Regional EMS Council of NYC

1
REMAC Protocol Update 2002

• Prepared for Chevra Hatzalah VAC
• By
• Jerry Rozenberg, PA-C, EMT-P (F98)
• Yosef Simha, EMT-P (F80)

2
Regional Emergency Medical Advisory Committee of
New York City
Acknowledgements Contributing Authors Lewis
W. Marshall, Jr., MD Manuel Delgado, EMT-P Peter
Andryuk, EMT-P Frank Mineo, EMT-P Yedidyah
Langsam, PhD EMT-P Greg Santa-Maria,
EMT-P Winston Lee, EMT-P Wil Silvestry,
EMT-P John McFarland, EMT-P Chris Stewart,
EMT-P Daniel Meisels, EMT-P John Violante,
EMT-P James Mejias, EMT-P Willard Wright, EMT
3
Regional Emergency Medical Advisory Committee of
New York City Training program developed and
edited by

• Marie Diglio
• Executive Director, Operations
• Regional EMS Council
• of New York City
• Liz Donnelly, EMT-P
• Quality Assurance/REMAC Coordinator
• Regional EMS Council
• of New York City

Todd E. R. Strom, BS, EMT-P, CIC Training Center
Coordinator Wyckoff Heights Medical
Center Manuel Delgado, EMT-P REMAC
Liaison FDNY-EMS Office of Medical Affairs
4
Revisions inGeneral Operating Procedures (GOP)

5
Protocol Update Training Curriculum Objectives

• General Operating Procedures
• To familiarize all emergency medical service
  providers in the NYC region with the changes and
  additions to the general operating procedures

6
REMAC

• The Regional Emergency Medical Advisory
• Committee (REMAC) of New York City is
• designated by Article 30 of the New York
• State Public Health Law to develop triage,
• treatment, and transportation protocols for
• the NYC region.

7
Reasons for Changes

• Changes in AHA Guidelines
• Need for changes to GOP identified through
  practice and quality improvement.
• Changes in New York State EMT Curriculum
• Questions and comments from EMS Providers

8
Direct Medical Control at the Scene

• Physicians who are credentialed by
• Their EMS system/agency
• REMAC as an On-Line Medical Control Physician
• May provide direct medical control
• Only within the scope of practice for the EMS
  Provider
• Only to EMS Providers on Scene who operate within
  the system/agency that credentialed the physician.

9
Direct Medical Control at the Scene

• Physicians may not give EMS providers orders that
  exceed the providers training or scope of
  practice
• EMS Providers should not follow orders of a
  physician that exceed their level of training or
  scope of practice.
• Physicians may not provide direct medical control
  to providers outside their EMS system/agency.

10
Direct Medical Control at the Scene

• Physicians may perform procedures that are beyond
  the EMS providers scope of practice.
• The physicians name, NYS License , and REMAC
  On-Line Medical Control Physician must be
  documented on the PCR or ACR.

11
Oxygen Administration

• Criteria for Assisted Ventilations
• Any ONE of the following
• Breathing less than 8 times per minute
• Breathing more than 24 times per minute
• Exhibiting signs of inadequate ventilations

12
Oxygen Administration

• Assisted Ventilations
• The presence of a DNR order does not alter this
  requirement for a patient who in not in
  respiratory or cardiac arrest.

13
Suspected Child/Spouse/Elder Abuse

• New York State Social Services Law considers EMTs
  and AEMTs, but not CFRs, to be mandatory child
  abuse reporters.
• Failure to report suspected cases of child abuse
  to the New York State Child Abuse and
  Maltreatment Register (State Central Register)
  may subject the EMT or AEMT to liability for
  criminal and civil prosecution and penalties.
• Notification of suspected child abuse is to be
  accomplished in accordance with agency policy.
  The State Central Register may be contacted by
  telephone at 1-800-635-1522.

14
Abandoned Infant Protection Act

• New York State Social Services Law states that
  infants five days of age or younger may be
  abandoned by their parents or caretakers in a
  suitable safe location, such as a hospital,
  ambulance, police station, or fire house, or with
  an appropriate person.
• Some of these parents or caretakers may wish to
  remain anonymous, but if they offer their name
  and address, they should be recorded in the
  comment section of the Prehospital Care Report.

