Transcript Encountering the Pediatric Patient

Encountering The Pediatric
Patient
Condell Medical Center
EMS System
September 2008 CE
Site Code #10-7200E1208
Prepared by: Sharon Hopkins, RN,BSN, EMT-P
Objectives
• Upon successful completion of this module,
the EMS provider should be able to:
– Review and understand the components of
the Pediatric Assessment Triangle (PAT)
– Identify the difference between
respiratory distress and respiratory failure
– State the landmarks for the EZ IO needle
– Choose the appropriate 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)
– Demonstrate the ability to obtain
information from the Broselow tape and
SOP pediatric medication tables
– Participate in calculating and drawing up
medications
-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
Mental status / interactivity
level
Consolability
Eye contact or gaze
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
• Decide if they must go to the closest
emergency department or do you
have time to honor the family
request if their hospital is not the
closest
Additional Assessment
• Includes:
Focused history
Physical exam
SAMPLE history
Physical Exam
• Toe to head in the very young
– Infants, toddlers, and
preschoolers
• Head to toe in the older child
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 (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
• You are 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
your 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)
Putting It All Together Index of Suspicion
• For this 2 year-old you are
anticipating major traumatic
injuries due to mechanism of
injury (minimally anticipating
head injury and orthopedic
fractures)
General Impression For This
2 year-old
• Category I trauma patient with head
& orthopedic injuries
• 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
•
•
•
•
•
•
•
•
•
•
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
IO Indications
• Shock, arrest, or impending arrest
• Unconscious/unresponsive to
stimuli
• 2 unsuccessful IV attempts or 90
second duration
• Use Peds needle for 3 – 39 kg
(up to 88 lbs)
- Peds needle 15 G 5/8
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
Altered Level of
Consciousness
• 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
– Give Narcan
<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, oxycodone,
Demerol, heroin, Dilaudid, 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 and how
much?
8 month-old
• < 1 year old receives Dextrose 12.5%
• 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 do you give 12.5% Dextrose
when you carry 25%?
How To Draw Up 12.5%
Dextrose
• 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 you
•
administer? 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
GCS For Pediatric
Patient
• Same tool used for the adult
population with minor changes to
accommodate the non-verbal
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 – Verbal Response
•
•
•
•
5 points if oriented (coos, babbles)
4 points if cry is irritable
3 points if the patient cries to pain
2 points if there is some noise
response to pain (similar to moans &
groans in the adult)
• 1 point if there is silence
GCS – 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
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 needs this drug “forced”
into the lungs
• The drug must be given in-line
– Attach nebulizer to the BVM 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?
•
•
•
•
•
•
•
•
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
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
– 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 4j/kg or equivalent
biphasic
•Resume CPR
•Establish IV/IO
VF/VT
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
• 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 or Asystole?
• 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
• 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
• Hypovolemic or distributive
– 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 – too much fluid
•
for the heart to handle
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
•
•
•
•
•
•
Irritability
Poor feeding
JVD
Hepatomegaly – enlarged liver
Hypotension
Children can often tolerate the
rapid rate fairly well
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
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
• Patient pushes your hands away
when you touch them
GCS Calculations 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 Calculations 3 & 4
• Pt #3 – 7
– Eye opening – 2 (eyes flutter to pain)
– Verbal – 2 (responds to pain)
– 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
• Discuss your general impression
based on the pediatric assessment
triangle (PAT)
• Discuss interventions appropriate to
the situation
• Discuss documentation to include
specific to the call
Case Study #1
• You are 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
• 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 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
– Defibrillate 1st at 2j/kg
– 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, cries & 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 11 (3, 3, 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
Case Study #2 Is Valium Indicated Now?
• 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 you give humidified O2 in
the field?
Humidified Oxygenation
• 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, give 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 administer a bronchodilator
(Albuterol) via nebulizer via mask
(won’t be able to put mouth around
mouthpiece)
Case Study #4
• Monitor respiratory status closely
– If decreased respiratory effort or
slowing of the rate, consider BVM
support 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
• You are called 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
Case Study #6
• You run this call:
– 8 year-old patient in full arrest
– Monitor shows VF
– What tasks need to be
assigned?
• Remember to assign someone
to take care of the family
– Now run the call
Case Study #7
• You run the call:
– Your 4 month-old is
hypoglycemic with a glucose
level of 35
– How are you going to handle
this call?
– Go through the steps as a
team; draw up the meds
Case Study #8
• You run the call:
– Your 6 year-old is found listless
with a GCS of 9
– The monitor shows:
–
–
What’s the rhythm?
What do you do?
Case Study #8
• Pediatric bradycardia is a hypoxia
problem until proven otherwise
• Start CPR with attention to ventilation
• Establish IV/IO
– Where are the IO landmarks?
– How do you place an IO needle?
• What drug therapy is necessary for
•
the pediatric symptomatic
•
bradycardia?
Case Study #8
• EZ IO landmarks
– 2 fingerbreadths down from patella
– 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 brady, contact Medical
Control for Atropine order
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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