encountering the pediatric patient

8/2/2019 Encountering the Pediatric Patient

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Encountering The Pediatric

PatientCondell Medical CenterEMS System

September 2008 CE

Site Code #10-7200E1208

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


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Objectives

Upon successful completion of this module,the EMS provider should be able to:

Review and understand the components ofthe Pediatric Assessment Triangle (PAT)

Identify the difference betweenrespiratory distress and respiratory failure

State the landmarks for the EZ IO needle

Choose the appropriate medication & doseto administer for a variety of conditions(Dextrose, Narcan, Albuterol, Valium,Epinephrine, Atropine, Adenosine,

Versed, Benadryl)


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Calculate medication dosages given thepatients weight

Calculate the GCS given the pts responses Identify and appropriately stateinterventions for a variety of EKG rhythmsspecific to the pediatric population (VF,

SVT, bradycardia) Demonstrate the ability to obtain

information from the Broselow tape andSOP pediatric medication tables

Participate in calculating and drawing upmedications

-Successfully complete the 10 question

quiz with a score of 80% or better


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Pediatric Assessment

Triangle - PAT Establishes a level of severity

Assists in determining urgencyfor life support

Identifies key physiological

problems using observational &listening skills


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General Assessment -

PAT Performed when first approaching

the child

Does not take the place ofobtaining vital signsCheck appearance

Evaluate work of breathingAssess circulation to the skin


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PAT - Appearance

Reflects adequacy of:

Oxygenation

Ventilation

Brain perfusion

HomeostasisCNS function


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Assessing Appearance

Evaluate as you cross the roomand before you touch the child:

Muscle tone

Mental status / interactivitylevel

ConsolabilityEye contact or gaze

Speech or cry


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PAT - Breathing

Reflects adequacy of :oxygenationVentilation

In children, work of breathingmore accurate indicator of

oxygenation & ventilation thanrespiratory rate or breathsounds (standards used in adults)


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Assessing Breathing

Evaluate:Body position

Visible movement of chest orabdominal walls

6-7 years-old & younger areprimarily diaphragmatic (belly)breathersRespiratory rate & effort

Audible breath sounds


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PAT - Circulation

Reflects:

Adequacy of cardiac outputand perfusion of vitalorgans (core perfusion)


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Assessing Circulation

Evaluate skin color:

Cyanosis reflects decreased

oxygen levels in arterial bloodCyanosis indicatesvasoconstriction and respiratory

failureTrunk mottling indicateshypoxemia


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Priority Patients &

Transport Decisions Decide what level of criticality thispatient is

Decide if they must go to the closestemergency department or do youhave time to honor the family

request if their hospital is not theclosest


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Additional Assessment Includes:

Focused historyPhysical exam

SAMPLE history


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Physical Exam

Toe to head in the very young

Infants, toddlers, andpreschoolers

Head to toe in the older child


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SAMPLE History

S signs & symptoms

A allergies

M medications including herbal and overthe counter (OTC)

P past pertinent medical history

L last oral intake (to eat or drinkincluding water)

E events leading up to the incident


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Assessment &

Interventions Vital signs Determine weight and age

SaO2 reading preferably before & afterO2 administration

Cardiac monitor if applicable

Establish IV if indicated

Determine blood glucose if indicated

Reassess vital signs, SaO2, patient

condition


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Detailed Physical Exam

Information gathered buildson the findings of the initialassessment and focused exam

Use the toe to head for

infants, toddlers, andpreschoolers


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Putting It All Together You are called to the scene for a2 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 tothe right forehead and the right arm

is deformed


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Putting It All Together -

Mechanism of Injury Fall from height greater than 3 timesthe toddlers height

For this 2 year-old, the mechanism ofinjury indicates a Category I traumapatient based on mechanism of injury

(fall from height) and level ofconsciousness (unresponsiveness)


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Putting It All Together -

Index of Suspicion For this 2 year-old you are

anticipating major traumaticinjuries due to mechanism ofinjury (minimally anticipating

head injury and orthopedicfractures)

G l F h


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General Impression For This2 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 baggedor intubated

Hemorrhage control / interventionswith IV/IO access needing to beobtained

Cardiac monitoring

Determining blood glucose level


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Whats The Difference?

