Title: Caring for the Pediatric Patient
1Caring for the Pediatric Patient
- Condell Medical Center EMS System
- Continuing Education
- February 2004
- Program prepared for CMC EMS by Sharon Hopkins,
RN, BSN
2Objectives
- Upon successful completion of this program, the
participant will be able to
- assess the airway status and make appropriate
intervention decisions
- recognize situations where the pediatric patient
is hypoventilating and in need of intervention
3Objectives
- assess identify the circulatory status of the
pediatric patient and be able to determine when
the pediatric patient is in need of
interventions - verbalize actions, indications,
contraindications, dosing side effects of
medications used in the pediatric situations
4Objectives
- actively participate in review of the Condell
Medical Center EMS System Standard Operating
Guidelines (SOGs)
- participate in hands-on skill practice including
intubation, Broselow tape, calculating drawing
up medications, IO needle insertion, pediatric
megacode
5Is there a need for EMS to know how to take care
of the pediatric patient?How many pediatric
patients does EMS care for?
6Children account for 5-10 of ambulance runs but
25-30 of ED visits.
- Most frequently seen are
- children
- for medical problems
- children 10 years
- old for trauma
- related problems
-
7Medical problems most likely encountered
- respiratory problems
- stridor
- wheezing
- apnea
- seizures
- most commonly from febrile events
- altered mental status
- always check glucose levels
- abdominal pain
- pregnancy related problems
- pre-hospital births
8What might that respiratory distress noise
indicate?
- If you hear stridor (inspiratory crowing-type of
sound usually heard without a stethoscope), think
an upper airway obstruction like
- croup
- epiglotitis
- foreign body
- If you hear wheezing (high pitched musical noises
usually heard louder on exhalation), think lower
airway involvement like
- acute bronchitis
- asthma
- chronic lung disease
- (yes, kids can have a chronic lung disease)
9Trauma related problems most likely encountered
- MVC
- occupant
- pedestrian
- drownings
- ages 1-4 have the highest drowning death rate
- burns/inhalation injuries
- intoxication
- choking/suffocation
- penetrating trauma from firearms
10Is there a difference between adults children
and how they present when theyre in trouble?
11In adults
- ?sudden cardiac arrest is a primary event
- ?adults usually have underlying cardiac disease
- ?most commonly seen dysrhythmias are ventricular
in nature
12In children
- ?cardiac arrest is usually a secondary event
- ?usually involved is
- respiratory failure
- CNS insufficiency
- cardiovascular collapse with multiple etiologies
- ?most commonly seen dysrhythmia is asystole
13Assessment-based, problem focused pediatric
patient care
- ?assess the patient
- ?find the problem
- ?provide intervention prioritizing care as
emergent, urgent, non-urgent
14Categorizing your patient?Emergent situations
immediately life threatening?Urgent
potentially life threatening or seriously
compromising?Non-urgent not life threatening
or compromising
15Assessments should follow the ABC approach -
? airway ?
breathing ? circulation
16Assessment of Airway Status
- Is the airway open?
- ?To open airways on infants, gently tip the head
backwards
- ?To maintain an open airway, pad under the
shoulders (pelvis due to large occiput)
- ?Too much head tilt on the infant will actually
close off the airway
17Assessment of Breathing
- ?Observe for chest abdominal movement and
effort
- ?Infants young children use their diaphragmatic
muscles to breath which makes the abdominal area
(belly) move with respirations
- ?Is the rate depth age appropriate?
18Are signs of respiratory distress, failure or
arrest present?