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Abandoned Infant Protection Act

• THE ABANDONED INFANT PROTECTION ACT DOES NOT
  RELIEVE THE EMT OR AEMT OF THE RESPONSIBILITY TO
  REPORT SUCH ABANDONMENT TO THE NEW YORK STATE
  CHILD ABUSE AND MALTREATMENT REGISTER (STATE
  CENTRAL REGISTER). THE STATE CENTRAL REGISTER
  MAY BE CONTACTED BY TELEPHONE AT 1-800-635-1522

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Mandated Reporting

• Contact your area Coordinator, who will then
  contact the appropriate EMHT
• Follow-up with your Coordinator

17
MAST Trousers

• MAST trousers have been removed from the NYC
  REMAC protocols.

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Regional Emergency Medical Advisory Committee of
New York City

• BLS
• PROTOCOLS

19
Protocol Update Training Curriculum Objectives

• Basic Life Support Protocols
• To familiarize all emergency medical service
  providers in the NYC region with the additions
  and revisions to the basic life support protocols

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400 WEAPONS OF MASS DESTRUCTION NERVE
AGENT EXPOSURE PROTOCOL

• NEW PROTOCOL To ensure safe operations at
  incidents involving weapons of mass destruction
• Authorization for the use of the MARK I Antidote
  kits comes ONLY from the FDNY Office of Medical
  Affairs (OMA) through a class order issued by a
  FDNY-OMA Medical Director who is on-scene or as
  relayed by an FDNY-OMA Medical Director through
  On-Line Medical Control (Telemetry) or through
  FDNY Emergency Medical Dispatch.

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400 WEAPONS OF MASS DESTRUCTION NERVE
AGENT EXPOSURE PROTOCOL

• The issuance of any class order shall be conveyed
  to all regional medical control facilities for
  relay to units in the field.
• Treatment within the hot and warm zones maybe
  performed only by appropriately trained personnel
  wearing appropriate chemical protective clothing
  (CPC) as determined by the FDNY Incident
  Commander.

22
401 Respiratory Distress/Failure

• Clarification DNR Orders
• Only NYS Prehospital DNR Orders are to be
  honored.
• Only valid for patients in respiratory or
  cardiac arrest.
• Patients with valid DNRs NOT in arrest must be
  treated like any other patient!
• THIS INCLUDES PROVIDING ASSISTED
  VENTILATIONS for patients with signs of
  inadequate respirations or having respiration
  rates of less than 8 or more than 24 times a
  minute.

23
401 Respiratory Distress/Failure

• Change Criteria for assisted ventilations
• Any ONE of the following
• Breathing less than 8 times per minute.
• Breathing more than 24 times per minute.
• Exhibiting signs of inadequate ventilations.

24
401 Respiratory Distress/Failure

• Added Option Transport Position
• In addition to the previously allowed transport
  positions for patients in respiratory distress
  (Fowlers or semi-Fowlers), position of
  comfort.
• This option added to reflect current practice by
  EMTs and AEMTs, as well as the fact that patients
  find their position of comfort.

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401 Respiratory Distress/Failure

• Added Reference Asthma Patients
• For patients between 1 and 65 years of age who
  experiencing exacerbation of their previously
  diagnosed asthma, refer to protocol 407
  (Asthma) including Albuterol treatment

26
403 Non-Traumatic Cardiac Arrest

• Added Reference Pediatric AED
• The term Semi-Automated External Defibrillator
  has been replaced with the term Automated
  External Defibrillator (AED).
• Do not use the AED for pediatric patients less
  than 8 years old unless the pediatric modified
  pad and cable system is available.
• Do not defibrillate patients less than one year
  of age.

27
404 Non-Traumatic Chest Pain

• ALS Assistance Requests
• ALS assistance should be requested, if available.
  
• Do NOT delay transport.

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404 Non-Traumatic Chest Pain

• Added Aspirin Administration
• Administer 2 chewable Baby-Aspirin tablets (162
  mg total) to patients experiencing non-traumatic
  chest pain and that fall into either of the
  following categories
• 35 years of age or older
• Patients of any age with a cardiac history

29
404 Non-Traumatic Chest Pain

• Aspirin Administration
• Contraindications
• Known Aspirin allergy or hypersensitivity
• Recent GI bleeding (bloody stool or vomitus)
• Bleeding disorder (e.g. hemophilia, clotting
  disorder...)
• Taking Warfarin (Coumadin) blood thinners

30
407 Asthma
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Inclusion Criteria

• Patients between the ages of 1 and 65 years old
  (with no ALS immediately available).
• Patients complaining of difficulty breathing
  secondary to an exacerbation of their previously
  diagnosed asthma.

