Encountering The Pediatric Patient

1. Encountering The Pediatric Patient Condell Medical Center EMS System September 2008 CE Site Code #10-7200E1208 Prepared by: Sharon Hopkins, RN,BSN, EMT-P

2. Objectives • Upon successful completion of this module, the EMS provider should be able to: • Review and understand the components of the Pediatric Assessment Triangle (PAT) • Identify the difference between respiratory distress and respiratory failure • State the landmarks for the EZ IO needle • Choose the appropriate medication & dose to administer for a variety of conditions (Dextrose, Narcan, Albuterol, Valium, Epinephrine, Atropine, Adenosine, Versed, Benadryl)

3. Calculate medication dosages given the patient’s weight • Calculate the GCS given the pt’s responses • Identify and appropriately state interventions for a variety of EKG rhythms specific to the pediatric population (VF, SVT, bradycardia) • Demonstrate the ability to obtain information from the Broselow tape and SOP pediatric medication tables • Participate in calculating and drawing up medications -Successfully complete the 10 question quiz with a score of 80% or better

4. Pediatric Assessment Triangle - PAT • Establishes a level of severity • Assists in determining urgency for life support • Identifies key physiological problems using observational & listening skills

5. General Assessment - PAT • Performed when first approaching the child • Does not take the place of obtaining vital signs • Check appearance • Evaluate work of breathing • Assess circulation to the skin

6. PAT - Appearance • Reflects adequacy of: • Oxygenation • Ventilation • Brain perfusion • Homeostasis • CNS function

7. Assessing Appearance • Evaluate as you cross the room and before you touch the child: • Muscle tone • Mental status / interactivity level • Consolability • Eye contact or gaze • Speech or cry

8. PAT - Breathing • Reflects adequacy of : • oxygenation • Ventilation • In children, work of breathing more accurate indicator of oxygenation & ventilation than respiratory rate or breath sounds (standards used in adults)

9. Assessing Breathing • Evaluate: • Body position • Visible movement of chest or abdominal walls • 6-7 years-old & younger are primarily diaphragmatic (belly) breathers • Respiratory rate & effort • Audible breath sounds

10. PAT - Circulation • Reflects: • Adequacy of cardiac output and perfusion of vital organs (core perfusion)

11. Assessing Circulation • Evaluate skin color: • Cyanosis reflects decreased oxygen levels in arterial blood • Cyanosis indicates vasoconstriction and respiratory failure • Trunk mottling indicates hypoxemia

12. Initial Assessment • Airway – is it open? • Breathing – how fast, effort being used, is it adequate? • Circulation – what is the central circulation status as well as peripheral? • Disability – AVPU and GCS • Expose – to complete a hands-on examination

13. Priority Patients & Transport Decisions • Decide what level of criticality this patient is • Decide if they must go to the closest emergency department or do you have time to honor the family request if their hospital is not the closest

14. Additional Assessment • Includes: • Focused history • Physical exam • SAMPLE history

15. Physical Exam • Toe to head in the very young • Infants, toddlers, and preschoolers • Head to toe in the older child

16. SAMPLE History • S – signs & symptoms • A – allergies • M – medications including herbal and over the counter (OTC) • P – past pertinent medical history • L – last oral intake (to eat or drink including water) •E – events leading up to the incident

17. Assessment & Interventions • Vital signs • Determine weight and age • SaO2 reading preferably before & after O2 administration • Cardiac monitor if applicable • Establish IV if indicated • Determine blood glucose if indicated •Reassess vital signs, SaO2, patient condition

18. Detailed Physical Exam • Information gathered builds on the findings of the initial assessment and focused exam • Use the toe to head for infants, toddlers, and preschoolers

19. Putting It All Together • You are called to the scene for a 2 year-old who has fallen off the 2nd floor porch. • The toddler landed in the grass • The toddler is unresponsive upon your arrival; there is a laceration to the right forehead and the right arm • is deformed

20. Putting It All Together - Mechanism of Injury • Fall from height greater than 3 times the toddler’s height • For this 2 year-old, the mechanism of injury indicates a Category I trauma patient based on mechanism of injury (fall from height) and level of consciousness (unresponsiveness)

21. Putting It All Together - Index of Suspicion • For this 2 year-old you are anticipating major traumatic injuries due to mechanism of injury (minimally anticipating head injury and orthopedic fractures)

22. General Impression For This 2 year-old • Category I trauma patient with head & orthopedic injuries • SOP’s to follow • Spinal immobilization • Care of the airway with anticipation for need to be bagged or intubated • Hemorrhage control / interventions with IV/IO access needing to be obtained • Cardiac monitoring • Determining blood glucose level

23. What’s The Difference? • Respiratory distress • The patient exhibits increased work of breathing but the patient is able to compensate for themselves • Increased respiratory effort in child who is alert, irritable, anxious, and restless • Evident use of accessory muscles • Intercostal retractions • Seesaw respirations (abdominal breathing) • Neck muscles straining

24. Respiratory failure • Energy reserves have been exhausted and the patient cannot maintain adequate oxygenation and ventilation (breathing) • Sleepy, intermittently combative or agitated child • Heart rate usually bradycardic as a result of hypoxia

25. Respiratory Distress • Stridor • Grunting • Gurgling • Audible wheezing • Tachypnea (increased respiratory rate) • Mild tachycardia • Head bobbing • Abdominal breathing (normal < 6-7 years-old) • Nasal flaring • Central cyanosis resolved with O2

26. Stridor • Harsh, high-pitched sound heard on inspiration associated with upper airway obstruction • Sounds like high-pitched crowing or “seal-bark” sound on inspiration

