Pediatric Focused Review: Broselow Tape, Pediatric Codes, After Action Report

1. Pediatric Focused ReviewBroselow Tape, Pediatric Codes, After Action ReportCondell Medical Center EMS SystemMay 2010 CE Objectives provided by: Mary Ann Zemla, RN Packet prepared by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives • Upon successful completion of this module, the EMS provider will be able to: • Define ages for the pediatric population • Describe the Pediatric Assessment Triangle. • Identify common age-related illnesses and injuries in the pediatric population. • Describe signs, symptoms, and management of selected pediatric respiratory emergencies. • Describe signs, symptoms, and management of shock.

3. Objectives cont’d • Describe management of the pediatric patient with seizures. • Describe signs, symptoms, and management of hypoglycemia in the pediatric patient. • Describe signs, symptoms, and management of hyperglycemia in the pediatric patient. • Identify common causes of poisoning and toxic exposure in the pediatric patient. • Identify injury prevention for infants and children.

4. Objectives cont’d • Describe the indication, dosage, route, and special considerations for medication administration in infants and children. • Identify when to complete an After Action Report and how to forward it. • Actively participate in scenario discussion and practice. • Given a Broselow tape and the patient’s estimated weight calculate the correct medication dose for a pediatric patient. • Given a Broselow tape identify equipment used for a specific patient. • Successfully complete the post quiz with a score of 80% or better.

5. What is a Pediatric Patient? • Newborn – first hours after birth • Neonate – birth to 1 month • Infant – 1 to 12 months • Toddler – 1 to 3 years old • Preschooler – 3 to 5 years old • School-age – 6 to 12 years old • Adolescent – 13 to 18 years old

6. Region X SOP • Pediatric patient • “considered under the age of 16” • Patient is between the ages of 0 and 15 • Source: Follows guidelines of EMSC – Emergency Medical Services for Children

7. Common Pediatric Fears • Fear of • being separated from parents/caregivers • being removed from home and not returning • being hurt • being mutilated or disfigured • the unknown

8. Anatomical and Physiological Differences – Peds vs Adult • Tongue proportionately larger – may block airway • Smaller airway structures – more easily blocked • Abundant secretions – can block airway • Baby teeth – easily dislodged, may block airway • Flat nose and face – difficult to get good seal with face mask

9. Differences cont’d • Heavy head with less developed neck muscles to support head – head may be propelled forward and cause more head injuries • Open fontanelles – bulging may indicate increased ICP; shrunken may indicate dehydration • Thinner, softer brain tissue – increased susceptibility to brain injuries

10. Differences cont’d • Head larger in proportion to body – head tips forward making neutral alignment difficult • Shorter, narrower, more elastic trachea – trachea can close with hyperextension • Short neck – difficult to stabilize/immobilize • Abdominal breather – difficult to evaluate breathing • Faster respiratory rate – fatigued muscles leading to respiratory distress

11. Differences cont’d • Obligate nasal breathers as newborns – may not open mouth to breathe if nose is blocked • Larger body surface area relative to body mass- prone to hypothermia • Softer bones – more flexible, less easily fractured, transmitted forces may injure internal organs without rib fractures, lungs easily damaged • Spleen and liver more exposed- increased risk of injury with significant force to abdomen

12. Initial Pediatric Assessment • Active and alert child • Can spend time slowly approaching patient • Can spend time making patient more comfortable • Critically injured or ill child • Requires quick assessment and quick intervention

13. Pediatric Assessment TrianglePAT • Obtain information as you enter the area and are walking towards the child • Use to determine level of severity and determine urgency of situation • Based on visual observation and listening skills • Does not require equipment

14. PAT • Evaluate: • Appearance • Work of breathing • Circulation to skin • Information gained on: • Underlying cardiopulmonary status • Level of consciousness • Is not a replacement but an addition to the ABC assessment and vital signs

15. PAT - Appearance • Appearance most important factor • Reflects adequacy of • Oxygenation and ventilation • Perfusion • Homeostasis • CNS function • Observe child while in caregiver’s lap • Hands-on contact by caregiver may cause agitation and crying; may complicate assessment

16. PAT - Appearance • Tone – good muscle tone or limp, listless? • Interactive – how alert, looking around, distracted, interested in playing? • Consolable – able to be comforted by caregiver? • Eye contact/gaze – can gaze be fixed on an object or is gaze glassy eyed? • Speech/cry – strong, spontaneous or weak and high-pitched?

