Curriculum Update: Pediatrics

1
Curriculum UpdatePediatrics

• Condell Medical Center
• EMS System
• October 2005
• Site Code 10-7200-E-1205
• Revised by Sharon Hopkins, RN, BSN

2
Objectives

• Upon successful completion of this module, the
  EMS provider should be able to
• discuss injury prevention tactics
• describe differences in body systems from the
  pediatric patient compared to an adult
• describe pain assessment scales for the pediatric
  population
• list pain medications used in the prehospital
  setting for children

3
Objectives continued

• list special health care needs noted in the
  pediatric population
• describe technological equipment used to assist
  in the lives of children
• describe specific disease processes in the
  pediatric population and the appropriate EMS
  intervention
• describe traumatic injuries unique to the
  pediatric population and the appropriate EMS
  intervention

4
Objectives continued

• describe the Broselow tape and demonstrate use of
  the tape
• describe the placement of an IO needle and
  successfully demonstrate the skill
• demonstrate infant/child CPR
• participate in scenario practice regarding
  pediatric situations
• participate in calculating and drawing up
  medication
• successfully complete the quiz with a score of
  80 or better

5

• The EMS providers role in treating infants and
  children are often found in two places
• Prehospital care
• providing treatment
• and primary
• transportation
  
• Interfacility transfers
• providing secondary
• transport

6

• To maintain pediatric knowledge and clinical
  skills there are a variety of courses and
  certifications available

• PALS - Pediatric Advanced Life Support
• APLS - Advanced Pediatric Life Support
• PPC - Prehospital Pediatric Care/NAEMT
• PEPP - Pediatric Education for Prehospital
• Professionals
• PEP - Pediatric Emergencies for Paramedics
• PBTLS - Pediatric BTLS
• ENPC - Emergency Nurse Pediatric Cert
• System/Region CE programs

7
Emergency Medical Services for Children - EMSC

• National effort to reduce child and youth
  disability and death from severe illness and
  injury
• Areas of healthcare concern are
• Education Emergency Care
• Data Collection Definitive care
• Injury Prevention Rehabilitation
• Prehospital Care Ongoing healthcare
• Awards grant monies to provide funding to develop
  primary and continuing education, equipment
  guidelines, designation of facilities with
  special capabilities, and instructor resources

8
EMSC Patient Goals Outcome

• 1st goal - prevention of illness and injury
• If 1st goal fails, 2nd goal is to improve
  outcomes in children who are ill or injured by
  teaching recognition of stable and unstable
  conditions specific to children and developing
  clinical skills to expedite and improve
  treatment.

Bottom line To have higher qualified prehospital
and hospital personnel to care for sick and
injured children
9
Reduction of Pediatric Morbidity and Mortality

• Data and facts documented in
• registries
• epidemiological research
• Education and prevention programs
• schools
• community
• parents
• safety inspections

10
Injury PreventionBirth to 6 Months

• Avoid shaking baby powder
• on infant (inhaling powder
• particles is harmful to lungs)
• Know emergency procedures
• for choking and post emergency numbers
• Dont tie pacifier around infants neck
• Never leave alone in the bath
• Beware of cigarette ashes falling on child
• Properly restrain in motor vehicles, strollers
  and bicycles
• Avoid placing stuffed animals in the crib

11
Illinois Car Seat Laws

• Birth - 7 years-old
• in approved safety seat or booster
• 8 - 16 years old
• secured by seat belt
• air bag in place
• All front seat passengers must be restrained
  regardless of age

12
Injury PreventionFour to Seven Months

• Avoid feeding hard candy, nuts, hot dogs, and
  coin shaped foods
• Properly store cleaning fluids out of reach
• Use non-toxic, lead-free paints
• Lower mattress and raise crib rails to full
  height
• Place hot objects out of reach
• Minimize exposure to sun
• apply appropriate sunscreens
• Carefully select toys

13
Injury PreventionEight Twelve Months

• Fence swimming pools
• Fence off stairways
• Secure front-loading appliances and cabinets
• Administer medications as a drug do not refer to
  medicine as candy

• Use plastic guards on electric outlets
• Direct supervision is a must

14
Injury PreventionTwelve Months 4 Years

• Supervise during play
• Ensure a properly sized helmet, trikes, bikes,
  and roller blades
• Teach children to obey pedestrian safety rules
• Fence pool areas enroll in water safety
  swimming lessons
• Keep automatic garage door opener inaccessible
• Teach personal safety (name, address, phone
  number)

15
Injury PreventionFive to Twelve Years

• Teach proper use of seat belts
• Teach proper behavior in the event of a fire
• Teach safe cooking practices
• Avoid personalized clothing in public places
• Teach use of hand signals when riding bikes and
  insist on use of helmets at all times
• Teach Rules of the Road for bicycles