Respiratory distress The patient exhibits increased work of

breathing but the patient is able tocompensate for themselves

Increased respiratory effort in childwho is alert, irritable, anxious, andrestless

Evident use of accessory muscles Intercostal retractions Seesaw respirations (abdominal

breathing)

Neck muscles straining


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Respiratory failure

Energy reserves have beenexhausted and the patient cannotmaintain adequate oxygenation and

ventilation (breathing) Sleepy, intermittently combativeor agitated child

Heart rate usually bradycardicas a result of hypoxia


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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


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Stridor

Harsh, high-pitched soundheard on inspirationassociated with upper airway

obstruction Sounds like high-pitched

crowing or seal-bark soundon inspiration


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Grunting

Compensatory mechanism to helpmaintain 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


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Nasal Flaring


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Retractions

A visible sign where the softtissues sink in duringinhalation

Most notable are in the areas

above the sternum or clavicle,over the sternum, andbetween the rib spaces


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Respiratory Failure

Decreased level of responsiveness orresponse to pain

Decreased muscle tone Inadequate respiratory rate, effort,or chest excursion

Tachypnea with periods of bradypneaslowing to agonal breathing


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IV Access

Peripheral access can be difficultto find in a child

More sub Q fat Smaller targets

More fragile veins Lack of our experience


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Hint to Find Peds Veins

Hold your penlight across the skin toreflect the veins

Hold the penlight under the site toilluminate the veins


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IO Indications

Shock, arrest, or impending arrest Unconscious/unresponsive to

stimuli

2 unsuccessful IV attempts or 90second duration

Use Peds needle for 3 39 kg(up to 88 lbs)

- Peds needle 15 G 5/8


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EZ IO Landmarks

Proximal medial tibia


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Tibialtuberosity


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EZ IO Infusion

All patients need to have the IOflushed prior to connecting the IVsolution

The primed extension tubing must beused with a syringe attached

Only the syringe is removed after

flushing in preparation to attachingIV fluid

All IV bags need a pressure bag to

flow


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If you suspect narcotic influence

or as a diagnostic tool if bloodsugar is okay or patient does notrespond to Dextrose

Give Narcan20 kg = 2 mg IVP/IO/IM

Max total dose is 2 mg


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Dextrose

The brain is a very sensitive organ toinadequate levels of glucose

When the glucose levels drop thepatient will have an altered level ofconsciousness

If glucose levels reach a critically lowlevel, the patient may have a seizure


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Narcan Useful to reverse the effects of

narcotics (respiratory depression anddepression of the central nervoussystem)

Morphine, hydromorphine, oxycodone,Demerol, heroin, Dilaudid, codeine,percodan, fentanyl, darvon, methadone

Consider the children that get intoothers purses and have access tothe medicine cabinet & other

areas where drugs can be found


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Calculation Practice

Your 8 month-old patient weighs17 pounds

Which strength Dextrose shouldthis patient receive and howmuch?


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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% Dextrosewhen you carry 25%?


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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 filledwith sterile saline

16 ml 25% dextrose mixed with 16 mlsterile normal saline

Administer in largest vein possible and atslowed rate Extremely irritating to the veins


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Narcan Calculation

Your patient weighs 19 pounds


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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


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GCS For Pediatric

Patient Same tool used for the adult

population with minor changes to

accommodate the non-verbalinfant

Most accommodations made in

the verbal section Makes sense if this is for the

non-verbal patient


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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 eyelidsflutter to touch or painful stimuli

1 point if eyes do not open


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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 noiseresponse to pain (similar to moans &groans in the adult)