19Respiratory Distress
- compensation noted with ? respiratory ? heart
rates
- normal or agitated mental status
- respiratory rate elevated
- bilaterally audible breath sounds
- minimal or lack of evidence of use of accessory
muscles
- treatment geared to ?correcting hypoxia,
?observation of the condition, and
?investigation of the cause
20Respiratory Failure
- decreased mental alertness (sleepy but arousable,
possibly agitated)
- tachypnea, tachycardia, diaphoresis
- low pulse ox
- retractions
- use of accessory muscles
- nasal flaring
- see-saw respirations
- chest moves inward as abdomen moves outward
- head bobbing
- airway noises (ie grunting)
21Respiratory Pre-arrestIncludes findings of
respiratory failure plus
- extreme tachypnea
- 60 breaths/minute
- or
- extreme bradypnea
- peripheral core cyanosis
- prominent use of accessory muscles or no muscle
movement
- altered, depressed mental status
- diminished muscle tone
- bradycardia
- diminished peripheral perfusion
- prominent grunting on exhalation
22Immediate aggressive care is needed now before
the patient progresses to the next step of
23Respiratory ArrestCompensatory measures have
failed!
- unresponsive
- minimal or absent respirations
- flaccid muscles
- slow respiratory rate
- slow, weak, or absent peripheral pulses
- slow, weak, or absent central pulses
- hypoperfusion
- apnea
24The time frame from decompensated respiratory
failure to respiratory arrest is rapid!Be
proactive prepared!
25Goal of airway assessment
- Determine if
- the airway is patent/open
- the airway is likely to remain patent
- interventions are necessary to obtain and
maintain airway patency
26Airway interventions
- positioning - consider a small towel under
shoulders. (to keep head neck aligned)
- clearing foreign bodies
- 1-8 years old - abdominal thrusts
- no finger sweeps on any peds patients
- suctioning - limit time to 5 seconds in peds
27Airway interventions continued
- suctioning - avoid stimulating the pharynx (back
of throat) to avoid stimulating gag reflex
- airway adjuncts
- oropharyngeal - measure central incisor to angle
of jaw
- nasopharyngeal - size to little finger size
length from nose to tragus (front part) of ear
- intubation - confirm tube placement with direct
visualization, 3 point auscultation (stomach,
midaxillary areas) watch for bilateral chest
rise
28Airway interventions continued
- additional clinical assessment confirmation of ET
tube placement - improvement in heart rate, skin
color, mental status, general condition
- if there might be a problem with ET tube
placement, think through DOPE to trouble
shoot
- D - displacement
- O - obstruction
- P - pneumothorax (from injury or rescuer
created)
- E - equipment failure
29What components need to be assessed to determine
the adequacy of pediatric circulation?
30Determine pediatric circulatory adequacy by
evaluating
- Mental status changes
- AVPU category
- heart rate
- capillary refill
- urinary frequency
- blood pressure
31Assessment of Pediatric Circulatory Adequacy
- ?Mental status changes
- how alert is the child to the environment?
- how does the child interact with the
environment?
- does the child interact with the parents and
respond to the parents?
- does the child recognize the presence of
strangers (EMS) in the area?
32Mental status evaluated using AVPU
- A - alert, responsive to their normal (need to
- ask parents/caregivers whats normal for
- this child)
- V - responds to verbal stimuli
- P - responds to painful/obnoxious stimuli
which may be as simple as gentle shaking
- U - unresponsive, flaccid, no movement
33Circulatory assessment using heart rate
- ? Heart rate
- central circulation assessment
- 1 year old - carotid or femoral
- peripheral circulation assessment
- 1 year old - radial pulse
34Circulatory assessment using capillary refill
- ?Capillary refill
- normal response is for the area to refill in
under 2 seconds
- any area of the body may be checked for capillary
refill
- fingernail beds are useful available on older
children
- on infants, squeeze the whole foot to check
capillary refill
- more reliable in pediatric patients than adults
35Circulation assessment using kidney function
- Urinary frequency
- ask the parents or caregiver if the frequency and
weight of wet diapers has changed
- are the diapers even getting wet?
