pediatrics cme 2006

Pediatrics CMENick Mark, EMT-C

Outline

• Background: Pediatrics in EMS

• General Pediatric Assessment Strategies

• Pediatric Emergencies– Respiratory Emergencies– Seizures

• Scenarios

Background: Pediatrics in EMS

• Pediatrics constitute over 50% of ER visits but only about 5% of EMS calls are for pediatric patients.– Why is this?

• This has two consequences:– EMS providers have few opportunities to

practice working with pediatric patients– The few calls we do get for pediatric patients

tend to be more serious

Background: Pediatrics in EMS

• Some common pediatric emergencies include:– FBAO– Fever– Meningitis– Respiratory distress– Sepsis– Seizures– SIDS– Trauma

Pediatric Age Groups

• Newborn (first 6 hours)• Neonate (first 28 days)• Infant (first year)• Toddler (1 to 3 years)• Preschooler (3 to 5 years)• School age (6 to 12

years)• Adolescent (12 to

adulthood)

How much does a child weigh at each age?

Pediatric Assessment Techniques

• Initial Assessment (quick assessment that can be done within seconds of arriving on scene)– Appearance

• Mental status (alert, crying, obtunded, no response)• Muscle tone (moving, not moving, limp)

– Breathing• Respiratory rate (too fast, too slow, irregular)• Respiratory effort (use of accessory muscles, nasal flaring,

retractions, grunting)• Check breath sounds

– Circulation• Skin color (pallor, peripheral cyanosis, central cyanosis)• Capillary Refill (normal is within 2 seconds)• Pulse (too fast, too slow, irregular, normal)

Pediatric Assessment Techniques

• Detailed assessment– With adults this is typically done head to toe, with

pediatrics it is better to do the opposite• Why?

– Take a SAMPLE history (use the parents for detailed hx if possible)

– Determine • Hx of fever or infection• Hx of vomitting or fever and check hydration status (skin

turgor, check fontanalles in infants, look for xerosis)• Frequency of urination

– Why are these important questions to ask?

– Take vitals and measure pulse oximetry• How is pulse oximetry different in pediatrics than in adults?

Pediatric Assessment Techniques

• Detailed assessment (cont.)– Try to invent a game you can play or begin a

conversation about something you can talk about for at least several minutes (Batman, Sesame Street, toys, school, etc.).

– Explain each step in your assessment (“now I’m going to feel your tummy…”).

– With older patients explain why you are doing each step (“I need to make sure your stomach is OK”).

– With younger patients, avoid separating them from their parents if possible.

• Why?

Pediatric Assessment Techniques

• Detailed assessment (cont.)– Explain things as simply as possible avoiding

technical terminology and jargon.– Do NOT condescend.– Do NOT lie or make promises you cannot be sure to

keep.– Be alert for injuries that seem inconsistent with their

explanation – this is usually a sign of child abuse.• Examples?

– If you suspect child abuse, you must report it by calling 1-800-RICHILD.

Normal Vital Signs by Age

• In general remember as children age their pulse and breathing rates get slower, and their BP gets higher.

• By adolescence these values approach those of adults.

• Two general rules (for children 1-10):– Weight in kg = 2 x age (in years) + 8– Lowest permissible systolic BP = 70 + 2 x age

(in years)

Normal Vital Signs by Age

Age Breaths/Min Beats/Min Minimum Systolic BPNeonate 30-50 120-160 60

Infant 20-30 80-140 70

Toddler 20-30 80-130 74-76

Preschool 20-30 80-120 76-80

School Age 12-30 60-100 80-84

Adolescent 10-20 60-100 84-90

Respiratory Emergencies

Respiratory Emergencies

• Respiratory distress is the leading cause of ER visits and EMS calls for children

• Respiratory compromise is one of the leading causes of death in children– What is the leading cause of death in

children?

• Respiratory emergencies can effect children of all ages

• EMS intervention can be life-saving

Respiratory Emergencies

• Many different etiologies– Choking (FBAO)– Epiglottitis– Croup– Asthma– Bronchiolitis– Which of these is most common? Which is

most serious?

The Pediatric Airway• Several key differences

between adult and pediatric airway

– Larger floppier epiglottis

• Epiglottitis• More difficult

intubations

– Smaller, funnel shaped trachea

• FBAO is more likely

• No blind finger sweeps

• Why?