17. What is your general impression

18. PAT – Work of Breathing • Indicator of • Oxygenation • Ventilation (breathing) • More accurate than counting the respiratory rate and auscultating breath sounds • These are more typically used in the adult • Listen for abnormal sounds • Observe for increased effort of breathing

19. PAT – Work of Breathing • Abnormal positioning – sniffing position, tripoding, refusing to lie down • Abnormal airway sounds – snoring, stridor, grunting, wheezing, hoarse • Retractions – chest wall & neck muscles; head bobbing in infants • Flaring – of nares on inspiration

20. Tripod Position • Leaning forward, hands placed on thighs for support, expands the lungs

21. Abnormal Airway Sounds • Snoring – blocked airway; usually tongue • Stridor – partial airway obstruction; harsh high-pitched sound on inspiration • Grunting – Poor gas exchange; short, low-pitched sound at end of exhalation; helps keep airway open • Wheeze – whistling sound especially during exhalation

22. Which infant is in more distress? • Retractions noted  Playful, interested

23. Positioning of Airway • Rolled towels under the shoulders to gently extend the neck of the infant

24. PAT – Circulation to Skin • Important sign of core perfusion • Skin and mucous membranes non-essential and blood flow shunted away when cardiac output is inadequate • Expose long enough to determine circulation status • Avoid hypothermia • In dark skinned children, evaluate lips, mucous membranes, and nail beds

25. PAT – Circulation to Skin • Pallor • White or pale skin from inadequate blood flow • Mottling • Patchy skin discoloration due to vasoconstriction/vasodilation • Cyanosis • Bluish discoloration of skin and mucous membranes • Late finding of respiratory failure or shock

26. Pediatric Emergencies Are You Prepared? • Airway • Obstructions • Infections • Diseases • Croup • Epiglottitis • Asthma

27. Signs & Symptoms Respiratory Distress • Irritable, anxious • Tachypnea • Retractions • Nasal flaring (infants) • Poor muscle tone as condition deteriorates • Tachycardia • Head bobbing • Grunting • Cyanosis that improves with oxygen

28. Signs & Symptoms Respiratory Failure • Mental status deteriorating to lethargic • Marked tachypnea later deteriorating to bradypnea • Marked retractions deteriorating to agonal respirations • Poor muscle tone • Marked tachycardia deteriorating to bradycardia • Central cyanosis

29. Pediatric Emergencies Are You Prepared? • Shock • Inadequate tissue perfusion • Dehydration – vomiting or diarrhea • Infection – sepsis • Trauma – especially abdominal • Blood loss

30. Signs & Symptoms Compensated Shock • Irritability or anxiety • Tachycardia • Tachypnea • Weak peripheral pulses; full central pulses • Delayed capillary refill • Cool, pale extremities • Systolic B/P normal • Decreased urinary output

31. Decompensated Shock • Lethargy or coma • Marked tachycardia or bradycardia • Absent peripheral pulses, weak central pulses • Markedly delayed capillary refill • Cool, pale, dusky, mottled extremities • Hypotension • Markedly decreased urinary output • Absence of tears

32. Signs & Symptoms Mild Dehydration • Alert • Skin normal and dry • Pulse normal • Respirations normal • Blood pressure normal • Capillary refill normal

33. Signs & Symptoms Moderate Dehydration • Irritable • Skin dry, ashen and very dry • Pulse increased • Respirations increased • Blood pressure normal • Capillary refill 2 – 3 seconds

34. Signs & Symptoms Severe Dehydration • Lethargic • Skin dry, cool, mottled, very dry, no tears • Pulse markedly increased • Respirations markedly increased • Blood pressure hypotensive • Capillary refill > 2 seconds

35. Pediatric Fluid Resuscitation • Formula for all persons • 20 ml/kg • Calculate total amount based on weight • Administer one full fluid challenge, volume based on weight • If total volume greater than 200 ml, assess at every 200 ml increment • Reassess to determine need for 2nd fluid challenge • Reassess after 2nd fluid challenge to determine need for 3rd fluid challenge

