Encountering The Pediatric Patient

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

2. Objectives • Upon successful completion of this module, the ECRN should be able to: • Review and understand the components of the Pediatric Assessment Triangle (PAT) • Identify the difference between respiratory distress and respiratory failure • Choose the appropriate EMS field 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) • 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 – can they sit up on own? • Mental status / interactivity level • Consolability • Eye contact or gaze – do they watch you? • 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 • EMS to decide if the patient must go to the closest emergency department or if they have time to honor the family request if their hospital is not the closest

14. Additional Assessment • Includes: • Focused history • Physical exam • Toe to head approach in the very young (infants, toddlers, preschoolers) • Head to toe in the older child • SAMPLE history

15. 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 (anything to eat or drink including water) •E – events leading up to the incident

16. 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

17. 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

18. Putting It All Together • EMS is 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 EMS arrival; there is a laceration to the right forehead and the right arm • is deformed

19. 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)

20. General Impression For This 2 year-old • Category I trauma patient with head & orthopedic injuries • EMS Region X 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

21. 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

22. 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

23. 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

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

25. 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

26. Nasal Flaring

27. 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

28. 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

29. 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

30. 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

31. EMS IO Indications • Shock, arrest, or impending arrest • Unconscious/unresponsive to stimuli • 2 unsuccessful IV attempts or 90 second duration • Peds needle used for 3 – 39 kg (up to 88 lbs) - Peds needle 15 G 5/8 (G same as adult, length is shorter)

32. 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

33. Tibial tuberosity

34. 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

35. EMS Altered Level of Consciousness SOP • 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)

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

37. 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

38. Narcan • Useful to reverse the effects of narcotics (respiratory depression and depression of the central nervous system) • Morphine, hydromorphine (Dilaudid), oxycodone, Demerol, heroin, 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

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

40. 8 month-old • < 1 year old receives Dextrose 12.5% • More diluted form for smaller, more fragile veins • 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 does EMS give 12.5% Dextrose when they carry 25% as their weakest dilution?

41. Drawing Up 12.5% Dextrose From D25% • 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

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

43. 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

44. Broselow Tape • Often gives mg but not always the ml to fill the syringe with • Mg helpful for accurate documentation • Holding a syringe, need to know how many ml’s to draw up into syringe • Back of SOP’s has medical and cardiac pediatric reference tables • Includes mg and ml of medications

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

46. 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

47. GCS – Peds 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

48. GCS – Peds 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

49. 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

50. Why Albuterol? • Albuterol is a bronchodilator • Receptors are in the lungs • Opens up constricted bronchiole passages • Albuterol also triggers receptors in the heart and you may see an increase in heart • rate