Respiratory Emergencies - FBAO

• Foreign Body Airway Obstruction (FBAO)– Usual causes are hard candy, nuts, small toys, coins, and

balloons

• Recognition– Apnea, inspiratory stridor, rales, rhonchi, wheezing, inability to

speak, anxiety, decreased breath sounds, muffled voice

• Treatment– If the patient is not breathing, open the airway and perform the

AHA approved maneuvers for clearing the obstruction• Heimlich, backblows, abdominal or chest compressions. • If properly trained you may use a laryngoscope with Magills forceps

to try and remove the obstruction.

– If patient is breathing, be as calming and supportive as possible. Do not agitate the patient and transport sitting up as comfortably as possible. Be alert for change in status.

Respiratory Emergencies - FBAO

• Treatment (cont.)– If patient is not breathing ventilate using a

BVM.– Administer oxygen at 15 LPM by NRB.– If patient is wheezing

• Contact Medical Control for permission to administer ALBUTEROL 2.5 mg (0.083%) by nebulizer over 5-10 minutes.

– For infants younger than 6 months use half the dose.

Respiratory Emergencies – Epiglottitis

• Inflammation of the epiglottis and surrounding structures caused by bacterial infection.

• This condition is a true emergency with mortality rates as high as 10%.

• Typically occurs in children 3-7 years old.

Respiratory Emergencies – Epiglottitis

• Recognition– Rapid onset (6-8 hours) of sore throat,

dysphagia, muffled voice, high fever, drooling, inspiratory stridor or rattle

– Child is often found obtunded in tripod position

– Signs of respiratory distress are often present

Respiratory Emergencies – Epiglottitis

• Treatment– It is absolutely essential that the patient be handled

as calmly as possible. Anxiety or aggravation can cause increased swelling and precipitate respiratory arrest.

• Defer all painful procedures.• Transport patient sitting up in position of comfort.• Do not try to visualize the swelling or look in the mouth.

– Administer high flow humidified O2 by NRB.– Administer 5 ml of EPINEPHRINE 1:1,000 by

nebulizer. This can reduce upper airway swelling.– Have airway equipment (BVM, ET equip) ready in

case patient’s condition deteriorates.– Inform medical control early so preparations can be

made at hospital for treatment.

Respiratory Emergencies – Croup

• Inflammation of the upper airways caused by a viral infection.

• Very common (50 per 1000 children)

• Usually occurs in children aged 6 months to 3 years. (median age of onset is 18 months).

Sites of inflammation in pediatric airway infections

Respiratory Emergencies – Croup

• Recognition– Low grade fever, barking cough,

hoarseness, inspiratory stridor, wheezing– Signs of respiratory distress– Often occurs at night

• Treatment– Same as for epiglottitis. – The patient is likely to respond well to cool

humidified O2.

Respiratory Emergencies – Epiglottitis vs. Croup

• Croup• 6 months – 3 years• Slow onset• Barking cough• No drooling• Low grade fever (<104°F)

• Responds well to tx

• Moderately serious

• Epiglottitis• 3 – 7 years• Rapid onset• No barking cough• Copious drooling• High fever (>104°F)

• Very Serious

Respiratory Emergencies – Asthma

• In contrast to croup & epiglottitis, asthma is inflammation of the lower airways.

• It is very common (effects 50-100 out of 1000 children under 10 YO)

Respiratory Emergencies – Asthma

• Recognition– Typically it is either exercise, allergy, or

infection induced– S/Sx include wheezing, prolonged expiration,

tachypnea, dyspnea, and anxiety– A silent chest is an especially bad sign.

• Why?

Respiratory Emergencies – Asthma

• Treatment– Administer cool humidified oxygen.– Provide ventilations if breathing is inadequate.– Contact Medical Control for permission to administer

ALBUTEROL 2.5 mg (0.083%) by nebulizer over 5-10 minutes. • For infants younger than 6 months use half the dose.

– If patient has severe respiratory distress, administer EPINEPHRINE 1:1,000 0.01 mg/kg SQ.

• Maximum dose is – 0.3 mg in pt. > 20 kg – 0.2 mg in pt. < 20 kg– 0.1 mg in pt. < 10 kg

• For patients with cardiac problems call medical control before administering EPINEPHRINE.