16
Injury PreventionThirteen to Eighteen Years

• Reinforce dangers of drugs when
• operating moving vehicles
• Instruct in the use and respect of firearms,
  power tools, and firecrackers
• Be alert to signs of depression as a risk factor
  for suicide
• Be alert to signs of eating disorders

17
Children are not
Little Adults

• Variety of differences in
  anatomy and
• physiology
• Head
• Proportionally larger in size
• Larger occipital region - challenge to maintain
  proper C-spine alignment
• Fontanelles open in infancy - anterior closes
  between 9-18 months
• Face is smaller in comparison
  to size of head

18

Airway

• Narrower at all levels -
• easier to obstruct
• Infants are obligate nose breathers - keep nasal
  passages clear of secretions with bulb syringe
• Jaw is posteriorly smaller in young children
• Larynx is higher (C3-C4), more anterior -
  visualization more difficult
• Cricoid ring is narrowest part of airway - no
  room for a cuff on the ET tube in small airways
• Tracheal cartilage is softer - easier to compress
  and obstruct
• Trachea is smaller in length and diameter

small towel
19
Airway continued

• Epiglottis
• Not fully cartilage - floppier
• straight blade (Miller) preferred for intubation
  attempts
• Epiglottis extends at 45 degree angle into airway

To maintain airway position Use small folded
towel or diaper placed from shoulders to hips in
children
glottic opening
Anterior surface
20
Respiratory System

• Tidal volume smaller
• Metabolic oxygen requirements higher
• Smaller functional residual capacity
• smaller oxygen reserves
• Hypoxia develops rapidly because of increased
  oxygen requirements and decreased oxygen reserve

21
Chest and Lungs

• Ribs are more horizontally oriented
• Chest wall more pliable
• Ribs offer less protection to organs
• Chest muscles are immature and fatigue easily
• Kids are diaphragmatic belly breathers
• Lung tissue is more fragile - pulmonary
  contusions more common than rib fractures
• Mediastinum is more mobile
• Thin chest wall allows for breath sounds to be
  easily transmitted across the entire chest
• best to auscultate in axillary line as far away
  from opposite lung as possible

22
Pediatric vs Adult Chest
Pediatric Xray Ribs softer, smaller, more
horizontal
Adult Xray Ribs more rigid, larger, angle downward
23
Interventions Related to The Pediatric Chest and
Lungs

• CPR is performed using 2 finger tips
• or thumb tips encircling the chest wall
• Ribs tend to bend with the force of trauma
• fractured ribs more common in child abuse
• Infants are prone to gastric distention
• Internal injury can be present without external
  signs
• Transmitted breath sounds may cause missing a
  misplaced ET tube or pneumothorax - auscultate
  breath sounds in axillary areas

24
Abdomen

• Immature abdominal muscles offer less protection
• Abdominal organs are closer together
• Liver/spleen proportionally larger more
  vascular most frequently injured organs
• Multiple organ injury is more common than
  isolated organ injury
• Spleenectomy is avoided if possible - do not want
  to lose one of bodys natural defenses to
  infection/disease
• if spleen removed
• will need a
• pneumovax
• shot periodically

Spleen
25
Extremities

• Bones are softer more porous
• Immobilize any sprain or strain as it more likely
  could be a fracture
• IO access - medications go directly into the bone
  marrow, then drains into the central circulation

- Growth plate injury can disrupt bone
growth watch angles of entry with IO
needles
26
Skin and Body Surface Area (BSA)

• Skin is thinner and more elastic
• Larger surface area to body mass
• Less subcutaneous fat
• Thermal exposure results in deeper
• burns
• Children tend to have a greater loss of fluids
  and heat when the integumentary system (skin) is
  disrupted

27
Cardiovascular System

• Cardiac output is rate dependent
• children unable to adjust contractility cardiac
  output adjusted by changing heart rate
• Vigorous, but limited, cardiovascular reserve
• Bradycardia is a response to hypoxia
• when you see bradycardia, evaluate breathing
• Maintains blood pressure longer before crashing
• hypotension becomes a late sign of shock
• Circulating blood volume larger in proportion
• but absolute blood volume is
  smaller
• smaller volumes of fluid/blood loss
  cause shock

Intervene early to prevent
decompensation
28
Shock

• Compensated shock is inadequate tissue perfusion
  with a normal blood pressure
• Decompensated shock is inadequate tissue
  perfusion with hypotension
• Underlying cause must be determined and treated
  promptly
• Adequate tissue perfusion relies on
• adequate fluid volume, intact blood vessels,
  functioning pump (heart)
• Fluid replacement schedule is 20ml/kg NS bolus
  