36It is difficult to rely on pediatric blood
pressures
- ?Blood pressures are hard to obtain
- under age 3 usually rely on presence strength
of central peripheral pulses instead
- size of the equipment needs to be accurate
- cuff should cover 2/3 the length of the upper
arm
- just the act of taking the B/P can influence an
increase in the pulse respiratory rates
- B/P changes are late markers of perfusion problems
37If you want to remember a formula then
- B/P (2 x age in years) 70
- example normal B/P for 2 year old
- (2 x 2) 70
- 4 70 74 systolic
38When circulation is poor in the pediatric patient
consider
39Cardiovascular compromise
- ?1st impressions that indicate a problem
- altered mental status - not alert, not
interactive with caregivers, not looking around
- limp muscle tone
- weak respiratory effort
- paleness or cyanosis
40The most common cause of hypoperfusion and
bradycardia in the pediatric patient is...
41Good patient outcome is dependent on early
recognition of shock /or inadequate perfusion
and timely interventions!
42Whats the difference between compensated
decompensated shock?
43Compensated shock
- irritability
- rapid heart rate
- tachypnea
- normal systolic B/P
- full central pulses, weak peripheral pulses
- delayed capillary refill
- decreased urine output
- cool, pale extremities
44Weak peripheral pulses in compensated shock are
- ?radial pulses
- ? dorsal pedal pulses
- ?posterior tibial pulses
45Decompensated shock
- decreased mental alertness
- very rapid or slowed heart rate
- very rapid or slowed respiratory rate
- low blood pressure
- absent peripheral pulses weak or absent central
pulses
- markedly delayed or absent capillary refill
- markedly decreased or absent urine output
- dusky, mottled extremities
46Weak central pulses in decompensated shock are
the
- ?brachial artery
-
- ? femoral artery
- ?carotid artery in
- older children
47Causes of hypoperfusion
- vomiting diarrhea
- osmotic diuresis (ie diabetic ketoacidosis
(DKA))
- blood loss (ie trauma including head injuries
especially if fontanelles still open skull is
not yet a closed box)
- plasma loss (ie burns)
- anaphylaxis - due to vasodilation
- generalized sepsis - massive infection
- spinal cord injury - due to vasodilation
bradycardia
- cardiac failure (ie congenital heart disease
respiratory failure from hypoxia acidosis)
48What do I do if inadequate perfusion is present?
- Start CPR if
- pulse is absent altogether
- OR
- pulse is perfusion
49Management of hypoperfusion
- prompt, aggressive management
- vascular access
- peripheral sites
- IO
- fluid resuscitation 20 ml/kg infused in under 20
minutes reassess prepare to give another 20
ml/kg
- frequent reassessment, rapid transport
50Pediatric assessment triangle Another
assessment tool suggesting assessment of
Appearance mental status body position m
uscle tone
Breathing movement effort rate audibl
e
sounds
Circulation skin color
51Appearance
- mental status - level of consciousness,
interactions with parents, response to strangers
(at 6-8 months the child should respond to
their name being called) - body positioning muscle tone - normally
somewhat flexed extremities, symmetrical movement
(at 4-6 months a child can sit up 8 months
sits without assistance) - ? PROBLEM floppy child or unusually stiff
52Breathing
- visible movement, effort, rate, sounds need to
be assessed
- children are normally abdominal breathers
- ? PROBLEM no visible movement of chest,
struggling to breathe, rate too fast or too slow,
grunting on exhalation, needs to maintain a
specific position to breathe
53Circulation
- skin color - if dark complexion, check lips,
tongue, palms, sole of feet
- ? PROBLEM pale, bluish, mottled
- appearance
54What are some other key differences between
adults children that impact our assessment
interventions?
