Encountering The Pediatric Patient

Condell Medical Center EMS System September 2008 CE Site Code #10-7200E1208

Prepared by: Sharon Hopkins, RN,BSN, EMT-P

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)

 Calculate medication dosages given the patients weight Calculate the GCS given the pts 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

Pediatric Assessment Triangle - PAT

Establishes a level of severity Assists in determining urgency for life support Identifies key physiological problems using observational & listening skills

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

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

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

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)

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

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

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

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

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

Additional Assessment
Includes: Focused history Physical exam SAMPLE history

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

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

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

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

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

Putting It All Together Mechanism of Injury

Fall from height greater than 3 times the toddlers 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)

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)

General Impression For This 2 year-old

Category I trauma patient with head & orthopedic injuries SOPs 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

Whats 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

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

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

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

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

Nasal Flaring

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

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

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

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

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

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

Tibial tuberosity

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

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)

 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

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

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 others purses and have access to the medicine cabinet & other areas where drugs can be found

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

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%?

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

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!

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 mls 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

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

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

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

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

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

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

Albuterol Dosing
2.5 mg/3 ml for all patients The drug will be more successful when the patient is coached through use of the nebulizer The drug only works if it is inhaled deeply into the lungs Short, shallow breaths will not help drug absorption

Nebulizer Delivery
This route is most effective if there is someone coaching the patient during use Have someone talk the patient through the process Verbal encouragement essential to success Encourage slower breaths for a few ventilations Then encourage the breaths to be a bit deeper Then encourage the deeper breaths to be held a bit longer to get the drug down into the lungs

In-line Albuterol
Any patient no longer able to take a deep breath needs this drug forced into the lungs The drug must be given in-line
Attach nebulizer to the BVM as you start bagging the patient to get some drug into the lungs Once intubated, the ambu bag will continue to force the drug into the airway and down into the lungs

What Are the Risk Factors That Expose Kids To Seizures?

Fever most common Hypoxia Infections Electrolyte imbalance Head trauma Hypoglycemia Toxic ingestions Tumor

Status Epilepticus
A series of one or more generalized seizures without any periods of consciousness Concern is with periods of prolonged apnea that can lead to hypoxia

Assessment of Seizures
ALWAYS obtain a glucose level if level of consciousness is altered Ask if there is a history of recent illness Ask for description of the seizure activity Jerking of both sides of the body, jerking limited to a particular part of the body, eye blinking, staring, lip smacking

Seizure Intervention
Support the airway Consider BVM if active seizure To terminate current seizure Valium 0.2 mg/kg IVP No IV access, Valium rectally 0.5 mg/kg Max total rectally 10 mg Remove extra clothing if febrile Cool cloths over patient, fan patient Shivering will increase body temp!

Valium Calculation
Patient with active seizure Patient weighs 26 pounds 26 # 2.2 = 11.8 KG (12 KG) Valium is 0.2 mg/kg 12kg x 0.2 = 2.4 mg

Where are your resources to use to check how many mls to pull up into the syringe?

Medication Resources
Back of SOPs Meds by mg for documentation and by ml to draw up into the syringe Broselow tape 2007 Edition B Legend gives the formula Valium (diazepam) exact mg given under each respective weight category Careful!!! Diazepam broken down by IV AND rectal so read columns carefully

Possible Causes of Critical Rhythms

6 Hs Hypovolemia fluid challenge Hypoxia supplemental O2 Acidosis ventilate to blow off CO2 Hyper/hypokalema Hypothermia warm core Hypoglycemia check glucose level

 5 Ts Tablets drug overdose Tamponade supportive care in field Tension pneumothorax needle decompression Thrombosis, coronary or pulmonary Trauma

Peds VF or Pulseless VT
After 2 minutes of CPR if unwitnessed, defibrillate 2j/kg or equivalent biphasic AED can be used if >1 years old Immediately resume CPR for 2 minutes / 5 cycles Rhythm checks after 2 minutes CPR Repeat defibrillate 4j/kg or equivalent biphasic Resume CPR Establish IV/IO

