Pediatric Medical Emergencies

1
Pediatric Medical Emergencies

• Condell Medical Center
• EMS System
• August, 2007 CE
• Site Code10-7200E1207

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

• Upon successful completion of this module, the
  EMS provider should be able to
• identify critical situations in the pediatric
  population
• identify and appropriately state interventions
  for a variety of EKG rhythms
• actively participate in a pediatric code
  situation
• successfully complete the quiz with a score of
  80 or better

3
Children are not small adults!

4
Relationship of Head to Body Changes
5
Pediatric Population Defined

• A patient under the age of 16 is considered to be
  a pediatric patient
• This means the patient is 15 years of age or less
• When medications are calculated based on the
  pediatric patient weight, the dose is to never
  exceed the amount that would be administered to
  an adult!

6
Children and EMS

• Adults may be glad to see EMS arrive
• but
• children are often frightened when EMS comes to
  their rescue

7
Critical Determination

• Rapid assessment needs to be performed to
  determine
• Is this child sick or not?
• Any sick child needs immediate attention and
  intervention

8
Pediatric Assessment Triangle(PAT)

• Helps establish a general impression
• Used to
• establish a level of severity
• determine urgency for life support
• identify key physiological problems
• Provider to assess
• appearance
• work of breathing
• circulation to skin

9
Pediatric Assessment Triangle (PAT)
10
Pediatric Assessment Triangle (PAT)

• Does not require any equipment to complete
• Uses observational and listening skills
• Can be completed in under 60 seconds
• To be used as you cross the room to make
  contact with the patient

11
Pediatric Assessment Triangle (PAT)

• Evaluates underlying cardiopulmonary,
  neurological, and metabolic states
• Can help identify the general physiological
  problem for the child
• PAT does not replace vital signs and the ABCDEs
  but precedes compliments them

12
Pediatric Assessment

• Scene size-up
• General assessment - pediatric assessment
  triangle (PAT)
• Initial assessment
• ABCDEs and transport decision
• Additional assessment
• focused history and physical exam detailed
  physical exam if trauma
• Ongoing assessment

13
Pediatric Assessment Triangle Appearance

• Reflects adequacy of
• oxygenation
• ventilation
• brain perfusion
• homeostasis
• CNS function

14
Assessing Appearance

• Evaluate
• muscle tone
• mental status/interactivity level
• consolability
• look or gaze
• speech or cry

15
Pediatric Assessment TriangleBreathing

• Reflects
• adequacy of oxygen
• oxygenation
• ventilation

16
Assessing Breathing

• Evaluate
• body position
• visible movement of chest or abdomen
• lt6-7 years old is primarily a diaphragmatic
  breather (belly breather)
• respiratory rate effort
• audible airway sounds

17
Pediatric Assessment Triangle Circulation

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

18
Assessing Circulation

• Evaluate
• skin color
• peripheral cyanosis refers to the extremities
• central cyanosis is always pathological
  evaluated in the central part of the body mucous
  membranes of the mouth and trunk area
• reflects decreased oxygen in arterial blood
• Trunk mottling indicates hypoxemia
• Cyanosis indicates respiratory failure and
  vasoconstriction

19
Principles of Infant Assessment

• Ask caregiver for patients name use it
• To decrease the infants stress, perform
  assessment in the following order
• observation
• auscultation
• palpation
• Approach infant slowly, calmly, and talk in quiet
  voices warm your hands before contact
• Try to be at patients eye level

20
Infant Assessment

• Observe interaction between caregiver and infant
• Consider offering a toy as a distraction
• Perform assessment based on acuity level
• if quiet calm, obtain respiratory rate and
  breath sounds
• if critical, obtain most important information
  1st
• Make non-threatening contact 1st
• make 1st contact with extremity can also obtain
  capillary refill simultaneously

21
Principles of Toddler Assessment

• Beginning to assert independence but fearful of
  separation from caregiver
• Approach slowly keep contact to a minimum
• Be at eye level
• If possible, allow toddler to stay on caregivers
  lap
• Introduce equipment slowly and use distraction
  (ie penlight, toy)
• A toddler is the center of his universe - ask
  questions about them (ie pets, clothing, events)