55Airway
- ?diameter is smaller
- ?tongue is proportionately larger - correct
positioning is crucial
- ?epiglottis is floppier - use of the Miller or
straight blade is easier preferred
- ?larynx is more anterior - visualization of
anatomy is more difficult while intubating use
of cricoid pressure could help
56Airway continued
- ?to assist in intubation attempts increase
visualization, have someone pull on the right
corner of the patients mouth
- ?infants are obligate nose breathers - nasal
secretions can obstruct the airway
- ?airway structures are more flexible - there is
more expansion contraction with air movement
57Breathing
- ?chest hyperresonnant - auscultation accuracy is
difficult place stethoscope as far laterally as
possible in axillary areas
- ?intercostal muscles not fully developed - these
children tire easily from the work of breathing
- ?children are abdominal diaphragmatic breathers
- compression of abdomen compromises breathing
58(No Transcript)
59Breathing continued
- ?tachypnea used for compensation - but can only
be sustained for short period of time
- ?tripod position assumed to assist in
respirations - use of the upper arm muscles act
as accessory muscles
60Cardiovascular System
- Cardiac output heart rate x stroke volume
- CO HR x SV
- ?Children cannot ? SV to ? CO - due to
- immaturity of the heart to alter
contractility
- ?Children can only ? CO by ? HR
61Cardiovascular System continued
- ?Children compensate for hypoperfusion with ?
systemic vascular resistance (remembering the
mottling that shows up) and ? HR
62Circulation
- ?total blood volume is much lower than an adults
(80-90 ml/kg so 1 year old averages 800 cc total
blood volume an adult has an average of 6000 cc
total blood volume) - ?vessels walls are healthier than adults -
pediatric patients can rely on potent
vasoconstriction to maintain the B/P you will
see mottling due to vasoconstriction - ?pediatric patients cannot ? cardiac
contractility - cardiac output sustained mostly
by ? the heart rate and creating potent
vasoconstriction
63Circulation continued
- ?compensation works well initially - then crashes
when output can no longer meet requirements
- ?heart varies with respirations - sinus
arrhythmia
- ?bradycardia is usually triggered by hypoxia -
monitoring the heart rate is critical in the
pediatric patient
64Kids dont become hypotensive as quick as
adults!But, compensatory mechanisms have their
limits!!!
- B/P will drop rapidly after loss of approx 15 of
circulating blood volume
- Total circulating blood volume is 80-90 ml/kg
(ie 1 year old has
65Trauma Considerations Related To Differences
- ?head - proportionately larger and heavier so
more prone to head injuries when falling
- ?infant heads are expandable - anterior
fontanelle (soft spot) open up to about 18 months
of age so shock is possible from intracranial
bleeding - ?chest is mostly cartilage - blunt trauma is
transmitted to thoracic organs without causing
ribs to fracture
66Trauma continued
- ?lower rib cage does not fully cover/protect
abdominal organs - so liver spleen more easily
injured
- ?bones flexible - bend easily without breaking
most fractures are near the growth plates which
could interfere with bone growth in the future
67Changes in mental status can cause or be caused
by
- poor airway tone
- ? respiratory drive
68Always be honest to the patient and family!!!
This builds trust!!!
69 Putting It All Together
Steps
in the
Assessment
Process
70Scene size-up
- 1st impression (think peds triangle look at
appearance, breathing, circulation (ABCs)
- Determine urgency rating do you consider this
patient emergent, urgent, or non-urgent?
- Always keep the patient warm
71Initial Assessment
- More detailed than 1st impression
- Builds on information already gathered
- Should attempt to be completed in less than 1
minute
72Steps in the Initial Assessment
- ?Mental status - AVPU
- A - patient awake
- V - patient responds to verbal stimuli name is
called patient responds before they are
touched
- P - some contact stimuli must be added to get the
patient to respond
- U - the patient is flaccid unresponsive there
is absolutely no movement
73Initial Assessment continued
- ?Airway - open airway with gentle head tilt if
necessary then look - listen - feel
- ?Breathing - ? adequacy of effort, breath sounds,
coloring, pulse ox
- whats the resp rate depth?