Meds given during CPR: Epinephrine 1:10,000 0.01 mg/kg IVP/IO Repeat every 3-5 minutes Choose one antidysrhythmic to alternate with Epi Amiodarone 5 mg/kg IVP/IO Lidocaine 1 mg/kg IVP/IO Repeat doses per Medical Control order

VF/VT

Why Epinephrine?
Epinephrine is a catecholamine and stimulant Epinephrine is a vasoconstrictor to improve blood flow Before drug therapy, always assess/evaluate the status of oxygen delivery and effectiveness of ventilation

PEA/Asystole
Start CPR and run thru the H & T checklist Secure airway Establish IV/IO Fluid challenge 20 ml/kg Epinephrine 1:10,000 0.01 mg /kg IVP/IO Repeat every 3-5 minutes NO Atropine in SOP for peds!!!

Why No Atropine in Peds PEA or Asystole?

Atropine will probably not help unless the patient has primary AV block and that is not likely in a young and healthy heart Improving oxygenation and ventilation are the primary treatments for pediatric bradycardia

Peds Symptomatic Brady

Severe cardiorespiratory compromise
Poor perfusion Bradycardia Weak, thready, absent pulse Hypotension Pallor Cyanosis Respiratory difficulty

Peds Brady
Heart rate <60 & poor systemic perfusion perform CPR IV/IO access Epinephrine 1:10,000 0.01 mg/kg IVP/IO Repeat every 3-5 minutes If persistent brady, contact Medical control for order of Atropine Atropine if ordered: 0.02 mg/kg (minimum dose to give 0.1 mg) IVP/IO May repeat Atropine x1 Max dose 1 mg Consider pacing

Peds Shock
Hypovolemic or distributive IV fluid challenge 20 ml/kg If no response repeat 20 ml/kg up to 60 ml/kg (ie: total 3 challenges) No fluid challenge for peds in cardiogenic shock too much fluid for the heart to handle

Peds Tachycardia
Bradydysrhythmias are more common in peds patients than tachycardias Sinus Tachycardia Heart rates in infants are under 220 and in children under 180 No drug therapy indicated Search for possible causes

Probable Supraventricular Tachycardia

Narrow complex tachycardia greater than 220 in infants and greater than 180 in a child Typically due to a problem in the cardiac conduction system Rapid heart rates prevent adequate ventricular filling that can lead to CHF and cardiogenic shock

Signs & Symptoms SVT

Irritability Poor feeding JVD Hepatomegaly enlarged liver Hypotension Children can often tolerate the rapid rate fairly well

Treatment SVT with Adequate OR Poor Perfusion

Vagal maneuvers
If a straw is available, have child blow thru one

Adenosine 0.1 mg/kg rapid IVP followed by 5 ml rapid saline flush Max 1st dose is 6 mg (max at adult dose) Repeat dose if needed is 0.2 mg/kg with 5 ml saline flush Max 2nd dose is 12 mg (adult dose)

Cardioversion for No Response to Adenosine or For Probable VT

Sedate with Versed 0.1 mg/kg IVP slowly over 2 minutes Cardioversion at 1 j/kg If no response, cardiovert at 2 j/kg

Why Versed?
Amnesic Relaxes patient Shorter acting than Valium Does NOT take away pain! Can cause respiratory depression Have BVM reached & ready whenever Versed or Valium are given in case the patient needs ventilation support

 No time to allow drugs to work to slow or convert rhythm Need to be more aggressive Cardiovert the patient 1st attempt 1 j/kg 2nd attempt if needed 2 j/kg If no response to cardioversion, contact Medical Control for possible Amiodarone or Lidocaine order

Probable VT with Poor Perfusion

 The bodys immune response to an antigen tries to eliminate the antigen (foreign material) from the body Bronchospasm so no more offending antigen can enter the respiratory tract Coughing to expel the antigen Leaky capillaries remove antigen from the blood stream and place it into the interstitial tissue for removal via lymph system Vomiting & diarrhea remove antigen from GI tract

Allergic Reactions Is Response Life Saving or A Killer?