22
Toddler Assessment

• Keep choices limited (ie should I use the red
  or blue package)
• Ask open ended questions avoid yes/no questions
• Praise toddler to get cooperation
• Use simple, concrete terms
• Perform most critical part of assessment 1st
  moving in toe-to-head order
• Ask caregiver to assist (ie removing clothing,
  holding stethoscope)
• Toddlers do not sit still

23
Principles of Preschooler Assessment

• Magical and illogical thinkers fear loss of
  control short attention spans
• Use simple terms explain procedures immediately
  before performing
• Allow child to handle equipment
• Its okay to set limits (ie you can cry but you
  cannot kick)
• Focus on one thing at a time

24
Principles of School-aged Assessment

• Fear separation from caregiver loss of control,
  pain, physical disability
• Speak directly to child, then to caregiver
• Respect privacy, these children are modest
• Dont offer too much information do use terms
  the child can understand explain immediately
  before the procedure is done

25
School-Aged Assessment

• Dont negotiate unless there really is a choice
  (ie IV in right or left hand, not if it is okay
  to start the IV)
• Offer praise for cooperation
• Physical assessment okay to be performed in
  head-to-toe format

26
Principles of Adolescent Assessment

• Time for experimentation and risk-taking
  behaviors
• Struggle with independence, loss of control, body
  image, sexuality, and peer pressure
• Relying more on friends than family
• When ill or injured, often revert back to lower
  maturity level
• Explain what you are going to do and why

27
Adolescent Assessment

• Encourage questions and involvement of the
  adolescent
• Show respect speak directly to teen
• Respect privacy and confidentiality
• Be honest and nonjudgmental

28
Pediatric Assessment - Appearance

• Provides most important look into the status of
  the child - are they sick or not?
• Start observation as you 1st enter the scene and
  while the child is still with the caregiver
• immediate hands-on may increase agitation, crying
  and may interfere with a true picture
• immediate hands-on is necessary if the child is
  unconscious or obviously critically ill

29
Normal/Abnormal Appearance

• Normal appearance
• good eye contact, has good muscle tone, and good
  color
• Abnormal appearance
• poor eye contact, listless, and pale
• Appearance doesnt indicate the cause of
  illness or injury but reflects that a problem is
  going on

30
Normal Appearance In Setting Of a Critical
Situation

• Maintain index of suspicion in children that look
  okay initially but may soon become critically
  ill
• toxicological problems (overdoses)
• blunt trauma
• powerful compensation abilities may fool the
  examiner
• when the child crashes they will crash quickly
  with rapid progression to decompensated shock

31
Work of Breathing

• In the pediatric patient, evaluation of work of
  breathing gives great insight into the pediatric
  patients oxygenation ventilation status
• Listen for abnormal airway sounds
• snoring, muffled or hoarse speech, stridor,
  grunting, wheezing
• Look for signs of increased breathing effort
• sniffing position, tripoding, refusing to lie
  down
• retractions (neck, intercostal, substernal
  muscles)
• nasal flaring

32
Tripod Positioning-leaning forward, hands
resting on thighs
33
Costal retractions use of accessory neck muscles
34
Abnormal Breath Sounds

• Upper airway obstruction
• snoring, muffled, hoarse speech, stridor
• stridor - high-pitched inspiratory sound
  abnormal airflow across partially obstructed
  upper airway
• Potential causes
• croup
• foreign body
• aspiration
• bacterial upper airway infection
• bleeding, edema

35
Abnormal Breath Sounds

• Grunting
• exhaling against a partially closed glottis
• keeps alveoli open for maximum gas exchange
• sound heard best at end of exhalation
• often present with moderate to severe hypoxia
• reflects poor gas exchange due to fluid in lower
  airways
• Potential causes
• pneumonia
• pulmonary contusion
• pulmonary edema

36
Abnormal Breath Sounds

• Wheezing
• continuous high-pitched musical sound a whistle
• movement of air across partially blocked small
  airways
• in disease process heard earliest during
  exhalation
• as obstruction increases, heard during inhalation
  and exhalation
• with increased obstruction heard audibly
• Most common cause - asthma
• Other potential causes
• bronchiolitis
• lower airway foreign body aspiration