- are there signs of ? effort like accessory muscle
use, retractions, nasal flaring
- breath sounds - best to listen mid axillary to be
as far away from opposite side as possible
74Initial Assessment continued
- Pulse ox - normal is 95 - 100
- mild hypoxia 91 - 95
- severe hypoxia
- ?Circulation - compare central pulses (carotid,
brachial, femoral) to peripheral pulses (radial),
? color (? lips), temp, capillary refill (normal
is 3 years old), cardiac
rhythm
75To check adequacy of circulation
- Rely on
- mental status changes
- heart rate
- capillary refill
- pulse character
- changes in urinary frequency
- The above information is easier to assess for
than a B/P in the little ones
76Normal pediatric vital signs
- Peds pulses 60-160 range
- formula for upper limit
- HR 150 - (5 x age in years)
- Estimated systolic upper limit formula
- SBP (2 x age in years) 90
- Estimated systolic lower limit formula
- SBP (2 x age in years) 70
77Children are different
- Poor circulatory status in a child is rarely of
primary cardiac origin.
- Consider possible causes of hypoxia and
hypovolemia in a child with symptomatic
bradycardia.
78Ive done the ABCs, now what?
79Focused History
- ?SAMPLE
- S - signs symptoms
- A - allergies (including iodine before IV start)
- M - current meds including vitamins and
- natural herbal medications
- P - past pertinent medical history including
- problems with birth
- L - last oral intake including liquid solids
- E - events leading up to the incident
80Focused history continued
- ?Additional pertinent history
- any changes from normal (sleep habits, eating
patterns)?
- neurological/developmental history
- recent trauma
- if falls, height, type of surface landed on
- if MVC - position in car, type of restraints
- if sports - use of helmet
- newborn history - any problems at birth
81Physical Exam So, what is the purpose of the
physical exam?
- The physical exam is a head-to-toe or toe-to-head
examination completed only if there is time
during transport. The EMS provider uses this
exam to gather more information to make effective
clinical patient care decisions.
82Components of a physical exam
- More interviewing history gathering
- Examination techniques
- inspection
- palpation
- percussion
- auscultation
- Vital signs
- Adjunctive equipment use (pulse ox, B/P cuff,
stethoscope)
83Physical Examination - begun during transport for
emergent urgent problems
- ?Toe to head or head to toe approach?
- Toe to head in younger ones to gain trust
- ?DCAP-BTLS on physical exam
- D - deformities (bones bend easily before
- breaking because theyre pliable)
- C - contusions -a bruise or birthmark?
- A - abrasions - is there a pattern?
- P - penetrations - immobilize as found
84Physical exam continued
- B - burns - is there an identifiable pattern?
- T - tenderness to palpation
- L- lacerations - dont cut clothing through
possible evidence
- S - swelling
- ?Fontanelles - remain open up to 18 months
- bulging with history of trauma think ?
intracranial pressure
85Physical exam continued
- Fontanelles
- bulging in presence of fever think meningitis
- sunken soft spot think dehydration
- ?GCS - use modified version usually up to 5
years of age
- 13-15 - mild head trauma
- 9-12 - moderate head trauma
- 3-8 severe head trauma
86Assessment tips!
- ?if possible, keep the child on the parents lap
- ?approach the infant with a smile offer a toy
they can grasp
- ?sit or kneel at eye level
- ?speak quietly, simple words, avoid baby talk
- ?talk to children throughout exam, tell a story
87Assessment Tips Continued
- ?ask questions about things child is interested
in
- ?explain interventions immediately before
performing them - dont want kids to have a lot
of time to let their imaginations run wild with
their interpretations - ?dont ask permission of the child if the task
has to be done anyway -do allow the child to make
decisions where they can (ie B/P on right or
left arm) - ?allow parents to participate as much as possible
88So, whats got to be done for a pediatric patient?
- use a length-based resuscitation or Broselow tape
as guidelines
- another resource tool is protocol
- control the airway determine if intubation is
necessary for this patient
- determine need for venous access - consider
placement of an IO needle
89Broselow Tape
- ?What is it?