1 point if there is silence


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GCS Motor Response

6 points if the patient movesappropriately

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


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Acute Asthma

Many patients will try to selfmedicate and may try for too longon their own before they call forhelp

The patient can deteriorate fast

once they fatigue and theirrespiratory muscles are exhausted


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Albuterol Dosing

2.5 mg/3 ml for all patients

The drug will be more successful

when the patient is coached throughuse of the nebulizer

The drug only works if it is inhaled

deeply into the lungs Short, shallow breaths will nothelp drug absorption

N b li D li


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Nebulizer Delivery

This route is most effective if there issomeone 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 drugdown into the lungs


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In-line Albuterol

Any patient no longer able to take adeep breath needs this drug forcedinto 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 willcontinue to force the drug into theairway and down into the lungs

What Are the Risk Factors


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What Are the Risk FactorsThat Expose Kids To

Seizures? Fever most common Hypoxia

Infections Electrolyte imbalance Head trauma

Hypoglycemia Toxic ingestions Tumor


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A t f S i


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Assessment of Seizures

ALWAYS obtain a glucose level iflevel of consciousness is altered

Ask if there is a history of recentillness

Ask for description of the seizureactivity

Jerking of both sides of the body,jerking limited to a particular partof the body, eye blinking, staring,lip smacking


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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 0.5mg/kg

Max total rectally 10 mg

Remove extra clothing if febrile Cool cloths over patient, fan patient Shivering will increase body temp!


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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 useto check how many mls to pull up into the syringe?


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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 byIV AND rectal so read columns

carefully

P ibl C f


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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


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5 Ts

Tablets drug overdose Tamponade supportive care in

field

Tension pneumothorax needledecompression

Thrombosis, coronary or pulmonary

Trauma

d l l


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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 for2 minutes / 5 cycles

Rhythm checks after 2 minutes CPR

Repeat defibrillate 4j/kg or equivalentbiphasic

Resume CPREstablish IV/IO


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VF/VT

Meds given during CPR: Epinephrine 1:10,000 0.01 mg/kgIVP/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


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PEA/A t l


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PEA/Asystole

Start CPR and run thru the H & Tchecklist

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!!!

Wh N At i i P d


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Why No Atropine in PedsPEA or Asystole?

Atropine will probably not help unlessthe patient has primary AV block and

that is not likely in a young andhealthy heart

Improving oxygenation and

ventilation are the primarytreatments for pediatric bradycardia


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Peds Symptomatic Brady

Severe cardiorespiratory compromisePoor perfusion

Bradycardia

Weak, thready, absent pulseHypotension

Pallor

Cyanosis

Respiratory difficulty


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Peds Brady

Heart rate


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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


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Peds Tachycardia

Bradydysrhythmias are more commonin 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

P b bl i l


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Probable SupraventricularTachycardia

Narrow complex tachycardia greaterthan 220 in infants and greater than

180 in a child Typically due to a problem in thecardiac conduction system

Rapid heart rates prevent adequateventricular filling that can lead to

CHF and cardiogenic shock

&


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Signs & Symptoms SVT

Irritability Poor feeding

JVD Hepatomegaly enlarged liver Hypotension

Children can often tolerate therapid rate fairly well

Treatment SVT with


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Treatment SVT withAdequate OR Poor Perfusion

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

one

Adenosine 0.1 mg/kg rapid IVP followedby 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


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Cardioversion for NoResponse 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


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Why Versed?

Amnesic Relaxes patient Shorter acting than Valium

Does NOT take away pain! Can cause respiratory depression

Have BVM reached & readywhenever Versed or Valium aregiven in case the patient needsventilation support


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Allergic Reactions Is


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gResponse Life Saving or

A Killer? The bodys immune response to an antigentries to eliminate the antigen (foreignmaterial) from the body

Bronchospasm so no more offendingantigen can enter the respiratory tract Coughing to expel the antigen Leaky capillaries remove antigen from

the blood stream and place it into theinterstitial tissue for removal via lymphsystem

Vomiting & diarrhea remove antigen

from GI tract

Antigen Exposure &


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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


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Is it an Allergic Reactionor Anaphylaxis?