37
Abnormal Visual Signs - Increased Work of
Breathing

• Providers must evaluate visually to determine
  evidence of increased work of breathing
• this means all patients need to be eventually
  undressed for observation of the neck chestwall
• Sniffing position - severe upper airway
  obstruction used as attempt to increase airflow
• Tripoding - refuses to lie down, leans forward on
  outstretched arms attempting to use accessory
  muscles to breath

38

• Retractions - use of accessory muscles to help
  breath using extra muscle power to move air into
  lungs more prominent in child than adult
• includes head bobbing - use of neck muscles
  during severe hypoxia
• includes nasal flaring - exaggerated nostril
  opening during inspiration moderate to severe
  hypoxia

39
Respiratory Distress
40
Evaluating Respirations

• Respiratory rate
• Best to count for a minimum of 30 seconds due to
  the natural irregularity of the pattern
• Breath sounds
• Place the stethoscope as lateral as possible
• Pulse oximetry
• Evaluate results along with work of breathing
• Readings above 94 indicates probably good
  oxygenation

41
Normal Respiratory Rates By Age

• Infant 30-60 breaths/minute
• Toddler 20-30 breaths/minute
• Preschooler 20-30 breaths/minute
• School-aged child 20-30 breaths/minute
• Adolescent 15-20 breaths/minute
• Trending more helpful than a single reading
• Values differ by source

42
Abnormal Visual Signs - Poor Circulation to the
Skin

• Cold environment may cause false skin signs
• Inspect skin and mucous membranes
• Look at face, chest, abdomen, extremities, and
  lips
• Dark complexion patients
• assess lips and mucous membranes

43

• Circulation to skin reflects overall status of
  core circulation
• pallor - early sign compensated shock
• mottling - constriction of blood vessels to the
  skin
• cyanosis - late finding of respiratory failure or
  shock critical finding that indicates immediate
  resuscitative action

44
Evaluating Circulation

• Heart rate - bradycardia is ominous sign
• Pulse quality
• Brachial is the peripheral site for a child under
  one
• Central pulse - femoral in infants and young
  children carotid in older child or adolescent
• Skin temperature and capillary refill
• Good locations are at the kneecap or the forearm
• Blood pressure
• Should make an attempt on children older than 3
• Cuff size should cover 2/3 the length of the
  upper arm

45
Normal Heart Rates by Age

• Infant 100-160 beats per minute
• Toddler 90-130 beats per minute
• Preschooler 80-120 beats per minute
• School-aged child 70-120 beats per minute
• Adolescent 70-120 beats per minute
• Bradycardia indicates critical hypoxia and/or
  ischemia and indicates need for immediate
  interventions

46
Region X Pediatric SOPs
47
Region X Routine Pediatric Care SOPs

• General patient assessment - pediatric assessment
  triangle (PAT)
• appearance
• work of breathing
• circulation to skin
• Initial assessment - ABCDEs
• Identify priority patient and make transport
  decision

48

• Additional assessment and interventions
• vital signs
• determine weight and age
• pulse oximeter before during O2
• cardiac rhythm if applicable
• IV/IO access (20 ml/kg administered under 20
  minutes if fluid challenge is necessary)
• determine blood glucose if indicated
• altered level of consciousness
• unconscious, unknown reason
• known diabetic and related problem
• reassess previous assessments appropriateness
  of interventions performed

49

• Detailed physical exam
• Contact Medical Control
• Transport to closest most appropriate hospital
• Always remember to keep child warm
  hypothermia increases the rate of complications
  and negative outcome

50
Altered Level of Consciousness

• Dextrose
• Sugar to replace depleted stores
• Brain extremely sensitive to a drop in glucose
  levels
• Dose if less than 1 year old
• 12.5 4 ml/kg
• Dose for ages 1 - 15 (gt1 - lt16)
• 25 2 ml/kg
• Dose for ages 16 and over
• 50

51
Glucose Dosing

• To remember dosing schedule
• D 12.5
• 4 x 12.5 50 therefore D 12.5 is 4 ml/kg
• D 25
• 2 x 25 50 therefore D 25 is 2 ml/kg
• Diluting D 25 to make D 12.5
• Calculate total dose volume required
• Half the dose volume is D 25 half the dose
  volume is normal saline
• Mix 50/50 solution and administer slowly

52
Case Study

• A 12 year-old boy calls 911 for his unconscious 4
  year-old sister
• The brother reports a few minutes of full body
  shaking by the sister you are informed that the
  patient was recently diagnosed as a diabetic and
  she takes shots
• The patient is unresponsive, limp,
  pulse rate 140 RR 30 B/P 98/68
• What is your impression?
• What is your approach/intervention?