- This tape is a device that lists proper pediatric
equipment sizes and precalculated drug dosages
based on the length of the child.
- ?How do I use the tape?
- place the tape alongside the supine child with
the red end even with the top of the head.
Measure to the heel of the child.
90News on Revised Broselow Tape
- ?updated/revised Broselow tape out (2002
edition)
- ?Region X SOP will update peds medication dosages
to match the Broselow tape (until then, follow
current SOP for drug dosages if there is a
conflict of dosage guidelines) - ?color categories remain consistent
- ?medications printed in new lay-out format
91Revisions to Broselow tape continued
- ?IV drips are the only meds listed now that have
a range for dosing (ie IV Diazepam for a 10 kg
patient was 1.0 - 3.0 mg revised tape IV
Diazepam is 2 mg) - ?Children are grouped into color-coded zones
rather than individual kilogram weights
- ?Epi listed as 1st dose and high dose/ET dose
(TT) (follow 1st dose schedule for all IVP epi
doses)
92Intubation Techniques For Our Smaller Patients
- ?Intubation
- ventilate with 100 O2 for 1 minute
- apply cardiac monitor - watch for bradycardia
- assemble check equipment
- use Broselow tape protocol for sizing
guidelines
- stylets, if used, are not to extend beyond the
tip
- uncuffed ET up to size 6 (approx 8 years of age)
- suction to be turned down to 100 mmHg suction
time limited to
93Intubation continued
- positioning infant or child
- gentle head extension/sniffing position helpful
to put a towel roll under the shoulders
- provide blow-by oxygen when not bagging
- use a straight blade (preferred due to floppy
epiglottis large tongue) lift the epiglottis
- if using a curved blade, slip tip into the
valeculla and lift upward
- DO NOT ROCK THE HANDLE !!!
94Intubation continued
- ?place the ET tube only until the dark vocal cord
guide ring near the distal tip of the tube is at
the level of the vocal cords (this puts the
distal tip of the ET tube halfway between the
vocal cords carina) - ?never let go of the ET tube until secured
95Primary confirmation of ET tube placement
- ?visualization of the vocal cords
- ?auscultation of epigastric sounds - expecting to
hear none
- ?auscultation for bilateral breath sounds - place
stethoscope in axillary areas
- ?watching for bilateral equal chest expansion
96Additional helpful tools to ? ET tube placement
- ?positive findings with the ETCO2 - yellow color
after several ventilations with BVM (not reliable
in poor cardiac output states)
- ?improvement in heart rate skin color
- ?no gastric distension with ventilation
- ?improvement in pulse ox readings -
- normal is 95
- ?condensation in the tube during exhalation
97Not helpful in confirmation of ET tube placement
in pediatrics
- ?EDD - esophageal detector device
- If the ET tube is in the esophagus, the pressure
exerted by the EDD may be too high and could
damage the lining of the esophagus in the
pediatric patient -
- ?Adult ETCO2 will not function reliably in
smaller children because gas flow is minimal
98How often should the ET tube placement be
reconfirmed?
- ?Every time the patient is moved the ET tube
placement should be rechecked.
- ?This includes
- ? after each defibrillation
- ? after each transfer from cot-to-cot
- ? anytime the ET placement is questioned
- ?Consider c-spine immobilization (ie towel
rolls) to help immobilize
99What else about intubating a pediatric patient?
- As a reminder, the landmarks are very small
- The presence of any swelling will greatly reduce
the glottic opening
- Swelling may increase due to the trauma of being
intubated
- Make your first attempt your best attempt - it
may be your only attempt!
100Intraosseous NeedlesThe IO
- IO access allows the administration of fluids and
drugs directly into the bone marrow.
- Blood from the marrow space drains into the
central circulation
- If the fluid or drug can be given IV it can
usually go IO also.