29
Nervous System

• Develops throughout childhood
• Neural tissue is more fragile
• brain injury more devastating in children
• Brain/spinal cord have minimal protection from
  skull and spinal column
• Fontanelles remain
• open in early months

30
Metabolic Differences

• Limited glycogen/glucose stores
• Stressors cause drop in blood glucose - remember
  to check glucose levels PRN
• Vomiting/diarrhea cause high volume loss - watch
  for hypovolemia
• Hypothermia due to increased body surface area -
  keep warm, dry, cover head
• Very young unable to shiver to maintain body
  temperature -
• mechanism not yet
• fully matured

31
Pain Management in Children

• Always take a childs pain seriously
• Avoid physical restraint for procedures (usually
  hospital based ones) when sedation can be used
  for painful, anxiety-producing prolonged
  procedures
• Accurate assessment
• requires careful
• observation of key
• behaviors appropriately
• related to the age of
• child

32
Pain Assessment in Children

• Once an infant becomes extremely agitated, it
  takes a great deal of time to get them under
  control and calmed down.
• Caregivers are good resources for history of how
  a child reacts to different procedures
• A crying child can easily cry themselves into
  exhaustion be difficult to arouse once asleep

33
Responses To Pain By Age

• Infant - intense crying, unable to be consoled,
  tremors, unable to suck without crying, may
  become exhausted from crying and fall into a deep
  sleep
• 1-2 year old - intense reaction to painless
  procedures, aggression, regression, physical
  resistance
• 3-5 year old - perceive pain as punishment,
  become aggressive with verbal attacks like
  I hate you

34
Pediatric Responses to Pain continued

• 6 10 year old - past experience influences
  reaction to pain exaggerated by fear of bodily
  injury and death
• due to the fear, cover injuries and deformities
• this age can localize and describe pain.
• Over 10 years old - can locate and quantify pain
  accurately they fear changes in appearance and
  bodily function able to control their response
  to pain and procedures

35
Pain Scales Used For
Children

• Numerical scales OK for older children
• 1 (mild) to 10 (severe)
• Scales that measure facial expressions
  (ie FLACC scale)
• when patient unable to verbalize presence or
  severity of pain
• appropriate in developmentally delayed
• non-English speaking individuals

36
Non-Pharmacologic Pain Management

• - Reduce anxiety
• Explain procedures and calm caregivers
• Allow child access to caregiver for comfort
• Help child find position of comfort
• ease for sucking thumb/fingers, holding toy,
  using pacifier
• Distract the patient with age-appropriate
  techniques

37
Distraction by Age

• Young children can use their imagination
• to help cope with stressful
  situations
• speak calmly, play music, offer a toy
• or puppet
• Young children in severe pain will not be able to
  be distracted

38
Cognitive Coping Strategies and Pain

• School age children can close eyes and picture a
  happy place/experience/memory
• Encourage them to count forward and backward
• Encourage them to tell you about a school
  experience or sport they play
• Offer choices to assist you in caring for the
  patient (ie right or left arm for B/P)

39
Pharmacologic Pain Mangement

• Analgesia
• Relief of pain
• Sedation
• Pharmacologically induced decreased level of
  consciousness
• Risk for aspiration
• greatest if feedings are within 4 hours of
  analgesia or sedation
• A childs response to analgesia or sedation is
  unpredictable - usually no history of previous
  exposure

40
Pharmacological Pain Management

• Gather a complete history
• Include history of allergies
• Be familiar with side effects and
• complications of medications
• risk for aspiration hypotension
• decreased respirations dysrhythmia
• Have equipment available to handle potential
  complications and side effects

41
Pharmacological Use

• You must practice within your Scope of Practice.
  This includes administering only medications that
  are listed on your Region X SOPs. This is the
  list your medical director has approved for your
  use while functioning under their license.
• Some of the following medications are for
  didactic discussion only are not used in Region
  X.
• The dosages listed for Versed and Valium are
  those listed in the Region X SOPs.

42
Prehospital Analgesic Pain Management

• Nitrous Oxide
• useful for orthopedic soft tissue
  injury
• feeling of disassociation/euphoria
  
• used on children that can follow
  directions
• to allow drug to be
  self-administered
• watch for nausea /or vomiting
• ? CMC SOG Infield Policy 16 - may
  administer to those 13 and older

43
Prehospital Analgesic Pain Management

• Morphine Sulfate
• narcotic analgesic
• useful for continuous, significant pain
• given on order of MD for pediatric patient y/o
• given based on weight (0.05 to 0.15mg/kg)
• cannot be used on patient with head injuries
• patient should have an adequate level of
  consciousness to start with
• monitor for respiratory depression hypotension
  vomiting possible histamine-release side effects
  (redness, itching, hives)