Antigen Exposure & Histamine Release

Increased capillary permeability 3rd spacing (intravascular fluid into interstitial space) Edema Relative hypovolemia Peripheral vasodilation peripheral vascular resistance ( B/P) Smooth muscle constriction Abdominal cramps, vomiting, diarrhea Bronchoconstriction & laryngeal edema

Is it an Allergic Reaction or Anaphylaxis?

Anaphylaxis is the more severe response of the two
Usually occurs when a patient is exposed to a specific allergen, especially injected directly into the circulation

Anaphylaxis principally affects the cardiovascular, respiratory, GI systems and the skin Faster the reaction, usually the more severe the reaction is In anaphylaxis, the patient will be hypotensive (ominous sign)

Why Epinephrine 1:1000 For An Immune Response?

Stimulates certain receptors in the body (alpha & beta receptors) Constricts blood vessels to help counter vasodilation effects of anaphylaxis (alpha affect) Opens up airways by reversing bronchospasm of anaphylaxis (beta affect) Max dose calculated at adult dose (0.3ml)!

What Does Epinephrine Do?

Primary drug used in reactions Increases heart rate Increases strength of cardiac contractions Causes peripheral vasoconstriction Can reverse bronchospasm Can reverse capillary permeability Effects short term

Why Benadryl For Immune Response?

Antihistamines are the 2nd line agents to give in reactions Antihistamines block the effects of histamine released in the body by blocking histamine receptors Duration of action is 6-12 hours so anticipate rebound if the patient has not filled a prescription to continue taking the antihistamine Max dose given is at adult dosing

Benadryl Dosing
Epinephrine is 1st line drug if applicable Stable allergic reaction no airway involvement Benadryl 1 mg/kg slow IVP or IM Max 25 mg (adult dose) Stable allergic reaction with airway involvement Benadryl 1 mg/kg slow IVP Max 50 mg (adult dose) Anaphylactic shock - Benadryl 1 mg/kg slow IVP - Max 50 mg (adult dose)

Practice Calculating the GCS

Remember to use the PEDS alternative values when the patient is non-verbal If the patient is old enough to talk, follow the adult prompts to calculate the GCS

GCS Calculation #1
Patient is 7 months old Eyes are open but do not focus or follow activities The infant has an irritable cry The infant pulls their arms in when the IV stick is attempted

GCS Calculation #2
Patient is 3 years-old Eyes flutter open when the patient is yelled at The toddler cries after the injured extremity is manipulated The toddler pulls back when the injured extremity is manipulated

GCS Calculation #3
Patient is 5 months-old Eyes flutter open when the deformed extremity is manipulated The patient moans when the injured extremity is manipulated The patient pulls up their extremities tightly into their chest when touched (flexion)

GCS Calculation #4
Patient is 5 years-old Patient is watching your movement Patient is using repetitive words Patient pushes your hands away when you touch them

GCS Calculations 1 & 2

Pt #1 GCS 12 Eye opening 4 (spontaneous) Verbal 4 (irritable cry) Motor 4 (withdraws to pain) Pt #2 GCS 10 Eye opening -3 (eyes open to voice) Verbal 3 (cries to pain) Motor 4 (withdraws to pain)

GCS Calculations 3 & 4

Pt #3 7
Eye opening 2 (eyes flutter to pain) Verbal 2 (responds to pain) Motor 3 (flexes extremities into chest)

Pt #4 13
Eye opening 4 (spontaneous) Verbal 4 (repetitive words / confused) Motor 5 ( pushes hands away/purposeful)

Scenarios
Read the following case studies Discuss your general impression based on the pediatric assessment triangle (PAT) Discuss interventions appropriate to the situation Discuss documentation to include specific to the call

Case Study #1
You are at a local high school track meet when a 12 year-old boy collapses while running the 100-yard dash. Initial assessment reveals the child is apneic and pulseless. CPR is started What are the next appropriate steps to take? Can an AED be used on a 12 year-old?