53
Case Study

• This child is most likely hypoglycemic
• Sugar stores are quickly used and the brain is
  the most sensitive organ to ? glucose levels
• Protect the airway (positioning, have suction
  available)
• Obtain IV access and evaluate the glucose level
  (this patients blood sugar is 40)
• This patient needs dextrose (glucagon if no IV)
• gt1 years old D25 (2 ml/kg)
• Patient weighs 25 pounds

54
Practice Math - How much Dextrose does this
patient receive?

• 25 pounds ? 2.2 kg ? kg
• 2.2 25 (move decimal to right in both
  numbers)
• 22 250 11 kg
• D 25 formula 2 ml/kg
• 2(ml) x 11(kg) 22 ml D25
• Administer slowly through largest vein available
  (irritating to veins)

55
Altered Level of Consciousness

• Glucagon
• In the absence of IV access
• 0.1 mg/kg (max dose 1 mg (1 unit))
• Must be reconstituted
• May be followed by Dextrose if IV access obtained
  no improvement in LOC
• Narcan
• Known or suspected acute narcotic overdose
• lt 20kg 0.1 mg/kg IVP/IO/IM (max dose 2mg)
• gt20 kg (approx 4 year-old) 2 mg IVP/IO/IM

56
Protecting The Airway

• Positioning
• side lying
• securely strapped to the backboard with
  sufficient head/spine immobilization in case of
  need to rapidly turn the backboard onto its side
• Suctioning
• anticipate the need, unit turned on and ready to
  be used
• minimize time suction applied while removing
  catheter
• adults 10-15 seconds children lt 5 seconds
• Anticipate supplemental O2 - poss via BVM

57
Pediatric Acute Asthma

• Albuterol
• Bronchodilator with some cardiac side effects
  (?HR ? strength of contractions (pounding
  heart))
• 2.5 mg / 3ml in nebulizer
• May need to use nebulizer mask in place of
  mouthpiece
• Encourage deep slow breaths
• May need to administer Albuterol in-line
• Set up nebulizer equipment and start
  administering while bagging the patient even
  prior to intubation
• getting some drug into the lungs may prove
  helpful

58
Nebulizer Mask - when the patient cant tolerate
the mouthpiece
59
Acute Asthma

• Earliest in disease will auscultate bilateral
  wheezing breath sounds heard first on exhalation
• Eventually will hear audible wheezing standing
  next to the patient
• A silent chest (no breath sounds can be heard
  with a stethoscope) is a critical (deadly)
  situation in any patient
• Patients in an acute asthma attack are dry (lose
  moisture from the increased respiratory rate) and
  are potentially hypoxic

60
Patient Treatment

• Prior to any treatment, assessment must be done
• EMS needs to obtain a general impression
• this drives the decision regarding which SOP to
  work from
• EMS needs to think cause of the situation which
  can also drive a decision on which SOP to use

61
Possible Causes of Critical Cardiac Situations -
6 Hs 5 Ts

• Hypovolemia
• Hypoxia
• Hydrogen ion - acidosis
• Hyper/hypokalemia
• Hypothermia
• Hypoglycemia

• Tablets
• Tamponade, cardiac
• Tension pneumothorax
• Thrombosis, coronary (ACS)
• Thrombosis, pulmonary (embolism)
• Trauma

62
Pediatric Ventricular Fibrillation

• 2 minutes of CPR if arrest unwitnessed or gt4-5
  min
• Single defibrillation attempts for all persons
• Initial pediatric defibrillation - 2 j/kg
• 2nd subsequent defibrillation attempts - 4 j/k
• Immediately after defibrillation attempts, CPR
  resumed for all persons
• 302 for single rescuer on all patients
• 152 for 2 person with child infant CPR
• IV access
• Peripheral or IO routes attempted
• Flush all drugs with 5 ml NS to enhance delivery