36. Are You Prepared? Neurological Emergencies • Seizures • Fever • Hypoxia • Infections - meningitis • Idiopathic epilepsy (unknown cause) • Electrolyte disturbance • Head trauma • Hypoglycemia • Toxic ingestions or exposure • Tumor • CNS malformations

37. Status Epilepticus • Major emergency • Involves prolonged periods of apnea • Induces severe hypoxia • Seizures may cause • Respiratory arrest • Severe metabolic and respiratory acidosis • Increased intracranial pressure • Elevations in body temperature • Fractures of long bones and the spine • Severe dehydration

38. Respirations and Status Epilepticus • Patients in prolonged seizures must have respirations supported via BVM • Need to prevent hypoxia and acidosis • Ventilate 1 breath every 3 seconds for children • Ventilate 1 breath every 5 – 6 seconds for adults • Patients not in status and breathing on their own can be given a non-rebreather oxygen mask

39. Are You Prepared? GI Emergencies • Nausea • Vomiting • Diarrhea • Biggest risk – dehydration and electrolyte imbalance

40. Metabolic Emergencies Mild Hypoglycemia • Hunger • Weakness • Tachypnea • Tachycardia • Shakiness • Yawning • Pale skin • Dizziness

41. Metabolic Emergencies Moderate Hypoglycemia • Sweating • Tremors • Irritability • Vomiting • Mood swings • Blurred vision • Stomach ache • Headache • Dizziness • Slurred speech

42. Metabolic Emergencies Severe Hypoglycemia • Decreased level of consciousness • Seizures • Tachycardia • Hypoperfusion

43. Treatment Hypoglycemia • Situation develops rapidly (ie: minutes) • Ages less than 1 – D 12.5% 4 ml/kg IVP/IO • Ages 1 -15 – D 25% 2 ml/kg IVP/IO • Ages 16 and older – D 50% 50 ml (25 Gms) • Dextrose very irritating to veins • Need diluted strength for the younger veins • No IV access • Glucagon 0.1mg/kg (max dose 1 mg)

44. Metabolic Emergencies Early Hyperglycemia • Increased thirst • Increased urination • Weight loss despite increased intake • Stage in which many patients are diagnosed due to the 3 P’s of signs and symptoms: polyuria, polydipsia, polyphagia

45. Metabolic Emergencies Late Hyperglycemia • Weakness • Abdominal pain • Generalized aches • Loss of appetite • Nausea, vomiting • Signs of dehydration but with  urine output • Fruity odor to breath • Tachypnea • Hyperventilation • Tachycardia

46. Metabolic Emergencies –Hyperglycemia - Ketoacidosis • Continued decrease in level of consciousness progressing to coma • Kussmaul’s respirations – deep, rapid, becoming slow and gasping • An attempt to exhale excess acids (ie: CO2) produced during abnormal metabolism • Signs of dehydration • Sunken eyes • Dry skin, tenting • Tachycardia

47. Treatment Hyperglycemia • Develops over time (ie: days or weeks) • Patient prone to dehydration • Needs fluid administration • 20 ml/kg normal saline • Monitor carefully for fluid overload • Evaluate breath sounds frequently when administering fluid challenge

48. Are You Prepared? Evaluating for Poisoning • Possible indicators of ingested poisoning • Previous history of swallowing a poison • Change in level of consciousness • Vital sign alterations • Pupils – size and reaction • Skin and mucosa findings • Observation of mouth signs & odor • Abdominal complaints – nausea, vomiting, diarrhea

49. Toxicological Exposures • Carbon monoxide • Who else is ill? • Headache, nausea, vomiting, sleepiness • Cardiac medications • Nausea and vomiting • Headache, dizziness, confusion, dysrhythmias, bradycardia • Caustic substances (Drano, liquid plumber) • Burns, drooling, hoarseness

50. Toxicology cont’d • Salicylates (Aspirin toxic at 300 mg/kg) • Rapid resp, hyperthemia, altered level of consciousness, abdominal pain • Acetominophen (Tylenol toxic at 150 mg/kg) • Nausea, vomiting, weakness, abdominal pain, liver disorder, liver failure • Alcohol • CNS depression, impaired judgement • Marijuana • Euphoria, dilated pupils, altered sensation