44
Prehospital Analgesic Pain Management

• Fentanyl
• analgesic, opioid agonist
• lollipop form for oral dose or IVP route
• no histamine side effect like morphine
• dosage by weight (0.5 to 1 mcg/kg) slow IVP
• chest wall rigidity observed if administration
• is too rapid
• ? Not available in Region X SOPs

45
Prehospital Sedation

• Drugs used for sedation in children
• Midazolam (Versed)
• Diazepam (Valium)
• Lorazepam (Ativan)
• Etomidate
• available to those operating within the Region X
  SOPs

46
Midazolam (Versed)

• Short-acting benzodiazepine
• Rapid onset of action
• Duration of action-20 minutes-2 hrs
• Alters response to pain
• Does not alter perception of pain
• No analgesic effects
• Listed in Region X SOP for cardioversion
• Region X dose 0.1mg/kg slow IV push (2 min)
• Watch for respiratory depression (assist with
  BVM), hypotension
• Reversal agent is flumazenil (not carried in
  Region X)

47
Diazepam (Valium)

• Longer-acting benzodiazepine
• Powerful CNS depressant
• Rapid onset of action
• Duration of action 4 - 6 hrs
• Dosage weight based 0.2 mg/kg IVP over 2 - 5 min
  rectally 0.5 mg/kg
• May induce sleep, sedation, hypnosis, muscle
  relaxation
• Used for seizure control (Region X)
• Watch for hypotension respiratory depression

48
Lorazepam (Ativan)

• Benzodiazepine with shorter half-life than
  diazepam
• Useful for long-term sedation, seizure activity
• Powerful CNS depressant
• Short shelf life if not refrigerated
• Dosage weight based (0.05 to 0.1 mg/kg) over 2-5
  minutes IVP or can be given IM or PO
• Side effects to watch for include respiratory
  depression, sleep, sedation, muscle relaxation,
  amnesia, GI symptoms
• ? Not available in Region X SOPs

49
Etomidate

• Relatively new sedative just being introduced
  into pre-hospital care setting
• Very short acting
• No respiratory depression or hypotension or
  bradycardia
• Decreases intracranial pressure and metabolic
  demand so ideal for head injured patients
• Does not cause respiratory depression or
  hypotension
• Weight based dosage (0.2 to 0.4mg/kg) given slow
  IVP
• Most significant side effects are that it can
  induce twitching and focal seizures

? Not available in Region X SOPs
50
Special Health Care Needs Created by Many
Different Pathologies

• Prematurity
• Lung disease
• Heart disease
• Neurological diseases
• Chronic diseases
• Injuries or altered
  functions from
• birth - congenital
• and acquired

51
Technology Assisted Children (TAC)

• Tracheostomy Tube
• Mechanical device to maintain airway
• Usual indications include
• Surgery, prematurity, early need for ventilator,
• chronic respiratory infections, trauma

52
Tracheostomy TubeComplications

• Obstruction
• Bleeding
• Air leak
• Dislodgement
• Infection

53
Tracheostomy Tube Management

• Maintain open airway
• Suction with 6 - 8 fr suction catheter
• Position of comfort for the child
• If trach tube must be replaced, can use ET tube
  of same diameter with MD orders

54
Home Artificial Ventilators

• Caregiver usually familiar with operation of unit
  being used
• If called to the scene to provide treatment
• Ensure patent airway
• Artificially ventilate with BVM connected to
  tracheostomy tube
• Transport with
• early
• communication
• to receiving facility

55
Ventilator Complications

• Caregivers are generally skilled in managing the
  equipment and generally call EMS when they run
  out of options
• Complications
• Machine malfunction
• Airway obstruction
• Respiratory distress
• BVM
• Ventilate with enough volume to barely make the
  chest wall rise

56
Central Venous Lines

• Generally placed for
• Chronic illness
• Need for frequent access to venous circulation
  for drug therapy or fluid therapy

57
Types of Vascular Access Devices (VAD)

• Mediport-surgically implanted in chest
• PICC-peripheral vascular access usually in
  antecubital area with an exposed catheter access
  port
• Hickman/Groshong-central venous access
• with exposed ports surgically inserted
• Portacath - surgically implanted access under the
  skin below the clavicle requires special Huber
  needle to gain access

58
Central Venous Lines

• Complications
• Cracked line - torn or leaking catheter allows
  fluids to infiltrate into surrounding tissue
• Air embolism
• Bleeding
• Obstruction of tubing - seen as sluggish or
  absent flow
• Local infection - swelling, redness tenderness
  at site

59
Central Venous Lines

• Management of complications
• Maintain sterile technique
• Bleeding - control with direct pressure
• Cracked line clamp tubing between crack and
  patient insert point
• if altered mental status occurs - position
  patient on their left side with the head down
• head down position prevents air embolism from
  traveling to the brain
• Obstructed lines
• may need to be cleared with heparin and saline
  flushes by medically trained personnel