Anaphylaxis is the more severe response ofthe 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 andthe skin

Faster the reaction, usually the more severethe reaction is In anaphylaxis, the patient will be hypotensive (ominous sign)

Why Epinephrine 1:1000 For


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Why Epinephrine 1:1000 ForAn Immune Response?

Stimulates certain receptors in thebody (alpha & beta receptors)

Constricts blood vessels to helpcounter vasodilation effects ofanaphylaxis (alpha affect)

Opens up airways by reversingbronchospasm of anaphylaxis (betaaffect)

Max dose calculated at adult dose

(0 3ml)!

What Does Epinephrine


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What Does EpinephrineDo?

Primary drug used in reactions

Increases heart rate

Increases strength of cardiaccontractions

Causes peripheral vasoconstriction

Can reverse bronchospasm Can reverse capillary permeability

Effects short term

Why Benadryl For


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y yImmune Response?

Antihistamines are the 2nd line agentsto give in reactions

Antihistamines block the effects of

histamine released in the body byblocking histamine receptors Duration of action is 6-12 hours so

anticipate rebound if the patient has

not filled a prescription to continuetaking the antihistamineMax dose given is at adult dosing

Benadryl Dosing


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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 airwayinvolvement 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


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Practice Calculating theGCS

Remember to use the PEDSalternative values when the

patient is non-verbal If the patient is old enough to

talk, follow the adult prompts to

calculate the GCS


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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 inwhen the IV stick is attempted

GCS C l l ti #2


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GCS Calculation #2

Patient is 3 years-old Eyes flutter open when the

patient is yelled at The toddler cries after theinjured extremity is manipulated

The toddler pulls back when theinjured extremity is manipulated

GCS Calculation #3


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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 theirextremities tightly into their

chest when touched (flexion)

GCS C l l ti #4


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GCS Calculation #4

Patient is 5 years-old

Patient is watching your

movement Patient is using repetitive words

Patient pushes your hands awaywhen you touch them

GCS C l l ti 1 & 2


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GCS Calculations 1 & 2

Pt #1 GCS 12Eye 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)



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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


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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 includespecific to the call

Case Study #1


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Case Study #1

You are at a local high school trackmeet when a 12 year-old boycollapses while running the 100-yarddash. Initial assessment reveals thechild is apneic and pulseless. CPR isstarted

What are the next appropriate steps

to take? Can an AED be used on a 12 year-old?

Case Study #1


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Case Study #1

AEDs can be used in patients over 1years-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 personis 15:2; once intubated ventilations are

delivered once every 6-8 seconds

Case Study #1


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Case Study #1

Attach a monitor as soon as possible Stop CPR (witnessed arrest) as soonas monitor applied & ready

Whats the rhythm & treatment?

Case Study #1


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Case Study #

Rhythm: Torsades Most likely this young athlete has long

QT syndrome (conduction defect) thatmakes them prone to arrest duringphysical 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


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Case Study #2 A 2 year-old at preschool fell from a sitting

position and the teacher witnessed jerkingof the arms and legs that lasted for 1-2minutes. Parent told teacher the child wasnot feeling well during the night.

On arrival, the child is drowsy, will opentheir eyes to voice but does not answerquestions, cries & withdraws when touched.

VS: B/P 110/58; HR 100; RR 30; skin warm tothe touch

What is your impression based on theassessment triangle?

What is the GCS?

Case Study #2


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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 (nohistory trauma, history of being ill lastnight, feels warms to touch)

Field treatment limited to coolingmeasures Remove extra clothing, cool cloths on forehead

Case Study #2 -


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u yIs Valium Indicated Now?