27. Grunting • Compensatory mechanism to help maintain patency of small airways • A short, low-pitched sound heard at the end of exhalation • Patient trying to generate positive end-expiratory pressure (PEEP) by exhaling against a closed glottis • Prolongs the period of oxygen and carbon dioxide exchange

28. Nasal Flaring

29. Retractions • A visible sign where the soft tissues sink in during inhalation • Most notable are in the areas above the sternum or clavicle, over the sternum, and between the rib spaces

30. Respiratory Failure • Decreased level of responsiveness or response to pain • Decreased muscle tone • Inadequate respiratory rate, effort, or chest excursion • Tachypnea with periods of bradypnea slowing to agonal breathing

31. IV Access • Peripheral access can be difficult to find in a child • More sub Q fat • Smaller targets • More fragile veins • Lack of our experience

32. Hint to Find Peds Veins • Hold your penlight across the skin to reflect the veins • Hold the penlight under the site to illuminate the veins

33. IO Indications • Shock, arrest, or impending arrest • Unconscious/unresponsive to stimuli • 2 unsuccessful IV attempts or 90 second duration • Use Peds needle for 3 – 39 kg (up to 88 lbs) - Peds needle 15 G 5/8

34. EZ IO Landmarks • Proximal medial tibia • <39 kg (child) – tibial tuberosity often difficult to palpate & if not palpated • Go 2 finger breadths below patella and then on flat aspect of medial tibia • 40 kg (88 pounds or more) • 1-2 finger breadths below patella (this is usually 1/2 (1 cm) distal to tibial tuberosity) • 1 finger breadth medially from the tibial • tuberosity

35. Tibial tuberosity

36. EZ IO Infusion • All patients need to have the IO flushed prior to connecting the IV solution • The primed extension tubing must be used with a syringe attached • Only the syringe is removed after flushing in preparation to attaching IV fluid • All IV bags need a pressure bag to • flow

37. Altered Level of Consciousness • If blood glucose level is <60 • < 1 year old – Dextrose 12.5% 4 ml/kg • > 1 -15 years old – Dextrose 25% 2 ml/kg • If no IV/IO access • Glucagon 0.1 mg/kg IM • Max dose up to 1 mg (max at adult dosage)

38. If you suspect narcotic influence or as a diagnostic tool if blood sugar is okay or patient does not respond to Dextrose • Give Narcan • <20 kg = 0.1 mg/kg IVP/IO/IM • >20 kg = 2 mg IVP/IO/IM • Max total dose is 2 mg

39. Dextrose • The brain is a very sensitive organ to inadequate levels of glucose • When the glucose levels drop the patient will have an altered level of consciousness • If glucose levels reach a critically low level, the patient may have a seizure

40. Narcan • Useful to reverse the effects of narcotics (respiratory depression and depression of the central nervous system) • Morphine, hydromorphine, oxycodone, Demerol, heroin, Dilaudid, codeine, percodan, fentanyl, darvon, methadone • Consider the children that get into other’s purses and have access to the medicine cabinet & other areas where drugs can be found

41. Calculation Practice • Your 8 month-old patient weighs 17 pounds • Which strength Dextrose should this patient receive and how much?

42. 8 month-old • < 1 year old receives Dextrose 12.5% • To receive 4 ml/kg • 17 pounds  2.2 = 7.7 kg (8kg) • Dextrose is 4 ml / kg • 4 ml x 8 kg = 32 ml • How do you give 12.5% Dextrose when you carry 25%?

43. How To Draw Up 12.5% Dextrose • Use 25% and dilute 1:1 with sterile saline • Calculate the total dosage required (ie: 32 ml) • Half the syringe will be filled with 25% Dextrose and half the syringe will be filled with sterile saline • 16 ml 25% dextrose mixed with 16 ml sterile normal saline • Administer in largest vein possible and at slowed rate • Extremely irritating to the veins

44. Narcan Calculation • Your patient weighs 19 pounds • <20 kg the patient is to get 0.1 mg/kg • How much Narcan would you • administer? Never give more than the adult dose!

45. Narcan for 19 Pound Infant • 19 pounds  2.2 kg = 8.6 kg (9kg) • 9kg x 0.1 mg/kg = 0.9 mg • (You still need to know how many ml’s to put into the syringe) • What type of syringe would you use? • Under 1 ml use a TB syringe – much more accurate to draw up medications

46. GCS For Pediatric Patient • Same tool used for the adult population with minor changes to accommodate the non-verbal infant • Most accommodations made in the verbal section • Makes sense if this is for the non-verbal patient

47. GCS – Eye Opening Remains the same as the adult: • 4 points if eyes open spontaneously with or without focus • 3 points if eyes open or flutter to command or noises/voice • 2 points if eyes open or eyelids flutter to touch or painful stimuli • 1 point if eyes do not open

48. GCS – Verbal Response • 5 points if oriented (coos, babbles) • 4 points if cry is irritable • 3 points if the patient cries to pain • 2 points if there is some noise response to pain (similar to moans & groans in the adult) • 1 point if there is silence

49. GCS – Motor Response • 6 points if the patient moves appropriately • 5 points if the patient withdraws to touch • 4 points if the patient withdraws to pain • 3 points if there is abnormal flexion • 2 points if there is abnormal extension • 1 point if there is no movement/response of any kind

50. Acute Asthma • Many patients will try to self medicate and may try for too long on their own before they call for help • The patient can deteriorate fast once they fatigue and their respiratory muscles are exhausted