Case Study #1
AEDs can be used in patients over 1 years-old Use the child pads for 1 8 year olds If no child pads available, use adult pads Cannot use child pads though on the adult CPR for 12 year-old is adult standards CPR 1 person infant & child is 30:2; 2 person is 15:2; once intubated ventilations are delivered once every 6-8 seconds

Case Study #1
Attach a monitor as soon as possible Stop CPR (witnessed arrest) as soon as monitor applied & ready Whats the rhythm & treatment?

Case Study #1
Rhythm: Torsades Most likely this young athlete has long QT syndrome (conduction defect) that makes them prone to arrest during physical exertion Treat like VF Defibrillate 1st at 2j/kg Repeat defibrillations at 4j/kg Epinephrine 1:10,000 0.01 mg/kg IV/IO Repeat every 3-5 minutes Choose one antidysrhythmic (Amiodarone or Lidocaine; one dose)

Case Study #2
A 2 year-old at preschool fell from a sitting position and the teacher witnessed jerking of the arms and legs that lasted for 1-2 minutes. Parent told teacher the child was not feeling well during the night. On arrival, the child is drowsy, will open their eyes to voice but does not answer questions, cries & withdraws when touched. VS: B/P 110/58; HR 100; RR 30; skin warm to the touch What is your impression based on the assessment triangle? What is the GCS?

Case Study #2
Patient appears physiologically stable
Drowsy, no extra effort or noise for breathing, skin pink and warm GCS 11 (3, 3, 5) (currently post-ictal)

Initial impression is febrile seizure (no history trauma, history of being ill last night, feels warms to touch) Field treatment limited to cooling measures
Remove extra clothing, cool cloths on forehead

Case Study #2 Is Valium Indicated Now?

Valium stops the current seizure but does not prevent future seizures Valium indicated if multiple seizures occur or seizure lasts longer than a few minutes Long lasting seizure can cause hypoxia Side effects of valium are respiratory depression

Case Study #3
You are on the scene for an 18 month-old child who is having difficult breathing The mother states a 2 day hx of slight fever and wheezing esp when crying Pt suddenly woke tonight short of breath with loud noises on inhalation Child sitting on mothers lap, anxious, watches you and cries weakly when you approach

Case Study #3
Color pink, has retractions with nasal flaring HR 180; RR 42 Strong pulses, cap refill 2 seconds Loud, harsh breath sounds bilaterally

Case Study #3
How sick is this child? PAT (pediatric assessment triangle) Evaluate appearance, work of breathing, & circulation to skin What is your general impression? Do you think this is an upper or lower airway problem? How should you care for this child in the field?

Case Study #3
PAT: makes eye contact & cries when EMS approaches; exhibiting stridor & increased work of breathing; skin pink & warm This child is in respiratory distress, not failure, with an upper airway problem Stridor indicates upper airway obstruction and history of a few days of respiratory infection is consistent with croup

Case Study #3
Management upper airway obstruction based on severity of symptoms Position of comfort usually best to leave child sitting upright O2 best if humidified Can you give humidified O2 in the field?

Humidified Oxygenation
Place 6 ml normal saline into the nebulizer Finish assembling the nebulizer Connect tubing to the O2 source Turn up the liter flow to generate a flow of mist Aim the mist near the childs face Helpful for croup & epiglottitis

Case Study #3
If wheezing, give Albuterol 2.5 mg Used as bronchodilator FYI: Research indicates Albuterol does not have much affect in croup Place Albuterol into nebulizer Place nebulizer mask over patients face if child too small to place lips around mouthpiece or direct mist near childs face

Case Study #4
911 called to the scene for a 3-month old who has had 3 days of cough, runny nose & low-grade fever. Caregiver concerned because the child is working harder to breathe and having hard time feeding Child is in caregivers lap Child is sleepy, no eye contact or response to the exam

Case Study #4
Child limp, audible wheezing, deep retractions, nasal flaring, skin mottled, diaphoretic VS: HR 180; RR 70; SaO2 on room air 74% Breath sounds: tight with only fair air movement with high-pitched inspiratory & expiratory wheezes

Case Study #4
Is this child in respiratory distress or respiratory failure? What is your general impression? What do you need to do to manage this patient?