60
Gastric and Gastrostomy Tubes

• Placed into the stomach for a method to maintain
  the nutritional status of the patient who is
  unable to feed by mouth
• Variety of tubes available
• Need to remain alert for respiratory problems
  when tubes are used
• Tubes placed via nose or through upper left
  quadrant of abdomen with distal tip remaining in
  the stomach

anterior abdominal wall
stomach
61
Gastric and Gastrostomy Tubes

• Complications
• Obstruction to the tubing
• Pulmonary aspiration
• GI disturbances (vomiting/diarrhea)
• Irritation to mucous membranes
• Electrolyte imbalances
• Management
• Assure adequate airway
• Suction as needed
• Transport with head elevated

62
Cerebrospinal Fluid (CSF) Shunts

• Used to treat hydrocephalus -
• a condition caused by imbalance of CSF production
  and CSF removal in the cerebral ventricular
  system
• subarachnoid space unable to properly reabsorb
  fluid or there is an obstruction to outflow of
  fluid
• when fluid levels increase, intracranial pressure
  increases and ventricles dilate creating
  neurological symptoms

63
Types of CSF Shunts

• Ventriculoperitoneal (VP) shunt
• fluid transported from ventricles of brain to
  peritoneal space
• reservoir can usually be palpated over the
  mastoid area just behind the ear
• Ventriculoatrial (VA) shunt
• fluid carried from ventricles of brain to right
  atrium of the heart
• Ventriculopleural (V-pleural) shunt
• CSF drained into the pleural space

64
Shunt Complications

• Child has outgrown shunt and requires
  replacement
• Obstruction from clotted blood or fluid
• Catheter displacement
• Infection
• Signs symptoms of increased intracranial
  pressure
• headaches, crankiness, high pitched cry
• nausea vomiting
• visual disturbances
• Cushings triad - ?B/P, bradycardia, irregular
  respirations

65
Management of CSF Shunts

• Shunt problems are surgical emergencies that
  require transport to prevent brainstem herniation
• Patient prone to respiratory arrest
• Routine medical care with head elevated during
• transport
• Monitor for
• seizure activity

66
Neurological Emergencies

• Seizures can develop due to
• noncompliance with seizure medications
• head trauma
• intracranial infection
• metabolic disturbance
• poisoning
• fever
• Febrile Seizures
• Most common between ages of 6 months-6 years
• Fever is part of inflammatory process response
• Seizure often triggered by sudden fever or rapid
  rise more than the actual temperature in degrees

67
The Febrile Child

• Low-grade fever - 1000 - 102.50F
• High-grade fever - above 102.50F
• Key signs of potential serious illness
• fever above 100.50F in child
• altered mental status
• respiratory distress
• signs of shock
• history recent seizures
• bruising or spotty rash
• stiff neck

68
Seizures in Children

• Very common reason for 911 calls
• Most seizures in children are benign
• EMS should focus on supporting airway and
  ventilations
• Few other interventions are usually necessary
• Remember to evaluate for harmful, but reversible,
  causes of seizures
• hypoglycemia
• hypoxia
• poisonings

69
Febrile Seizures

• Prevention steps to teach caregiver
• to have working thermometer in household and know
  how to use it
• to understand importance of compliance with
  medications
• to understand significance of high fevers and
  know when to call the doctor
• how to care for the child
• with a fever
• avoid alcohol baths
• avoid overlayering the child
• with too much clothing
• use antipyretics (Motrin,
• Tylenol) PRN
• maintain hydration status

70
Traumatic Emergencies

• Trauma, blunt and penetrating, is the predominant
  cause of injury and death in children
  over medical causes

71
Circulatory Adequacy in Children

• B/P in children often difficult to obtain is a
  late marker of hypoperfusion
• To monitor circulatory status in children, best
  to assess focus on
• mental status changes
• heart rate
• capillary refill
• pulse character
• changes in urinary output

72
Traumatic Emergencies - Falls

• Single most common cause of injury
• Serious injury/death resulting from accidental
  falls is uncommon unless fall is from a
  significant height
• When children fall,
• they tend to fall
• head first

73
FallPrevention

• Raise crib rails
• Appropriately restrain children in
• strollers/highchairs
• Fence stairways
• Avoid walkers but especially near stairways
• Remove scatter rugs
• Install non-skid mat in tub/shower
• Supervise all play
• Install safety locks on windows that limit the
  amount a window can be opened

74
Motor Vehicle Crash

• Leading cause of permanent brain injury
• Leading cause of death and serious injury
• Minors cannot sign a release
• Emancipated minor
• girl under 18 who is pregnant
• a child under 18 who is a parent
• once a child is no longer a parent, the
  emancipated status is void