Valium stops the current seizure butdoes not prevent future seizures

Valium indicated if multiple seizuresoccur or seizure lasts longer than afew minutes

Long lasting seizure can cause hypoxia Side effects of valium are

respiratory depression

Case Study #3


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y

You are on the scene for an 18 month-oldchild 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 breathwith loud noises on inhalation

Child sitting on mothers lap, anxious,watches you and cries weakly when youapproach


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Case Study #3

Color pink, has retractions with nasalflaring

HR 180; RR 42 Strong pulses, cap refill 2 seconds

Loud, harsh breath sounds bilaterally

Case Study #3


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Case Study #3

How sick is this child? PAT (pediatric assessmenttriangle)

Evaluate appearance, work ofbreathing, & circulation to skin

What is your general impression?

Do you think this is an upper orlower airway problem?

How should you care for this

child in the field?


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Case Study #3


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Case Study #3

Management upper airwayobstruction based on severity ofsymptoms

Position of comfort usuallybest to leave child sittingupright

O2 best if humidifiedCan you give humidified O2 inthe field?

Humidified Oxygenation


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Humidified Oxygenation

Place 6 ml normal saline into thenebulizer

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


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as Stu y

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 patientsface if child too small to place lips

around mouthpiece or directmist near childs face

Case Study #4


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911 called to the scene for a3-month old who has had 3 daysof cough, runny nose & low-gradefever.

Caregiver concerned because thechild is working harder to breatheand having hard time feeding

Child is in caregivers lapChild is sleepy, no eye contactor response to the exam

Case Study #4


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Case Study #4

Child limp, audible wheezing, deepretractions, nasal flaring, skinmottled, diaphoretic

VS: HR 180; RR 70; SaO2 on room air74%

Breath sounds: tight with only fairair movement with high-pitchedinspiratory & expiratory wheezes

Case Study #4


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Case Study #4

Is this child in respiratorydistress or respiratory failure?

What is your general impression? What do you need to do to

manage this patient?

Case Study #4


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Case Study #4

You note increased work ofbreathing, abnormal appearance, andpoor circulation

This patient is in respiratory failure

With the wheezing, the problem ismost likely a lower airway obstruction

Most likely bronchiolitis(inflammation of the bronchiolesoften caused by RSV a viralinfection)

Case Study #4


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Case Study #4

Rapid and urgent transport This patient most likely does nothave an easily reversible respiratory

problem and is likely to deterioratefurther Enroute administer a bronchodilator

(Albuterol) via nebulizer via mask(wont be able to put mouth aroundmouthpiece)

Case Study #4


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y

Monitor respiratory status closely If decreased respiratory effort orslowing of the rate, consider BVMsupport using a slow rate and longexpiratory time

AHA ventilatory rate for rescuebreathing infant < 1 & child < 8

1 breath every 3-5 seconds (12 20 breaths per minute)

Give each breath over 1 second

Case Study #5


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Case Study #5

You are called for an unresponsive 3year-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


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ase Study 5

What is your generalassessment?

What is the GCS? What other assessments need to

be done?

What interventions are needed?

Case Study #5


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This patient is critical: unresponsive,

no abnormal appearance for work ofbreathing, 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


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Case Study #5

Calculating & administratingDextrose

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


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y 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 prefilledsyringe Administer IV dose slowly to minimize vein irritation

Case Study #6


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y

You run this call: 8 year-old patient in full arrest

Monitor shows VF What tasks need to be

assigned?

Remember to assign someoneto take care of the family

Now run the call

Case Study #7


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Case Study #7

You run the call:

Your 4 month-old is

hypoglycemic with a glucoselevel of 35

How are you going to handle

this call? Go through the steps as a

team; draw up the meds

Case Study #8


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y You run the call:

Your 6 year-old is found listlesswith a GCS of 9

The monitor shows:

Whats the rhythm?

What do ou do?

Case Study #8


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Case Study #8

Pediatric bradycardia is a hypoxiaproblem 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


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y 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


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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/

encountering the pediatric patient

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