Case Study #4
You note increased work of breathing, abnormal appearance, and poor circulation This patient is in respiratory failure With the wheezing, the problem is most likely a lower airway obstruction Most likely bronchiolitis (inflammation of the bronchioles often caused by RSV a viral infection)

Case Study #4
Rapid and urgent transport This patient most likely does not have an easily reversible respiratory problem and is likely to deteriorate further Enroute administer a bronchodilator (Albuterol) via nebulizer via mask (wont be able to put mouth around mouthpiece)

Case Study #4
Monitor respiratory status closely If decreased respiratory effort or slowing of the rate, consider BVM support using a slow rate and long expiratory time AHA ventilatory rate for rescue breathing infant < 1 & child < 8 1 breath every 3-5 seconds (12 20 breaths per minute) Give each breath over 1 second

Case Study #5
You are called for an unresponsive 3 year-old child There are no abnormal airway sounds Patient is pale & slightly diaphoretic VS: B/P 80/60; HR 160; RR 20 Pupils small, slow to react Withdraws from pain & moans Was playful before his nap and appeared healthy

Case Study #5
What is your general assessment? What is the GCS? What other assessments need to be done? What interventions are needed?

 This patient is critical: unresponsive, no abnormal appearance for work of breathing, pale & diaphoretic & tachycardic GCS - 7 Eye opening 1 (none) Verbal response 2 (moans) Motor response 4 (withdraws) Need to obtain glucose level (40) Keep airway open, supplemental O2, establish IV access Needs D25% 2 ml/kg slow IVP

Case Study #5

Case Study #5
Calculating & administrating Dextrose D25% ages 1 15 is 2 ml/kg This 3 year-old weighs 29 pounds How much D25% do you administer? Where are your resources to find the information?

Case Study #5
Check the back of the SOPs Check the Broselow tape Divide pounds by 2.2 to determine kg 29 2.2 = 13 kg Multiply kg by the formula (2 ml/kg) 13 kg x 2 ml/kg = 26 ml D25% D25% is packaged in 10 ml prefilled syringe Administer IV dose slowly to minimize vein irritation

Case Study #6
You run this call: 8 year-old patient in full arrest Monitor shows VF What tasks need to be assigned? Remember to assign someone to take care of the family Now run the call

Case Study #7
You run the call: Your 4 month-old is hypoglycemic with a glucose level of 35 How are you going to handle this call? Go through the steps as a team; draw up the meds

Case Study #8
You run the call: Your 6 year-old is found listless with a GCS of 9 The monitor shows:

Whats the rhythm? What do you do?

Case Study #8
Pediatric bradycardia is a hypoxia problem until proven otherwise Start CPR with attention to ventilation Establish IV/IO Where are the IO landmarks? How do you place an IO needle? What drug therapy is necessary for the pediatric symptomatic bradycardia?

Case Study #8
EZ IO landmarks 2 fingerbreadths down from patella 1 fingerbreadth toward medial surface away from tibial tuberosity Peds bradycardia treatment Epinephrine 1:10,000 0.01 mg/kg IV/IO Repeated every 3-5 minutes Persistent brady, contact Medical Control for Atropine order

Bibliography
Aehlert, B. PALS Study Guide. Elsevier. 2007. American Academy of Pediatrics. Pediatric Education for Prehospital Professionals. 2nd edition. Jones & Bartlett. 2006. Rahm, S. Pediatric Case Studies for the Paramedic. AAOS. 2006. Region X SOPs. Amended 1/08. www.peds.umn.edu/.../teaching/lung/ stridor.jpg