75
Federally Approved Car Seats

• Child under 20 pounds and 1 year old must face
  backwards (immature neck muscles)
• Seat should be professionally installed or at
  least evaluated
• Child should be transported to ED in the car seat
  if
• possible
• Immobilize C-spine
• with towel rolls

76
Pedestrian Vehicle Crash

• Lethal form of trauma in children
• Initial injury due to impact with vehicle
• Then child thrown from force of impact causing
  additional injury from impact with other
  secondary objects
• Child often run over by the same vehicle
• Waddells triad - the bumper-hood- ground
  mechanism of injury when car strikes child often
  producing injuries to left femur, spleen, and
  head

77
Pedestrian Safety Prevention

• Teach children pedestrian safety rules
• Dont allow children to stand behind parked cars
• Lock fences and doors
• Rules of the Road
• for bicycles- must
• ride with traffic

78
Special Considerations For Traumatic Emergencies

• Head injury most common cause of death in trauma
  patients
• Large mass of head and lack of neck muscle
  strength provide increased momentum in
  acceleration-deceleration injury
• 60-70 of fractures in children occur at the
  level of C1 or C2
• watch for respiratory arrest

79
Pediatric Head Injuries

• Focal (localized)
  injuries to one area of the brain are rare,
  injuries tend to be more diffuse
• Soft tissue, skull, brain more compliant than in
  adults
• Significant bleeds in an infant can produce
  hypotension
• Stretching of cranial vault possible because
  fontanelles are still open

80
Drowning

• 3rd leading cause of injury/death
• in children of all ages
• Defined as death by suffocation
• from submersion
• Causes approximately 2000
• deaths annually
• Severe, permanent brain damage occurs in
  5-20 of those injured
• Wet drowning - water aspirated into lungs
• Dry drowning - laryngospasm prevents water from
  entering lungs death by asphyxiation or airway
  occlusion

81
Prevention of Water Related Emergencies

• Did you know - a child only needs a few inches of
  water in a bucket to drown
• Lock front-loading appliance doors
• Keep bathroom doors closed and toilet lids down
• Fence swimming pools
• Teach water safety and offer swimming lessons
• Learn infant and child CPR and foreign body
  airway obstruction techniques

82
Penetrating Injury

• Risk of death from firearms increases with age
• Stab wounds/firearm injury account for 10-15 of
  pediatric hospital admissions
• Visual inspection of external injury cant fully
  evaluate internal involvement
• Store dangerous tools, firearms, garden equipment
  in locked cabinets

83
Burns

• Leading cause of accidental death under 14 years
  of age
• Burn survival is a function of burn size and
  related injuries
• Modified Rule of Nines - used to determine
  percentage of area involved
• Palmar method - childs palm equals 1 of their
  body surface area

84
Rule of Nines

• Region X SOP Breakdown of Percentages
• (equals 101)
• Full head, anterior thorax (includes chest and
  abdomen), back 18 each
• Full upper extremity 9 each
• Full lower extremity 14 each
• Perineum 1

Numbers equal 100
85
Burn Prevention

• Test formula/food prior to feedings
• Install smoke detectors in home one/level
• Beware of cigarette ashes
• Minimize sun exposure use sunscreen
• Cover electric outlets with plastic guards
• Turn pot handles toward back of stove
• Teach dangers of fire/flame
• Teach fire safety
• If hot liquid spilled on infant, remove diaper

86
Abuse Neglect

• Child abuse
• child suffered intentional physical or emotional
  injury by an individual responsible for the
  childs care
• Child neglect
• childs physical, mental, or emotional condition
  has been endangered due to failure to provide for
  basic needs including food, clothing, shelter,
  supervision, or medical care
• Prehospital care providers should never confront
  or accuse parents or caregivers - document
  objectively carefully

87
Abuse and Neglect

• 5 indicators or opportunities to observe signs of
  abuse or neglect
• environmental indicators
• historical indicators
• physical indicators
• abuser indicators
• abused child indicators
• What would you consider suspicious in each of the
  indicators?
• Presence of indicators are not proof of abuse or
  neglect but their presence should raise suspicions

88
Abuse Prevention

• Teach stranger danger
• Supervise children at all times
• Recognize the possibility of abuse, call report
  to 1-800-25-ABUSE
• Prehospital providers must phone in a report and
  follow-up with paperwork
• Transport to the ED where additional services can
  be made available
• Be alert for abuse/neglect in children with
  special needs

89
Pediatric Transport Considerations

• Transport should not be delayed to
  perform procedures that can be done en route
• Transport to the appropriate facility that has
  expertise in pediatric care
• The earlier the better to call in report
• allows appropriate personnel and equipment to be
  assembled
• Maintaining patient temperature very important -
  avoid hypothermia