• What are some potential problems that EPINEPHRINE and ALBUTEROL can cause? What should you be alert for when giving these drugs?

Respiratory Emergencies – Bronchiolitis

• Bronchiolitis is a viral inflammation of the lower airways.

• It usually effects children under 2 YO.

• Usually presents with symptoms similar to those of asthma.

• Can be very serious in infants.– Why do you think this is?

• More common in the winter months.

Respiratory Emergencies – Bronchiolitis

• Recognition– Wheezing and tachypnea are most common

symptoms. Also anxiety, shortness of breath, and cyanosis.

• Treatment– Same as asthma– Patient is not as likely to respond well to β-

agonists (EPI, ALBUTEROL)

Respiratory Emergencies – Asthma vs. Bronchiolitis

• Asthma• Occurs in all ages, more

common in children > 2 YO

• Occurs throughout the year

• Family hx of asthma

• Responds well to β-agonists (EPI and ALBUTEROL)

• Bronchiolitis• Usually occurs in

children under 2 YO

• Most common in winter, spring

• No family hx

• Does NOT respond well to EPI/ALBUTEROL

Respiratory EmergenciesGeneral Notes

• Treat respiratory emergencies aggressively. Be prepared for patients to decompensate.

• Do not hesitate to give neonates oxygen if you suspect they need it.

• Remember to treat the parents too.

Seizures

Pediatric Seizures• A seizure is caused by abnormal electrical activity in the

brain.• Seizures can cause impaired consciousness and/or

abnormal behavior.• There are many causes of seizures including:

– Epilepsy– Infection– Trauma– Neoplasm– Metabolic problems (electrolytes, uremia, hypoxia, acidosis, etc.)– Hypoglycemia– Poisoning– HyperthermiaWhich of these causes do you think is most common in children?

Which do you think is usually most serious?

Pediatric Seizures

• Types of pediatric seizures– Grand mal (tonic

clonic)– Petit mal (absence)– Partial– Status epilepticus

Which type is most common is children?

• Stages of a grand-mal– Aura– Tonic-clonic– Postictal

Pediatric Seizures - Febrile

• Febrile seizures are caused by fever resulting from a viral infection.

• Very common (20-50 per 1000) in children under 7 YO.

• Most common in children aged 6 months to 5 years.

• There is usually a family history.• They are usually benign.

– If they are longer than 20 minutes they are probably not febrile and indicate something much more serious.

Pediatric Seizures

• Recognition– Seizure phase: unresponsiveness, involuntary

skeletal muscle contractions, dyspnea, apnea– Postictal phase: confusion, altered LOC,

retrograde amnesia

Pediatric Seizures

• Treatment– Protect the airway

• Place patient LLR• Suction to clear vomit• Use airway adjunct and ventilate if patient is

apneic

– Protect patient from injury

Pediatric Seizures

• Treatment (cont.)– Take a thorough history of the parents to try and R/O

differentials• Hx of medical problems• Medication use• Possibility of head injury• Recent illness (fever, nucal rigidity, photophobia, phonophobia)• Possibility of poisoning

– Other important questions• Did patient vomit during the seizure?• Duration of seizure?• Description of seizure• Condition of child when found• Last meal

– Why are these important questions to ask?

Pediatric Seizures

• Treatment– Manage the airway and provide oxygen– If patient is febrile (temp > 102°F) administer

ACETAMINOPHEN 15 mg/kg rectally.– Check blood glucose using glucometer– If bG is < 60 mg/dl (or if you suspect hypoglycemia)

• If patient is awake with intact gag reflex who can swallow, administer ORAL GLUCOSE 15 gm PO. (If pt. is younger than one year, contact medical control.)

• For patients without an intact gag reflex, contact medical control and administer GLUCAGON 0.1 mg/kg (max dose 1.0 mg) IM.

Pediatric SeizuresGeneral Notes

• Never assume “it’s just a febrile seizure.”

• All patients who have a seizure should be transported for evaluation.

• Always consider differential causes especially trauma, hypoglycemia, and OD.

• Seizure activity ALWAYS extremely serious in a neonate.

• Remember to treat the parents too.

Scenarios