Encountering The Encountering The Pediatric Patient Pediatric Patient Condell Medical Center Condell Medical Center EMS System EMS System September 2008 CE September 2008 CE Site Code #10-7200E1208 Site Code #10-7200E1208 Prepared by: Sharon Hopkins, RN,BSN, EMT-P
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Encountering The Pediatric Patient Condell Medical Center EMS System September 2008 CE Site Code #10-7200E1208 Prepared by: Sharon Hopkins, RN,BSN, EMT-P.
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Encountering The Pediatric Encountering The Pediatric PatientPatient
Encountering The Pediatric Encountering The Pediatric PatientPatient
Condell Medical CenterCondell Medical CenterEMS SystemEMS System
September 2008 CESeptember 2008 CESite Code #10-7200E1208Site 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
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 historyPhysical examSAMPLE 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
• 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 OpeningRemains 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
• 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
• 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