63
Pediatric VF

• Meds
• Vasopressor -
• Epinephrine (primary action in arrest is to
  constrict blood vessels to support perfusion)
• 110,000 - 0.01 mg/kg IVP/IO
• repeated every 3-5 minutes for duration of arrest
• Antidysrhythmic
• Amiodarone 5 mg/kg IVP/IO 5 ml NS flush
• OR
• Lidocaine 1 mg/kg IVP/IO 5 ml NS flush

64
Antidysrhythmic Medications

• Do not mix administration of Amiodarone and
  Lidocaine
• The heart becomes more irritable when these drugs
  are administered simultaneously to patients
  during the same acute process
• IV drips
• Only establish a drip for the same drug
  administered IVP
• Lidocaine drip follows Lidocaine bolus
• Amiodarone drip follows Amiodarone bolus (usually
  hung at the hospital)

65
Pediatric Asystole, PEA, Pulseless
Idioventricular Rhythms

• CPR - push hard, push fast
• IV/IO fluid challenge
• 20ml/kg formula for all persons/all ages
• reassess as every 200 ml has been administered to
  the patient moving towards a total infusion
  amount
• monitor breath sounds on all patients receiving
  fluids
• Vasopressor drug
• Epinephrine 110,000
• 0.01 mg/kg IVP/IO followed by 5 ml NS flush
• Repeat every 3-5 minutes

66
What Is This Rhythm?

• Sinus Bradycardia
• What is the significance in the pediatric
  population?

67
Pediatric Bradycardia

• In pediatric patients, bradycardia almost always
  represents hypoxia
• Evaluate airway, airway, airway
• Ventilate, ventilate, ventilate (BVM)
• Vasopressor drug
• Epinephrine 110,000 0.01 mg/kg IVP/IO
• Repeat every 3-5 minutes
• Atropine - only helpful in pediatrics if the
  bradycardia is related to a vagal cause (more
  common in the adult)

68
What Is The Significance of This Rhythm In a
Newborn?

• This patient was born 5 days ago this rate is
  too slow
• A normal heart rate range in newborns should be
  100-160
• This patient is ill needs immediate ventilation
  support

69
Practice Math - Epinephrine

• Your patient weighs 26 kg
• Epinephrine 110,000 dose is 0.01 mg/kg
• 0.01 (mg) x 26 (kg) ? mg
• 0.01
• x 26
• 6
• 2
• 0 .26 (mg)

70
Formula 1 - To Determine ml Of Epinephrine To
Give

• mg on hand desired mg
• ml on hand X ml
• 1 mg 0.26mg
• 10 ml X
  ml
• (cross multiply) 1 x X 0.26 x 10
• 1X
  2.6
• (get X by itself) 1X?1 2.6 ? 1 (1 2.6 )
• X
  2.6 ml

71
Formula 2 - To Determine ml of Epinephrine To
Give

• Xml desired dose x vol on hand
• dose on hand
• X ml 0.26 (mg) x 10 (ml)
• 1 (mg)
• X ml 0.26 x 10
• 1
• X ml 2.6 (1 2.6 )
• 1
• X ml 2.6 ml IVP flushed with 5 ml NS

72
Pediatric Shock

• Hypovolemic
• Hemorrhage, diarrhea, vomiting, ? fluid intake
• Fluid challenge 20 ml/kg repeated twice more
  (60ml/kg)
• Reassess as every 200 ml is being administered
• Cardiogenic
• Usually congenital no fluid challenge to be
  given!
• Distributive
• Sepsis (massive infection), anaphylaxis
• Fluid challenge 20 ml/kg repeated twice more
• Reassess as every 200 ml is being administered
• If allergic response, add that protocol

73
Case Study

• You have been called to the home for a
  6-month-old vomiting for 24 hours.
• The infant is lying still with poor muscle tone
  irritable if touched weak cry.
• No abnormal airway sounds, retractions, or nasal
  flaring.
• Skin is cool, pale, mottled, with 4 second
  capillary refill time, weak brachial pulse.
• Heart rate 180 RR 30 breath sounds clear.
• Abdomen is distended.
• Impression? Intervention needed?