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Exclusion Criteria

• Patients with a history of hypersensitivity to
  albuterol sulfate.
• Patients exhibiting signs of respiratory failure
  (a patient requiring ventilations)
• Decreased level of consciousness
• Too dyspneic to speak
• Cyanosis (despite oxygen therapy)
• Diminished breath sounds

33
Pediatric Respiratory Failure

• Sign of ineffective respiratory effort
• central cyanosis
• agitation or lethargy
• severe dyspnea or labored breathing
• bobbing or grunting
• marked intercostal or parasternal retractions.

34
Differential Diagnosis of Bronchospasm

• COPD
• Foreign body obstruction
• Pulmonary Embolus
• Anaphylactic reaction
• Pulmonary Edema
• Asthma

35
Pathology of Asthma

• Reversible smooth muscle spasm of the airway
  associated with hypersensitivity of the airway to
  different stimuli. Primarily an inflammatory
  process.
• Smooth muscle contractions
• Mucosal edema
• Mucous plugging

36
Triggers of Asthma Attacks

• Allergies
• Infection
• Stress
• Temperature changes
• Seasonal changes

37
Signs and Symptoms

• Dyspnea
• Wheezing
• Tachypnea
• Tachycardia
• Cyanosis
• Cough

• Accessory muscle use
• Inability to speak..
• in complete sentences.
• Anxiety (hypoxia)
• Prolonged expiratory phase
• Tripod positioning
• Nasal Flaring (infants)

38
Assessment of the Asthmatic

• Chief complaint
• History of present illness
• Past medical history

39
History of Present Illness

• How long
• Events leading up to
• How severe (Borg Scale)
• Aggravating / Alleviating factors
• Other complaints
• Steroid use in last 24 hours (p.o. / inhaled)
• Other medications

40
Past Medical History

• Confirm asthma history
• Other medical conditions (cardiac)
• E.D. visits for asthma in the last 12 months
• Hospital admissions for asthma in last 12 months
• Previously intubated due to asthma?
• Allergies to medications, etc.

41
Physical Examination

• Respiratory distress vs. Respiratory failure
• Posturing (tripod positioning)
• Pursed lip breathing
• Vital signs
• Skin color, temperature and moisture
• Ability to speak... in complete... sentences
• Accessory muscle use
• BORG Scale

42
(No Transcript)
43
Physical Examination (cont.)

• Assessing lung sounds
• Rales
• Rhonchi
• Stridor
• Wheezing

44
Wheezes

• High pitched, continuous sounds
• Occur on inspiration or expiration
• Result of narrowed bronchioles

45
Absent or Diminished Sounds

• Pneumothorax
• Hemothorax
• Obesity
• Hypoventilation
• Fluid or pus in pleura or lung
• COPD or Asthma with poor airflow

46
Stethoscope Placement
47
Albuterol Sulfate Ampules
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Pharmacology Albuterol Sulfate

• Actions
• Bronchodilator
• Minimal side effects
• Nervousness Palpitations
• Dizziness Drowsiness
• Flushing Chest discomfort
• Tachycardia Muscle cramps
• Dry mouth Insomnia
• Tremors Weakness

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Dosage

• One unit dose, 3.0 cc or 0.083
• Via nebulizer at 6 liters per minute or at a
  flow rate that will deliver the medication
  over 5 to 15 minutes.
• Dose may be repeated if the symptoms persist for
  a total of 2 doses.

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Administration (cont.)

• Assemble nebulizer
• Add medication
• Attach to oxygen regulator
• Set flow meter to 6 lpm
• Instruct patient on use
• inform adult patient
• modify delivery for very young patients

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Nebulizer
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Assembled Nebulizer
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Assembled Nebulizer and Oxygen Tubing
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Treatment of Asthma Patient

• Assess breathing
• Administer oxygen via non - rebreather
• or assist ventilations
• Monitor Breathing
• Do not permit physical activity
• Place patient in position of comfort

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Assess and Document prior to administration of
albuterol

• Patient is between 1 and 65 years of age
• Dyspnea is secondary to previously diagnosed
  asthma
• Vital signs
• Ability to speak in complete... sentences
• Accessory muscle use
• Wheezing assessment

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Treatment (cont.)

• Administer albuterol sulfate (one unit dose) via
  nebulizer (6 lpm)
• Begin transport
• Do not delay transport to administer medication
• If symptoms persist, give 2nd dose
• Upon transfer of patient, reassess and document
  as before.