101Region X SOP IO Indications
- ?Children
- ?Presence of shock, cardiac arrest, or
unresponsiveness
- ?2 unsuccessful peripheral attempts or 90
seconds in time to insert a peripheral line
102IO Contraindications
- ?recent fracture of the bone being considered for
the site
- ?recent previous IO attempt in that same bone
- ?osteogenesis imperfecta - congenital disorder of
the bone bones are brittle
103IO Procedure
- ?reach equipment antiseptic, IO needle,
- 10 ml syringe filled with 5 ml 0.9 NS
- ?prep IV tubing with NS IV bag
- ?prepare anterior surface of leg below the tibial
tuberosity with antiseptic solution
- ?insert needle in a twisting fashion 1-3 cm below
tibial tuberosity perpendicular to skin
104IO procedure continued
- ?confirm IO needle placement
- lack of resistance or pop sensation when marrow
entered
- needle stands up without support
- bone marrow aspirated (this does not always
happen)
- IO easily flushed with NS syringe
- attached IV bag flows freely (may have to help
start the flow by squeezing on the bag initially)
105Review of more commonly used pediatric
medicationsAlbuterolGlucagonD25Valium
106Albuterol
- Bronchodilator
- Useful in asthma, croup, allergic reactions,
anaphylaxis
- Dosage 2.5 mg (3 ml) (same as adults)
- To be successful, need to coach patient thru
treatment encourage slower deeper breathes
eventually holding the deep breath slightly.
- Consider use of neb mask if necessary
107Glucagon
- Hormone and antihypoglycemic
- Causes a breakdown of stored glycogen, from the
liver, into glucose
- Only effective if there are sufficient stores of
glycogen in the liver
- Must be reconstituted
- Takes time to work if IV gets established after
a dose of glucagon is given, recheck sugar
levels. If blood sugar is low pt still has ?
LOC, give D25
108D25
- A carbohydrate to rapidly elevate the blood
glucose level
- Rapid action necessary in hypoglycemia to prevent
serious brain injury
- All patients with an altered LOC must have
glucose levels checked
- Administer as slow IVP in decent sized vein - can
be very irritating to injection site
- Infiltration of IV site could cause necrosis
109Valium
- Benzodiazepine used as an anticonvulsant
- Works on stopping the current seizure activity,
does not prevent future seizures
- Relatively short acting - watch for return of
seizure activity
- Manage respiratory depression by bagging the
patient to support respirations
- Relatively rapid onset when given rectally
110Review on drug calculations
- Formula 1
- X desired dose x volume on hand
- dose on hand
- Formula 2
- mg on hand mg ordered
- ml on hand X ml to be
given
111Case Scenario 1
- You respond to the scene of a 12 year old girl
who has passed out. Upon arrival, scene is safe,
BSIs are on. The girl is found unresponsive on
the bathroom floor with several girlfriends
standing around. - What do you do next?
112Initial Patient Assessment - ABCs LOC - Case 1
- patient is unresponsive on the floor in a side
lying position.
- how would you open the airway?
- what would you look for to evaluate for adequacy
of breathing?
- where is it appropriate to check for pulses?
113ABCs LOC continued - Case 1
- consider the possibility of trauma and protect
the c-spine when opening the airway
- evaluate skin color, chest expansion, rate
depth of breathing, pulse ox
- consider applying oxygen
- as a 12 year old, you may check for peripheral
pulses in the radial area
114Initial Assessment FindingsCase 1
- airway is open, she moans to her name
- patient is breathing 16 times/minute
- skin color is warm, dry, pink
- pulse ox is 95
- radial pulse is strong at 120/minute
- do you deem your patient stable or unstable?
Emergent, urgent, or non-urgent?
115Focused History Physical Exam - Case 1
- care initiated
- c-spine control
- oxygen therapy
- blood glucose level (110)
- SAMPLE - no allergies, no meds, no hx, girls
skipped school admit to drinking vodka shots
over last couple of hours
- detailed physical exam
- age appropriate for head-to-toe
116Physical Exam continued - Case 1
- DCAP-BTLS - no injuries found, assisted to floor
by friends
- GCS - eye opening (to voice) - 3
- verbal response (moans) - 2
- motor response (pushes you away) -
5
- Other interventions necessary?