74
Case Study

• This infant is severely ill - in shock
• Poor appearance, diminished tone, poor
  interactiveness, weak cry
• Requires resuscitation rapid transport
• Vital signs are deceptive
• Need to be correlated with pediatric assessment
  triangle full assessment
• Immediate airway support (possible BVM support)
• IV/IO access - fluid challenge 20 ml/kg

75
Do The Math - How Much Fluid?

• The patient weighs 15.5 pounds.
• What is the amount of the fluid challenge that
  needs to be administered?
• How is the fluid challenge to be administered?
• 15.5 ? 2.2 ? 2.2 15.5 (move decimal point
  over to the right one space in each number)
• 22 155 7 kg
• 7 kg x 20 ml 140 ml fluid challenge NS
• Administer in under 20 minutes reevaluate

76
Pediatric Tachycardia

• Children compensate by increasing heart rate more
  than increasing contractility
• Sustained high respiratory rates and heart rates
  indicate a vascular problem
• Low respiratory rate, heart rate, and blood
  pressure indicate a serious problem with
  oxygenation, ventilation, and/or perfusion
• Trends in vital signs more important than taking
  one reading

77
Probable Sinus Tachycardia

• Most common tachycardia in pediatrics
• Rates can be higher than expected compared to the
  adult population
• Infants usually lt 220 beats per minute
• Child usually lt180 beats per minute
• Most common approach is symptomatic treatment

78
Pediatric Tachycardia

• May be a nonspecific sign not representing
  anything serious
• fear
• anxiety
• pain
• fever
• May be indicating a life-threatening problem such
  as hypoxia or hypovolemia
• Evaluate heart rate and QRS width

79
What Is This Rhythm?

• Probably sinus tachycardia in a pediatric patient
• Appearance is altered from typical adult rhythm
  pattern
• Treatment is geared to determining the underlying
  reason

80
Probable Supraventricular Tachycardia

• QRS narrow
• Rate can be higher than expected
• Infants usually 220 beats per minute
• Child usually 180 beats per minute
• Vagal maneuvers
• Have child hold their breath or have child blow
  hard through a straw
• Adenosine 0.1 mg/kg rapid IVP with flush
• Repeat Adenosine 0.2 mg/kg rapid IVP with flush

81
What is this rhythm?

• 9 wk old infant presents listless,
• sweaty, short of breath

Probably SVT
82
Pediatric Ventricular Tachycardia with Poor
Perfusion

• Severe systemic insult that must be reversed as
  soon as possible
• Electrical countershock - cardioversion
• Pre-medicate Versed 0.1 mg/kg IVP slowly over 2
  minutes, titrate to sedation
• Cardiovert 1 j/kg observing safety precautions
  (look call all clear)
• If repeat cardioversion required, 2 j/kg
  observing safety precautions

83
Pediatric Ventricular Tachycardia with Adequate
Perfusion

• You have time to attempt drug therapy
• Amiodarone 5 mg/kg IVPB
• Dose diluted in 100 ml D5W
• Pediatric drip rate at 30 mcgtt/10 seconds
• OR
• Lidocaine 1 mg/kg IVP
• Cardioversion after versed sedation if no
  response to drug therapy

84
Do The Math - Amiodarone

• Your 4 year-old patient weighs 40 pounds and will
  need Amiodarone 5 mg/kg
• Amiodarone in the arrested state is to be given
  as a diluted rapid IVP bolus (stable patients
  receive the drug slow IVPB)
• Calculate pounds to kilograms
• 40 (pounds) ? 2.2 (kg) ? Kg
• 2.2 40 (move the decimal to the right and
  need to move decimal space behind 40)
• 22 400 18 kg

85

• Calculate dosage of drug to administer
• 18 (kg) x 5 (mg/kg) 90 mg (of Amiodarone)
• Calculate volume of medication to administer
• Amiodarone packaged 50 mg/ml need to administer
  90 mg
• Formula 1 mg on hand desired mg
• ml on hand X ml
• Formula 2 Xmldesired dose x vol on hand
• dose on hand