57
Treatment (cont.)

• Medical control MUST be contacted for any patient
  who refuses medical assistance or transport.
• Request ALS if the patient is in respiratory
  failure

58
Documentation

• ACR All pertinent data should be recorded in
  the Comments and Treatment / Response
  sections

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410 Anaphylactic Reaction

• Many studies have shown that
• the use of an EPI- PEN can be safely
• administered by an EMT
• Goals
• Early recognition of anaphylaxis
• Early BLS intervention
• Early ALS intervention
• Administration of Epinephrine using the Epi-Pen
  Auto injector

60
410 Anaphylactic Reaction

• Clarification Criteria for administration of
  Epi-Pens
• Epinephrine Auto-Injectors
• (Epi-Pen) should only be used for patients
  presenting with true anaphylactic reactions.

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410 Anaphylactic Reactions

• Symptoms of anaphylactic reactions
• Respiratory Distress
• Upper Airway Obstruction (Stridor)
• Lower Airway Disease/Severe
  Bronchospasm(Wheezing)
• Cardiovascular Collapse/Hypotensive Shock

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Anaphylaxis

• Allergic reaction immune response to any
  substance.
• Reaction can be localized or severe and life
  threatening (anaphylaxis)
• Allergen substance that causes the immune
  response

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Common allergens

• Insects bees, wasps
• Food nuts, fish, milk, chocolate
• Plants poison ivy, oak
• Medications antibiotics
• Other outdoor allergens, fragrances
• Latex

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Patient Assessment
65
Skin

• Swelling to face, neck, hands, feet, tongue and
  periorbitally
• Urticaria hives
• Itching
• Erythema redness
• Flushed skin
• Warm tingling feeling to face, mouth, chest, feet
  and hands

66
Respiratory system

• Tightness to throat and chest
• Cough
• Tachypnea
• Labored breathing
• Hoarseness
• Noisy breathing stridor or wheezing
• bronchoconstriction

67
Cardiovascular system

• Tachycardia
• Vasodilation
• Hypotension

68
Other systems

• Itchy, watery eyes
• Headache
• Sense of impending doom
• Runny nose, nasal congestion
• Decreased mental status

69
Reminder

• Findings that reveal hypoperfusion (shock), or
  respiratory distress (upper airway obstruction,
  lower airway disease, severe bronchospasm ) may
  indicate the presence of a severe allergic
  reaction (anaphylactic shock).

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Treatment ProtocolPatients Over Age 9 or
Weighing Over 30 Kilos

• Determine that patients history includes past
  history of anaphylaxis, severe allergic
  reactions, and/or recent exposure to an allergen
• Administer high concentration oxygen
• Request ALS assistance
• Assess the cardiac and respiratory status of the
  patient

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Continued

• If both the cardiac respiratory status of the
  patient are normal, initiate transport
• If either the cardiac or respiratory status of
  the patient is abnormal, proceed as follows

72
Continued

• If the patient has severe respiratory distress or
  shock and has a prescribed Epi-Pen assist the
  patient in administration. If the auto injector
  is not available or expired and the EMS agency
  carries one, administer (0.3 mg.) as authorized
  by the agency medical directors.
• If the patient does not have a prescribed
  Epi-Pen, begin transport and contact medical
  control for authorization to administer 0.3 mg
  via auto injector

73
Note

• If unable to make contact with on-line medical
  control and the patient is under 35 years old,
  you may administer 0.3 mg epinephrine via an
  auto-injector if indicated.
• The incident should be reported to medical
  control or your medical director as soon as
  possible

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Protocol cont.

• Contact medical control for authorization to
  administer a second dose if needed
• Refer to other protocols as needed (resp
  distress/failure, obstructed airway, shock)
• If patient arrests treat as per the non-traumatic
  cardiac arrest protocol

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Pediatric differences

• The age for pediatrics in this protocol is
  patients under 9 years old or weighing less than
  30 kg (66 lbs)
• The dose of epinephrine is 0.15 mg

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Pharmacology - Epinephrine

• Medication name
• Generic Epinephrine
• Trade Adrenalin
• Properties
• Bronchodilation
• Vasoconstriction

77
Indications

• Must meet the following three criteria
• Patient must exhibit findings of severe allergic
  reaction (anaphylaxis)
• Medication is prescribed for this patient by
  their physician, direction by medical control, or
  inability to contact medical control and
  epinephrine is indicated

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Contraindications

• None when used to treat anaphylaxis

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Dosage

• Adult- one adult auto injector (0.3 mg)
• Infant and Child- one auto injector
  (infant/child) 0.15 mg

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Administration

• Obtain order from medical control either on line
  or as per protocol
• Obtain patients prescribed unit if available
• Ensure prescription is written for patient
• Ensure medication is not discolored
• Remove safety cap from device

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Administration cont.