117Patient 1 Outcome
- Patient outcome
- patient had elevated ETOH levels. Needed fluid
hydration. Remained hospitalized overnight until
LOC ETOH levels had improved
118Case Scenario 2
- You are responding to a call for a 15 month old
male having a seizure.
- Scene is safe, many family members in the house
most non-English speaking.
- BSIs are on.
- Initial impression?
119Initial Patient AssessmentABCs LOC- Case 2
- airway breathing are hard to evaluate as the
child is actively seizing
- so, how would you evaluate airway breathing?
- circulation - the patient has a carotid radial
pulse which are rapid skin warm/hot pale
- is this patient stable or unstable? Emergent,
urgent, or non-urgent?
120Focused History Physical Exam - Case 2
- Care initiated start BVM support because this
long lasting active seizure disrupts the patient
from breathing effectively
- Pulse ox initially went from 95 RA to 99 with
BVM support
- SAMPLE - no allergies, started an antibiotic
yesterday for ear infections, no other hx,
nibbled on breakfast today
121Detailed Physical ExamCase 2
- DCAP-BTLS - no unusual findings
- GCS - eye opening (none) - 1
- verbal response (moans) - 2
- motor response (withdraws) - 4
- Glucose level - 72
- Other interventions necessary?
122Patient 2 Outcome
- This patient presented with bacterial spinal
meningitis. The patient received IV antibiotics
and recovered. All EMS members listed on the EMS
run report were contacted for prophylactic
antibiotic therapy. No one else contracted
bacterial meningitis traced to this patient.
123Case Scenario 3
- You are called to the scene for a 2 year old with
noisy respirations for the past 5 hours. You
arrive to find a pale 2 year old patient sitting
in moms lap appearing tired is clingy to mom,
using accessory muscles with an increased
respiratory - rate
- What do you think is going
- on what should you do next?
124Initial AssessmentABCs LOC - Case 3
- airway is open
- the pt is using accessory muscles, retractions
evident, prolonged exhalation times, audible
wheezing, mucous membranes dry.
- the radial pulse is present rapid
- is this patient stable or unstable? Emergent,
urgent, or non-urgent?
125Focused History Physical Exam - Case 3
- Care initiated
- pulse ox (89 RA, 98 on O2)
- supplemental oxygen therapy - what device would
you use?
- SAMPLE - no allergies, meds are atrovent, hx
asthma, sipping juice today
126Physical Exam continued Case 3
- Detailed physical exam
- DCAP-BTLS - no injuries noted
- GCS - eye opening (open) - 4
- verbal response (normal) - 5
- motor responses (moves all
spontaneously)
-
- 6
- Other interventions necessary?
127Patient 3 Outcome
- This patient had an acute onset of asthma. They
continued to deteriorate in the ED and pulse ox
remained low with increasing respiratory work
efforts. The patient was intubated and
transferred to a pediatric center. They
gradually improved, were extubated and returned
home.
128Nobody wants a bad outcome
129With preparation practice you can improve your
odds on a good outcome
130Our goal is for a good outcome!
131Now skill practice time!
132References
- American Academy of Pediatrics Neonatal
Resuscitation 2000.
- Bezyack, M. E. Respiratory Distress - Making the
Diagnosis in Kids
- Bledsoe, B., Clayden, D., Papa, F. Prehospital
Emergency
- Pharmacology 5th Edition. Brady. 2001.
- Broselow Tape. 2002 Edition.
- Markenson. Pediatric Prehospital Care. Brady.
2002.
- Region X SOP 2001 Implementation.
- Sanders, M. Paramedic Textbook Revised Second
Edition. Mosby.
- 2001.