86
Formula 1 - Desired Dose 90 mg

• mg on hand desired mg
• ml on hand X ml
• 50mg
  90mg
• 1 ml
  X ml
• (cross multiply) 50 x X 90 x 1
• 50X 90
• (get X by itself) 50X?50 90 ? 50 (50
  90)
• X
  1.8 ml

87
Formula 2 Desired Dose 90 mg

• Xml desired dose x vol on hand
• dose on hand
• X ml 90 (mg) x 1 (ml)
• 50 (mg)
• X ml 90 x 1
• 50
• X ml 90 (50 90 )
• 50
• X ml 1.8 ml

88
Administering Amiodarone IVPB

• Add dose to 100 ml bag D5W (90 mg (1.8ml))
• Gently mix the contents label the bag
• Spike the bag with minidrip tubing run thru the
  tubing
• Wipe off the port with alcohol and attach
  piggyback line into main IV line
• Infuse the drip
• over 20 minutes for pediatric patient
  (lt16 years)
• run the piggyback at 30 minidrips/10 seconds

89
Pediatric Croup

• Viral infant/toddler population low grade
  fever barking cough
• Humidified O2
• 6 ml NS in nebulizer, place mask near childs
  face
• If wheezing, Albuterol 2.5 mg (may repeat once)
• If no improvement, Epinephrine 11000 1ml mixed
  with 2 ml NS in nebulizer (may repeat once)
• If unstable (cyanotic, respiratory distress),
  begin BVM ventilations, be prepared to intubate

90
Pediatric Epiglottits

• Bacterial usually 4 year-old and upward in age
  (no upper age limit) high fever drooling
  stridor
• Humidified O2
• 6 ml NS in nebulizer, place mask near childs
  face
• If patient deteriorates, ventilation via BVM be
  prepared to intubate (one attempt)
• True emergency requiring gentle handling,
  avoidance of agitating the patient, and rapid
  transport

91
Case Study

• You are called to the scene of a 23-month-old
  child for trouble breathing.
• Upon arrival the child is sitting on the mothers
  lap starts to cry when they see you.
• He has audible wheezing you observe intercostal
  retractions. Skin is pink.
• Mother states runny nose for 2 days.
• The child starts hitting you when you approach.
• What is your impression?
• What is your approach?

92
Case Study

• A normal toddler is afraid of strangers (hitting
  and kicking is not unusual).
• A quiet cooperative toddler is of more concern!
• Impression croup
• Approach get on the childs eye level
• Ask the parent to remove the shirt to observe
  breathing
• Start physical contact at the toes progress up
• Praise cooperative behavior
• Have caregiver hold nebulizer kit for the patient

93
Pediatric Seizures

• Remember to check glucose levels
• check on all altered/abnormal level of
  consciousness patients known diabetics with
  diabetic related problem
• To treat current seizure activity
• Valium 0.2 mg/kg IVP titrated to control seizure
  activity
• In absence of IV, administer Valium 0.5 mg/kg
  rectally
• Valium/Diazepam will only stop the current
  seizure activity does not prevent future ones

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Rectal Administration of Medication

• Rectum highly vascular
• Medication absorption fairly quick thru lining or
  mucosa of rectum (IVP is quicker)
• Calculate Valium dosage
• Draw up dosage into TB or 3-5 ml syringe
• If syringe larger than TB, attach the plastic
  catheter from an IV catheter (14-20 G) to tip
• Lubricate tip of syringe or catheter
• Carefully introduce 2? into rectum inject
• Hold buttocks closed for 10 seconds

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Rectal Medication
Draw up dosage
Gently administer dosage aspiration is
not necessary
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Allergic Reactions

• There is exposure to an antigen and the
  response is to form antibodies
• Immune response activated
• Antihistamines (ie Benadryl) given to stop
  histamines from their normal action/response
• conjunctivitis - inflammation of the eye
• rhinitis - inflammation of nasal mucous membranes
• angioedema - localized edema in tissues
• urticaria - itchy skin rash
• contact dermatitis - inflammation of skin

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• Vasopressors (Epinephrine) given in the presence
  of airway swelling, difficulty breathing, or
  clinical signs of shock
• Reverses bronchoconstriction to improve the
  respiratory status
• Supports a falling blood pressure
• In shock, IM a more predictable absorption than
  SQ route