90
Interventions for the Pediatric Patient

• Broselow Tape
• length-based resuscitation device
• lists medication dosages and equipment based on
  length or weight of child
• precalculated dosages based on weight in
  kilograms
• legend section is a reference for calculations
  and pediatric trauma score
• there are no vital signs on 2002 edition

91
Broselow Tape

• Place red end of tape (with arrow)
• at top of childs head
• Read the colored box at the heel of the child
  (not to where the toes
• stretch to)
• Information listed
• both sides of tape

92
Big Bag? Little Bag?

• 250 ml normal saline (little bag)
• when a drug route needs to be available
• when control of volume is essential
• pediatric patients
• patients in CHF pulmonary edema
• frail elderly patients
• 1000 ml normal saline (big bag)
• when fluids are needed or anticipated

93
To Calculate Medication Dosages

• Convert pounds to kilograms
• 1 pound 2.2 kilograms (kg)
• for older adults acceptable to divide pounds in
  half (150 ? 2 75 kg)
• for children divide pounds by 2.2
• 22 pounds ? 2.2 10 kg
• Multiply the kg by the formula given (example 0.2
  mg/kg)
• 10 kg x 0.2 mg 2 mg to give
• ?

94
Medication Calculation

• Need to calculate the amount of solution to
  administer the required amount of mg (example
  give 3 mg morphine comes 10 mg/ml). Use a
  formula
• 1 mg on hand mg ordered
• ml on hand ml desired (x ml)
• 10 mg 3 mg
• 1 ml X ml (cross
  multiply)
• 10 X 3
• 10 X / 10 3 / 10
• X 3 ? 10 0.3 ml

95
Formula for Medication Calculation

• Formula 2
• X ml (desired dose) (vol on hand)
• dose on hand (mg)
• X ml (3 mg) (1 ml)
• 10 mg
• X ml 3
• 10
• X ml 3 ? 10 0.3 ml

96
Airway Control in the Pediatric Population

• Intubation skill similar as in adults with
  changes in equipment and positioning
• Airway positioning
• due to large occiput, to maintain neutral c-spine
  alignment
  shoulders to hips
• Pulse oximetry cardiac monitoring
• pediatric patients will demonstrate bradycardia
  in presence of hypoxia
• correct bradycardia with ventilations versus
  giving medications

97
Intubation Equipment

• BVM - ventilate with enough volume to make chest
  rise gently oxygenate at least for 30 seconds
  prior to ETT attempts
• straight Miller blade - easier to lift floppy
  epiglottis
• ET tube (? Broselow for sizing)
• stylet - recess 1/2? from distal tip of ETT
• suction catheter (turn suction down time limit to
• ETCO2 built into BVM to confirm tube placement
  after several breaths
• tape towels or C-collar to help secure

98
ET Tube as a Drug Route

• L - lidocaine
• A - atropine
• N - narcan
• E - epinephrine
• To use ETT route, double the amount calculated
  for the IVP route
• Flush with 1-5 ml saline the smallest amount for
  the smallest of patients
• flushing washes the medication off the wall of
  the ETT and assures placement in lungs

99
Confirming ETT Placement

• Bilateral rise fall of chest
• Bilateral equal breath sounds - auscultate in
  axillary areas
• Absence of epigastric sounds
• Improvement in patient condition
• Improved heart rate
• Improved skin color
• Improved mental status

Confirm every time the patient is moved!!!
100
IV Access - Intraosseous Insertion

• Allows administration of drugs, fluids, and blood
  products directly into the bone marrow
• Indications for Region X
• child under 6 years of age
• presence of shock or cardiac arrest
• 2 failed attempts at peripheral IV insertion or
  90 second time limit
• Contraindication - fracture in same bone

101
Intraosseous Equipment

• IO needle - can usually adjust length to less
  than diameter of childs leg
• 10 ml syringe filled with 5ml 0.9 NS
• Skin prep material
• Primed IV bag
• with tubing

102
Intraosseous NeedleInsertion Technique

• Select site
• proximal tibia just below knee
• flat bone area 1-2 cm (3/8 - 3/4?) distal to
  slightly medial to tibial tuberosity (1? 2.5
  cm)
• Prep area
• Apply constant pressure with palm and use
  twisting motion to push thru cortex to enter
  marrow - avoid growth plate
• Use slight angle towards feet or 900 angle

103
Confirming Intraosseous Placement

• Feel pop or note lack of resistance
• Needle stands on own
• With inner trochar removed, connect syringe with
  saline to IO and aspirate watching for bone
  marrow
• Line flushes easily
• Observe for extravasation
• Consider use of pressure
• bag to maintain fluid flow or at least
  initially be prepared to squeeze IV bag

104
Securing IO Needle

• Secure with gauze dressing and tape
• Can use arm board to support leg
• Document site and size needle
• used

105
Pediatric Patients AEDs

• If an AED is to be used, the pediatric patient
  should receive one minute of CPR prior to
  analyzing with the AED.
• It is preferable to use pediatric pads but in the
  absence of peds pads, use adult pads placing them
  in the anterior/posterior positions.
• Doing something is better than nothing!
• Developed by EMSC Prehospital Committee May,
  2005. Accepted into Region X practice.