• Place tip of device against the patients thigh
• Use lateral portion of thigh midway between the
  waist and knee
• Push firmly until the injector activates
• Record activity and time
• Dispose of injector in appropriate container
• Can be administered through patients clothes

82
Reassessment

• Continually assess ABCS for signs of worsening
  patient condition such as
• Mental status change
• Increased respiratory rate
• Decreasing B/P

83
Reassessment

• Be prepared to initiate BCLS measures if
  indicated including CPR, AED, ALS intercept
• Treat for shock
• As the drug lasts in the system 10-20 minutes, be
  prepared for a potential return of the
  anaphylactic reaction

84
Transportation Decision

• Any patient who received Epinephrine should be
  transported to an Emergency Room for evaluation
• On-Line Medical Control must be contacted for any
  patient refusing treatment or transportation
  after treatment with Epi.

85
410 Anaphylactic Reactions

• Symptoms of Allergic Reactions
• Skin Rashes
• Hives
• Itching
• These are symptoms of allergic, NOT anaphylactic,
  reactions unless accompanied by severe
  respiratory distress or cardiovascular collapse.
  Such allergic reactions do NOT warrant treatment
  with Epi-Pens.

86
411 Altered Mental Status and 414 Poisoning or
Drug Overdose

• Clarification Gag-Reflex vs. Ability to Swallow
• Ensuring that patients have a gag-reflex is
  replaced by
• Ensure that patients are able to swallow,
• prior to administration of orange juice,
  non-diet soda, glucose, syrup of ipecac,
  or activated charcoal.

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412 Stroke

• NO CHANGES

88
413 Seizures

• Priority Change Transportation and
• Information Gathering
• Gathering of information regarding the seizure
  should
• NOT DELAY TRANSPORTATION.
• Added Information Gathering
• Without delaying transportation, ascertain if the
  patient has a history of seizures along with the
  other information gathering previously required
  by the protocol

89
413 Seizures

• Deleted Term Status Epilepticus
• The term status epilepticus has been deleted
  from the protocol since it is not a part of the
  revised NYS EMT curriculum.

90
414 Poisoning or Drug OD

• Deletion Utilization of Poison Control Centers
  by EMS Providers
• The option to contact poison control centers for
  direction of treatment of patients has been
  deleted in accordance with SEMAC policy. All
  direction should come from NYC REMAC authorized
  On-Line Medical Control Facilities.

91
414 Poisoning / Drug OD

• Deletion Hot Water Soaking of Marine
  Envenomations
• Patients with marine envenomations should be
  transported, but the direction to soak the area
  in hot water for 30 minutes has been deleted.

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415 Shock 420 Traumatic Cardiac Arrest

• Deletion Option to Use MAST Pants
• The application of MAST has been deleted from the
  all NYC REMAC protocols.

93
No Changes To

• 416 Abdominal Pain
• 421 Head and Spine Injuries
• 422 Neck Injuries

94
423 Chest Injuries

• OPEN CHEST WOUND
• Place an occlusive dressing over the wound and
  tape on three sides.
• If the patients condition worsens, remove the
  occlusive dressing and have the patient fully
  exhale. Replace and retape the occlusive
  dressing on three sides after exhalation, and
  request Advanced Life Support assistance.

95
No Changes To

• 424 Abdominal Injuries
• 425 Bone and Joint Injuries
• 426 Soft Tissue Injuries
• 427 Eye Injuries
• 428 Burns
• 430 Emotionally Disturbed Patient
• 431 Heat Related Emergencies

96
432 Cold Related Emergencies
Clarification Gag-Reflex vs. Ability to
Swallow Ensuring that patients have a gag-reflex
is replaced by Ensure that patients are able to
swallow, prior to administration of orange
juice, non-diet soda, glucose, syrup of ipecac,
or activated charcoal.
97
No Changes To

• 433 Drowning or Near Drowning
• 434 Decompression Sickness

98
440 Obstetric Emergencies

• Change ALS Assistance
• ALS assistance should be requested for the
  following special situations
• Hypertension
• Seizures
• Imminent delivery (if delivery has begun)

99
440 Obstetric Emergencies

• Change Terminology
• The term pre-eclampsia has been replaced by
  hypertension.
• The term eclampsia has been replaced by
  seizures.