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Pediatric Allergic ReactionStable

• Patient alert, skin warm dry
• Irritating signs and symptoms
• hives, itching, rash
• GI distress
• Benadryl
• 1 mg/kg slow (over 2 minutes) IVP or IM
• maximum 25 mg (equivalent to adult dose)

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Practice Math

• Your pediatric patient presents with an allergic
  reaction with hives, no airway involvement.
• They weigh 75 pounds (34 kg)
• How much Benadryl do they get?
• Formula 1mg/kg patient weighs 34 kg
• Calculation 34kg x 1mg 34 mg (of Benadryl)
• Note Do not give a pediatric patient a higher
  dosage than what the adult would receive
• Administration 25 mg Benadryl slow IV or IM

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Pediatric Allergic Reaction Stable with Airway
Involvement

• Patient alert skin warm dry
• Has external signs symptoms now with itchy or
  scratchy throat, hoarseness, wheezing
• Epinephrine 11000 SQ
• 0.01 mg/kg (maximum 0.3 ml/dose)
• May repeat every 15 minutes
• Benadryl
• 1 mg/kg IVP slow(over 2 minutes) IVP (max 50 mg)
• Albuterol 2.5 mg nebulizer (may repeat)

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Pediatric Allergic Reaction Anaphylactic Shock

• Patient with altered mental status
• THEY ARE IN SHOCK!!!
• Epinephrine 11000 IM 0.01 mg/kg (max 0.3
  ml/dose) may repeat every 15 minutes
• Benadryl 1 mg/kg IVP slowly over 2 minutes (max
  50 mg)
• IV fluid challenge 20 ml/kg (max 60 ml/kg)
• Albuterol 2.5 mg nebulizer

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Self-Administered Epi-pens

• Packaging
• Epi-pen (adult) - 0.3mg/0.3ml
• Epi-pen Jr (pediatrics) 0.15 mg/0.3ml
• Expiration dates need to be evaluated

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Epi-Pens

• EMT-Basic
• Epi-pens are taught as a patient assist device
• The epi-pen must belong to the patient
• The EMT-B may assist the patient in administering
  their own epi-pen
• Paramedic
• If medication is required, the paramedic will use
  their own supply of medications
• If the patient has injected their own epi-pen,
  you might need to contact Medical Control to
  determine if your Epinephrine should be held

104

• To use an Epi-pen
• Form fist around unit
• Remove black tip - keep fingers away from opening
• Pull off gray safety release
• Jab black tip firmly into outer thigh 900 angle
  (perpendicular)
• Hold firmly for 10 seconds then remove
• Massage site for 10 seconds
• Dispose of unit
• Patients may have been instructed to replace unit
  into carrier and return to prescribing MD for new
  prescription

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Can go through clothing
106
Broselow Tape

• Patient length used as a valid marker of size
  specific equipment and medication dosing
• Measure the childs length from the top of head
  to the heel (not the toe)

Measure top of head
to the heel
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Broselow Tape

• Colored sections display a range of weights
• Medications, defibrillation and cardioversion
  joules listed on one side
• Medications, fluid challenge amounts, and
  equipment sizing listed on the reverse side
• Medications are printed in mg and need to be
  calculated into ml to determine quantity of
  medication to deliver
• Region X SOPs match the Broselow tape
  calculations

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Calculating Medication Dosage

• 2 page reference printed in the SOPs
• one page for medical medications
• one page for cardiac medications
• Document dosage in mg (obtain from Broselow or
  SOP reference)
• Need ml to know what quantity of medication to
  put into the syringe

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Patient Deterioration

• Always be assessing for changes in patient status
• Key information that points to a patient change
• watch for rapid decrease in appearance especially
  interactiveness
• watch heart rate especially if the rate begins to
  drop
• watch for irregularity of the respiratory pattern

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Bibliography

• American Academy of Pediatrics. Pediatric
• Education for Prehospital Professioinals.
• Jones Bartlett. 2000.
• Bledsoe, B., Porter, R., Cherry, R. Paramedic
  Care Principles Practices 2nd Edition. Brady.
  2006.
• Region X SOPs, March 1, 2007.
• Sanders, M. Paramedic Textbook, Second
• Edition. Mosby. 2007