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Taking Control of the Pediatric EMS Call

Lou Romig MD, FAAP, FACEP. Taking Control of the Pediatric EMS Call. Never let them see you sweat. Romig’s Rule of Vital Sign Comparisons. It’s hardly ever good when the rescuer’s pulse or respiratory rate is greater than that of their pediatric patient. Romig’s Rules. Goals.

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Taking Control of the Pediatric EMS Call

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  1. Lou Romig MD, FAAP, FACEP Taking Control of the Pediatric EMS Call Never let them see you sweat

  2. Romig’s Rule of Vital Sign Comparisons It’s hardly ever good when the rescuer’s pulse or respiratory rate is greater than that of their pediatric patient. Romig’s Rules

  3. Goals Tell you the secrets of how many good “pedi people” control tough kid calls (even though they might not realize they’re doing it). To turn “How do they do that?” into “I can do that!” using the PREP approach

  4. The 3 P’s of Control Preparation Practice Perception

  5. The 3 P’s of Control Preparation Practice Perception

  6. Physiology Responses Equipment Protocols P R E P

  7. Using PREP, half of your scene control can be done before you even arrive.

  8. How’d you like to be caught unprepared for this?

  9. PREP before arrival: Physiology Given the available dispatch information on a pediatric call, what should you anticipate?

  10. PREP before arrival: Physiology • What is the anticipated age of the child? How does their age influence: • Physiology • Physiologic weaknesses and strengths Yes, EMTs can do this too!

  11. PREP before arrival: Physiology • What is the reported mechanism of injury (MOI) or chief complaint? • What are the most likely injuries based on the age/size and MOI? • What are the most common illnesses that present with this complaint? • What interventions are the child most likely to need on scene/in transit?

  12. PREP before arrival: Rescuer Responses • Given the age and MOI/chief complaint: • What kind of emotional reactions can you expect within yourself before, during and after the call? • How about in your crewmates?

  13. PREP before arrival: Rescuer Responses • Identify crew strengths and weaknesses • Who among the crew is most confident with children? • Should usual task assignments be modified for this call? • High stress/critical calls are not the time to practice weak skills

  14. PREP before arrival: Rescuer Responses • The Huddle: • Reinforce need for personal control if call is likely to be emotionally-charged. • Reinforce ability to relax if call is not emergent. • Reinforce the need to be able to change gears if the unexpected occurs.

  15. PREP before arrival:Non-rescuer Responses • The Patient • Assuming normal brain development for age, how is the patient likely to react to you and the situation? • “I would worry if …”

  16. PREP before arrival:Non-rescuer Responses • Family/caregivers • Child with chronic illness? • Set-up for guilt reactions? • Set-up for aggression? • What may be the expectations of the caregivers?

  17. PREP before arrival:Non-rescuer Responses Designate a crew member with good communications skills to be the liaison with the family/caregivers.

  18. PREP before arrival:Non-rescuer Responses • Bystanders • Will the emotional environment of the scene be stable and safe? • Are the bystanders likely to become a distraction? • What may be the expectations of the bystanders? How might they react if you don’t do what they expect?

  19. PREP before arrival: Equipment • Based upon your analysis of the expected physiology: • What kinds of gear are you most likely to need? • What sizes? • Where is the equipment? • What goes with you to the patient’s side?

  20. PREP before arrival: Equipment Use your memory aids!!!!

  21. PREP before arrival: Protocols • Based upon your analysis of the expected physiology: • What protocols/drugs are you most likely to use? • Where are your drugs? Do they need special preparation? • Based on your protocols, what are your alternatives for patient disposition? Might there be consent issues?

  22. PREPare for the worst.Hope for the best. Do practice runs as drills!

  23. PREParation: After Arrival

  24. Your first clue upon arrival:The Waver

  25. PREP after arrival • Scene size-up: • Safety • Mechanism of injury or illness • “OBTWs” (Oh-by-the-ways) • Completely different complaint • Additional patients • Emotional atmosphere • Need to change the game plan?

  26. PREP after arrival: Physiology • Should guide most actions during the rest of the call • Rapidly determine: • How sick is the child? • How quickly do you need to intervene?

  27. Physiology determines Response Intense goal-oriented rapid action focusing on the patient, with tight emotional control by crew OR More relaxed family-centered approach with increased interaction between crew, patient and others on scene

  28. Physiology determines Equipment and Protocols • What equipment is needed now? What might be needed later? • What kinds of treatment are indicated? Where should treatment take place? • Balance speed and efficiency • Determine patient disposition. Initiate additional notifications and responses if needed.

  29. How sick? How quick?

  30. The Pediatric Assessment Triangle (PAT) Work of Breathing General Appearance Circulation to the Skin From the AAP’s Pediatric Education for Prehospital Professionals (PEPP) course. www.PEPPsite.com

  31. The PAT • Can be considered a “patient size-up” • Is a pre-primary survey • Can be done in seconds • Often best done before getting close to the pediatric patient • Results in assignment of the patient into a “physiologic cubbyhole” • Can be done whenever you’re in the weeds!

  32. The PAT General Appearance Work of Breathing Circulation to the Skin

  33. General Appearance • Assesses higher brain function by looking mostly at interaction with the environment • Higher brain function depends on good oxygenation, ventilation and perfusion to the brain • Don’t be fooled by chronic features or dramatic physical findings that don’t affect function

  34. General Appearance TTone IInteractiveness CConsolability LLook/gaze SSpeech/cry

  35. Good general appearanceNormal to well-compensated physiology“Not sick”“Not quick”

  36. Poor general appearanceInadequate physiologic compensation“Sick!”“Quick!”

  37. Work of Breathing • More informative in children than absolute respiratory rate • Reflects resistance in small air passages, dependence on diaphragm and weakness of chest wall muscles • Increased WOB (including tachypnea) is a compensatory mechanism • Decreased WOB (poor effort/slow breathing) means decompensation

  38. Circulation to the Skin • Decreased circulation to the skin is an early sign of compensation for a circulatory problem in kids (not always true in adults) • Cap refill is a good measure in kids, especially when done in serial fashion in a normothermic environment

  39. Putting the PAT together Work of Breathing General Appearance Circulation to the Skin

  40. Respiratory

  41. Circulatory

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