Encountering The Encountering The Pediatric Patient Pediatric Patient Condell Medical Center Condell Medical Center EMS System EMS System November 2008 ECRN CE November 2008 ECRN CE Module III Module III Site Code #10-7200E1208 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
November 2008 ECRN CENovember 2008 ECRN CEModule IIIModule III
Site Code #10-7200E1208Site Code #10-7200E1208
Prepared by: Sharon Hopkins, RN,BSN, EMT-P
Objectives• Upon successful completion of this module, the ECRN
should be able to:– Review and understand the components of the
Pediatric Assessment Triangle (PAT)– Identify the difference between respiratory distress
and respiratory failure– Choose the appropriate EMS field 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)
– 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 appearanceEvaluate work of breathingAssess circulation to the skin
PAT - Appearance
• Reflects adequacy of:OxygenationVentilationBrain perfusionHomeostasisCNS function
Assessing Appearance• Evaluate as you cross the room and before you
touch the child:Muscle tone – can they sit up on own?
Mental status / interactivity levelConsolabilityEye contact or gaze – do they
watch you? Speech or cry
PAT - Breathing• Reflects adequacy of :
oxygenationVentilation
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 positionVisible movement of chest or abdominal
walls6-7 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)
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
• EMS to decide if the patient must go to the closest emergency department or if they have time to honor the family request if their hospital is not the closest
Additional Assessment
• Includes:Focused historyPhysical exam
Toe to head approach in the very young (infants, toddlers, preschoolers)
Head to toe in the older childSAMPLE history
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 (anything 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• EMS is 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
EMS 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)
General Impression For This 2 year-old
• Category I trauma patient with head & orthopedic injuries
• EMS Region X 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 by EMS and how much?
8 month-old
• < 1 year old receives Dextrose 12.5%– More diluted form for smaller, more fragile veins
• 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 does EMS give 12.5% Dextrose when they carry 25% as their weakest dilution?
Drawing Up 12.5% Dextrose From D25%
• 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 be administered? 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
Broselow Tape
• Often gives mg but not always the ml to fill the syringe with
• Mg helpful for accurate documentation• Holding a syringe, need to know how
many ml’s to draw up into syringe• Back of SOP’s has medical and cardiac
pediatric reference tables – Includes mg and ml of medications
GCS For Pediatric Patient
• Same tool used for the adult population with minor changes to accommodate the young 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 – Peds 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 – Peds 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
EMS 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 or remain conscious needs this drug “forced” into the lungs
• The drug must be given in-line– Attach nebulizer to the BVM mask 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
EMS 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 (Medical & Cardiac Pages)
– 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• Determine your general
impression based on the pediatric assessment triangle (PAT)
• Determine interventions appropriate to the situation
Case Study #1
• EMS is 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 immediately
• 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 (1-8 years-old per AHA) 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 (follow Region x SOP for EMS)– Defibrillate 1st at 2j/kg (peds pt <15)– 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, moans & 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 10 (3, 2, 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 • Reevaluate GCS watching for improvement as level of consciousness improves
Case Study #2 - Is Valium Indicated Now?
• No active seizure currently, so no drug• 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
• 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 EMS to administer a bronchodilator (Albuterol) via nebulizer via mask (won’t be able to
put mouth around mouthpiece)
Case Study #4
• Respiratory status monitored closely– If decreased respiratory effort or slowing
of the rate, support with BVM considered 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• EMS is called to the scene 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
• 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 from the med
Case Study #6• You run the call:
– EMS has a 6 year-old who was found listless with a GCS of 9
– The monitor shows:
– What’s the rhythm? – What do you do?
Case Study #7
• Pediatric bradycardia is a hypoxia problem until proven otherwise
• CPR started with attention to ventilation
• IV or IO access established • What drug therapy is necessary for the pediatric symptomatic
bradycardia?
Case Study #7• EZ IO landmarks
– 2 fingerbreadths down from patella over tibial tuberosity
– 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 , Medical Control would need to order Atropine
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/ stridor.jpg