Encountering The Pediatric Patient

1
Encountering The Pediatric Patient

• Condell Medical Center
• EMS System
• September 2008 CE
• Site Code 10-7200E1208

Prepared by Sharon Hopkins, RN,BSN, EMT-P
2
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)

3

• Calculate medication dosages given the patients
  weight
• Calculate the GCS given the pts 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

4
Pediatric Assessment Triangle - PAT

• Establishes a level of severity
• Assists in determining urgency for life support
• Identifies key physiological problems using
  observational listening skills

5
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

6
PAT - Appearance

• Reflects adequacy of
• Oxygenation
• Ventilation
• Brain perfusion
• Homeostasis
• CNS function

7
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

8
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)

9
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

10
PAT - Circulation

• Reflects
• Adequacy of cardiac output and perfusion of vital
  organs (core perfusion)

11
Assessing Circulation

• Evaluate skin color
• Cyanosis reflects decreased oxygen levels in
  arterial blood
• Cyanosis indicates vasoconstriction and
  respiratory failure
• Trunk mottling indicates hypoxemia

12
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

13
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

14
Additional Assessment

• Includes
• Focused history
• Physical exam
• SAMPLE history

15
Physical Exam

• Toe to head in the very young
• Infants, toddlers, and preschoolers
• Head to toe in the older child

16
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

17
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

18
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

19
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

20
Putting It All Together - Mechanism of Injury

• Fall from height greater than 3 times the
  toddlers 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)

21
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)

22
General Impression For This 2 year-old

• Category I trauma patient with head orthopedic
  injuries
• SOPs 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

23
Whats 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

24

• 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

25
Respiratory Distress

• Stridor
• Grunting
• Gurgling
• Audible wheezing
• Tachypnea (increased respiratory rate)
• Mild tachycardia
• Head bobbing
• Abdominal breathing (normal
• Nasal flaring
• Central cyanosis resolved with O2

26
Stridor

• Harsh, high-pitched sound heard on inspiration
  associated with upper airway obstruction
• Sounds like high-pitched crowing or seal-bark
  sound on inspiration

27
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

28
Nasal Flaring
29
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

30
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

31
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

32
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

33
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?

34
EZ IO Landmarks

• Proximal medial tibia
• 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

35
Tibial tuberosity
36
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

37
Altered Level of Consciousness

• If blood glucose level is
• 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)

38

• 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 2 mg IVP/IO/IM
• Max total dose is 2 mg

39
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

40
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
• others purses and have access to
• the medicine cabinet other
• areas where drugs can be found

41
Calculation Practice

• Your 8 month-old patient weighs 17 pounds
• Which strength Dextrose should this patient
  receive and how much?

42
8 month-old

• 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?

43
How To Draw Up 12.5 Dextrose

• Use 25 and dilute 11 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

44
Narcan Calculation

• Your patient weighs 19 pounds
• How much Narcan would you
• administer? Never give more than the adult
  dose!

45
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 mls 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

46
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

47
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

48
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

49
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

50
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

51
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

52
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

53
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

54
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

55
What Are the Risk Factors That Expose Kids To
Seizures?

• Fever most common
• Hypoxia
• Infections
• Electrolyte imbalance
• Head trauma
• Hypoglycemia
• Toxic ingestions
• Tumor

56
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

57
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

58
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!

59
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
  mls to pull up
• into the syringe?

60
Medication Resources

• Back of SOPs
• 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

61
Possible Causes of Critical Rhythms

• 6 Hs
• Hypovolemia fluid challenge
• Hypoxia supplemental O2
• Acidosis ventilate to blow off CO2
• Hyper/hypokalema
• Hypothermia warm core
• Hypoglycemia check glucose level

62

• 5 Ts
• Tablets drug overdose
• Tamponade supportive care in field
• Tension pneumothorax needle decompression
• Thrombosis, coronary or pulmonary
• Trauma

63
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

64
VF/VT

• Meds given during CPR
• Epinephrine 110,000 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

65
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

66
PEA/Asystole

• Start CPR and run thru the H T checklist
• Secure airway
• Establish IV/IO
• Fluid challenge 20 ml/kg
• Epinephrine 110,000 0.01 mg /kg IVP/IO
• Repeat every 3-5 minutes
• NO Atropine in SOP for peds!!!

67
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

68
Peds Symptomatic Brady

• Severe cardiorespiratory compromise
• Poor perfusion
• Bradycardia
• Weak, thready, absent pulse
• Hypotension
• Pallor
• Cyanosis
• Respiratory difficulty

69
Peds Brady

• Heart rate perform CPR
• IV/IO access
• Epinephrine 110,000 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

70
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

71
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

72
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

73
Signs Symptoms SVT

• Irritability
• Poor feeding
• JVD
• Hepatomegaly enlarged liver
• Hypotension
• Children can often tolerate the rapid rate fairly
  well

74
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)

75
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

76
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

77
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

78
Allergic Reactions Is Response Life Saving or
A Killer?

• The bodys 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

79
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

80
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)

81
Why Epinephrine 11000 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)!

82
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

83
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

84
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)

85
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

86
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

87
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

88
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)

89
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

90
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)

91
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)

92
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

93
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?

94
Case Study 1

• AEDs 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 302 2 person is
  152 once intubated ventilations are
• delivered once every 6-8 seconds

95
Case Study 1

• Attach a monitor as soon as possible
• Stop CPR (witnessed arrest) as soon as monitor
  applied ready
• Whats the rhythm treatment?

96
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 110,000 0.01 mg/kg IV/IO
• Repeat every 3-5 minutes
• Choose one antidysrhythmic (Amiodarone or
  Lidocaine one dose)

97
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?

98
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

99
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

100
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 mothers lap, anxious, watches
  you and cries weakly when you
• approach

101
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

102
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?

103
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

104
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?

105
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 childs face
• Helpful for croup epiglottitis

106
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 patients face if child
  too small to place lips
• around mouthpiece or direct
• mist near childs face

107
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 caregivers lap
• Child is sleepy, no eye contact
• or response to the exam

108
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

109
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?

110
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)

111
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 (wont be able to put
  mouth around
• mouthpiece)

112
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 breath every 3-5 seconds (12 20 breaths per
  minute)
• Give each breath over 1 second

113
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

114
Case Study 5

• What is your general assessment?
• What is the GCS?
• What other assessments need to be done?
• What interventions are needed?

115
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

116
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?

117
Case Study 5

• Check the back of the SOPs
• 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

118
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

119
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

120
Case Study 8

• You run the call
• Your 6 year-old is found listless with a GCS of 9
• The monitor shows
• Whats the rhythm?
• What do you do?

121
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?

122
Case Study 8

• EZ IO landmarks
• 2 fingerbreadths down from patella
• 1 fingerbreadth toward medial surface away from
  tibial tuberosity
• Peds bradycardia treatment
• Epinephrine 110,000 0.01 mg/kg IV/IO
• Repeated every 3-5 minutes
• Persistent brady, contact Medical
• Control for Atropine order

123
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 SOPs. Amended 1/08.
• www.peds.umn.edu/.../teaching/lung/
• stridor.jpg