress
• Benadryl
– 1 mg/kg slow (over 2 minutes) IVP or IM
– maximum 25 mg (equivalent to adult
dose)
Practice Math
• Your pediatric patient presents with an allergic
reaction with hives, no airway involvement.
• They weigh 75 pounds (34 kg)
• How much Benadryl do they get?
Formula: 1mg/kg; patient weighs 34 kg
Calculation: 34kg x 1mg = 34 mg (of Benadryl)
Note: Do not give a pediatric patient a higher
dosage than what the adult would receive
Administration: 25 mg Benadryl slow IV or IM
Pediatric Allergic Reaction Stable
with Airway Involvement
• Patient alert; skin warm & dry
• Has external signs & symptoms now with itchy
or scratchy throat, hoarseness, wheezing
• Epinephrine 1:1000 SQ
– 0.01 mg/kg (maximum 0.3 ml/dose)
– May repeat every 15 minutes
• Benadryl
– 1 mg/kg IVP slow(over 2 minutes) IVP (max 50 mg)
• Albuterol 2.5 mg nebulizer (may repeat)
Pediatric Allergic Reaction
Anaphylactic Shock
• Patient with altered mental status
– THEY ARE IN SHOCK!!!
• Epinephrine 1:1000 IM 0.01 mg/kg (max
0.3 ml/dose); may repeat every 15 minutes
• Benadryl 1 mg/kg IVP slowly over 2
minutes (max 50 mg)
• IV fluid challenge 20 ml/kg (max 60 ml/kg)
• Albuterol 2.5 mg nebulizer
Self-Administered Epi-pens
• Packaging
– Epi-pen (adult) - 0.3mg/0.3ml
– Epi-pen Jr (pediatrics) 0.15 mg/0.3ml
• Expiration dates need to be evaluated
Epi-Pens
• EMT-Basic
– Epi-pens are taught as a patient assist device
– The epi-pen must belong to the patient
– The EMT-B may assist the patient in
administering their own epi-pen
• Paramedic
– If medication is required, the paramedic will
use their own supply of medications
– If the patient has injected their own epi-pen,
you might need to contact Medical Control to
determine if your Epinephrine should be held
• To use an Epi-pen
– Form fist around unit
– Remove black tip - keep fingers away from
opening
– Pull off gray safety release
– Jab black tip firmly into outer thigh 900 angle
(perpendicular)
– Hold firmly for 10 seconds then remove
– Massage site for 10 seconds
– Dispose of unit
• Patients may have been instructed to replace unit
into carrier and return to prescribing MD for new
prescription
Can go
through
clothing
Broselow Tape
• Patient length used as a valid marker of size
specific equipment and medication dosing
• Measure the child’s length from the top of
head to the heel (not the toe)
Measure
top of head
to the heel
Broselow Tape
• Colored sections display a range of weights
• Medications, defibrillation and cardioversion
joules listed on one side
• Medications, fluid challenge amounts, and
equipment sizing listed on the reverse side
• Medications are printed in mg and need to be
calculated into ml to determine quantity of
medication to deliver
• Region X SOP’s match the Broselow tape
calculations
Calculating Medication Dosage
• 2 page reference printed in the SOP’s
– one page for medical medications
– one page for cardiac medications
• Document dosage in mg (obtain from
Broselow or SOP reference)
• Need ml to know what quantity of
medication to put into the syringe
Patient Deterioration
• Always be assessing for changes in patient
status
• Key information that points to a patient
change
– watch for rapid decrease in appearance
especially interactiveness
– watch heart rate especially if the rate
begins to drop
– watch for irregularity of the respiratory
pattern
Bibliography
• American Academy of Pediatrics. Pediatric
Education for Prehospital Professioinals.
Jones & Bartlett. 2000.
• Bledsoe, B., Porter, R., Cherry, R.
Paramedic Care Principles & Practices 2nd
Edition. Brady. 2006.
• Region X SOP’s, March 1, 2007.
• Sanders, M. Paramedic Textbook, Second
Edition. Mosby. 2007