106
ABCs of Infant Child CPR

• Airway -gentle head tilt, chin lift
• Breathing
• once every 3 seconds (20/minute)
• enough to make the chest gently rise
• Circulation / Compressions
• child 1-8 heel of one hand lower half of sternum
• infant or thumbs around the chest wall
• 51 for 1 and 2 man CPR
• compression rate of 100/minute minimum

107
Pediatric Case Scenarios

• Michael is 9 months old. Mom states she had a
  difficult time waking him up today.
• Assessment
• eyes open but seems unaware of environment
• increased work of breathing
• color pale
• history of failure to thrive, no other history
• the child is small for his age (15 pounds)
• VS HR 160 RR 16 weak peripheral pulses
• Cardiac monitor - sinus tachycardia

108
Case Scenario 1

• Interventions started
• assess ABCs
• apply supportive oxygen
• check glucose level (altered LOC!)
• Glucose level 38
• administer D12.5 4ml / kg
• How many kilograms is Michael (15 pounds)?
• How much glucose does he get and which dilution?

109
Case Scenario 1

• 15 pounds 2.2 6.8 kg 7kg
• Give 4ml/kg of D12.5
• 4ml x 7kg 28 ml of D 12.5
• 28 ml total solution volume is to be made as a
  11 dilution of D25
• draw up 14 ml D25 and mix with 14 ml of normal
  saline
• administer slowly due to vein irritation
• Reassessment Michael is more responsive after D
  12.5

110
Case Scenario 2

• Justin is a 3 year old who fell from playground
  equipment. He didnt move for several minutes
  and now is sleepy and is currently lying quietly
  in moms arms. Dried blood noted on face.
• Assessment
• unresponsive to pain
• breathing decreased from your first visual
  contact with the patient
• color pale with bluish tint around mouth
• VS HR 160 RR 20 B/P 98/58

111
Case Scenario 2

• Interventions necessary
• ABCs
• IV-O2-Monitor-C-spine control
• Watch vital sign trends
• Child becoming less responsive, more cyanotic,
  heart rate dropping, unable to get peripheral IV
• consider bagging, potential intubation
• prepare for IO insertion
• Resource for equipment sizing
• Broselow tape measured top of head to heel

112
Drug Calculation Practice 1

• Your 3 year old patient who weighs 30 pounds
  needs rectal valium. The dosage is 0.5 mg/kg.
  The valium syringe reads 10 mg/2ml
• a. how much does the child weigh?
• ____kg
• b. how much drug should the child
• receive? ____mg
• c. how many ml needs to be drawn up?
• ____ml

113
Drug Calculation Practice 2

• Your two year old patient weighs 25 pounds.
  Their symptomatic bradycardia requires
  Epinephrine 110,000 at 0.01 mg/kg IVP or IO.
  Epinephrine is packaged as 1 mg/10ml.
• a. how much does the child weigh?
• ____kg
• b. how much drug should the child
• receive? ____mg
• c. how many ml needs to be drawn up?
• ____ml

114
Drug Calculation Practice 3

• Your 31/2 year old patient weighs 35 pounds.
  They went into grandmas purse and now need to
  receive narcan at 0.1 mg/kg. The narcan syringe
  reads 2 mg/2ml.
• a. how much does the child weigh?
• ____kg
• b. how much drug should the child
• receive? ____mg
• c. how many ml needs to be drawn up?
• ____ml

115
Drug Calculation Answer Key

• ? 30 13.6 kg rounded to14 kg
• 14 x 0.5 mg/kg 7 mg
• 7 mg 1.4 ml
• ? 25 11.3 kg rounded to 11 kg
• 11x 0.01 mg/kg 0.11 mg
• 0.11 mg 1.1 ml
• ? 35 15.9 kg rounded to 16 kg
• 16 x 0.1 mg/kg 1.6 mg
• 1.6 mg 1.6 ml

116
Acknowledgement

• NIMSCA contribution for packet by Valued
  Gateway Client
• Additions/revisions made by
• Sharon Hopkins, RN, BSN
• Region X SOPs effective March 2005
• CMC EMS System SOGs

117
Pediatrics October 2005
Questions ??