100
441 Emergency Childbirth

• Change ALS Assistance Requests
• ALS Assistance must be requested if delivery has
  begun.

101
441 Emergency Childbirth

• Change Special Conditions Listing
• A listing of special conditions that have special
  instructions has been added to the beginning of
  the protocol.
• Prolapsed Umbilical Cord
• Umbilical Cord Wrapped Around the Newly borns
  neck
• Breech (Buttocks) Presentation
• Breech (Extremity) Presentation

102
441 Emergency Childbirth

• Special Conditions Listing (continued)
• Multiple Births
• Premature Births
• Amniotic Sac Not Ruptured
• Amniotic Fluid That is Meconium Stained

103
441 Emergency Childbirth

• Change Airway suctioning
• The direction to clear the airway by suctioning
  the mouth and nose utilizing a bulb syringe is no
  longer if time permits.

104
441 Emergency Childbirth

• Change Placement of Umbilical Cord Clamps
• First Clamp 8 to 10 from the newly born.
• Second Clamp Approximately 4 finger widths from
  the newly born.

105
441 Emergency Childbirth 442 Care of the Newly
Born 443 Care of the Newly Born

• Change Terminology Newly Born
• Newly Born Someone minutes to hours old
• Replaces Newborn

106
442 Care of the Newly Born

• Change Ventilation (Indications and Rates)
• Indications
• If the Newly Born has ONE of the following
• Persistent central cyanosis
• Respiratory rate lt30 breaths/min
• Heart rate less than 100 BPM
• Rates
• Initiate assisted ventilations at a rate of 30
  to 60 ventilations per minute. (Previously
  40 to 60).

107
443 Newly Born Resuscitation

• Ventilation Indications and Rates
• Initiate blow-by high concentration oxygen
  therapy when the newly born has ALL of the
  following
• Respiratory rate gt30 breaths/min
• Heart rate gt100/min
• Free of central cyanosis

108
443 Newly Born Resuscitation

• CPR Indications and Rates
• Indications
• If the Newly Born has EITHER of the following
• A heart rate lt60 BPM
• OR
• Cardiac Arrest

109
443 Newly Born Resuscitation

• CPR Indications and Rates (cont)
• Initiate the following resuscitation measures
• Begin CPR Immediately
• Stop CPR when the newly borns HR gt100 and
  provide assisted ventilations at 30 60
  ventilations per minute.

110
443 Newly Born Resuscitation

• CPR Indications and Rates (cont)
• Initiate blow-by high concentration oxygen
  therapy when the newly born has ALL of the
  following
• Respiratory rate gt30 breaths/min
• Heart rate gt120/min and central cyanosis
  disappears

111
No Changes

• 450 Pediatric Respiratory Distress / Failure
• 451 Pediatric Obstructed Airway
• 452 Pediatric Croup/Epiglottitis

112
453 Pediatric Non-Traumatic Cardiac Arrest and
Severe Bradycardia

• Added Reference Pediatric AED
• The term Semi-Automated External Defibrillator
  has been replaced with the term Automated
  External Defibrillator (AED).
• Do not use the AED for pediatric patients less
  than 8 years old unless the pediatric modified
  pad and cable system is available.
• Do not defibrillate patients less than one year
  of age.

113
455 Pediatric Anaphylactic Reaction
Clarification Criteria for administration of
Epi-Pens Epinephrine Auto-Injectors (Epi-Pen)
should only be used for patients presenting with
true anaphylactic reactions.
114
455 Pediatric Anaphylactic Reaction

• Symptoms of anaphylactic reactions
• Respiratory Distress
• Upper Airway Obstruction (Stridor)
• Lower Airway Disease/Severe Bronchospasm
  (Wheezing)
• Cardiovascular Collapse/Hypotensive Shock

115
455 Pediatric Anaphylactic Reaction
Symptoms of Allergic Reactions Skin
Rashes Hives Itching These are symptoms of
allergic, NOT anaphylactic, reactions unless
accompanied by severe respiratory distress or
cardiovascular collapse. Such allergic reactions
do NOT warrant treatment with Epi-Pens.
116
458 Pediatric Shock

• NO CHANGES

117
Questions

• ?