1. Pediatric Focused Review Broselow Tape, Pediatric Codes, After Action Report Condell Medical Center EMS System May 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 Triangle PAT
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: Information gained on:
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
What doyou notice about this child?
Sitting up on own, If crying, are tears present?
Looks malnourished. What clues do you observe in the environment?

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
Child sits up on their own, makes eye contact, appears content with no evidence of respiratory distress.

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
This thumb was accidently injected with epinephrine (Epi pen being handled during training) resulting in vasoconstriction and a delayed capillary refill time.

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
To calculate fluid challenge required, divide weight in pounds by 2.2. Multiply the kg amount by 20 (ie: 20 ml/kg) to determine volume for each individual fluid challenge. May repeat the fluid challenge 3 times for a total of 60 ml/kg.

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
Treatment including medications are less effective when administered in an acidotic and hypoxic environment.

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 – 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)
To administer D12.5%, dilute D 25% 1:1 with normal saline. Take calculated total, divide in half and mix half Dextrose 25% with half the amount of normal saline.

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
Large glucose molecules are “stuck” in the vascular space and are not transported into the cell where they can be used for energy. The glucose pulls water out of the cell (osmotic effect) causing dehydration. The increased urination is an attempt to rid the body of the excess glucose molecules. The patient is hungry trying to replenish energy sources fort he body.

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
The body is functioning less efficiently. Abnormal metabolism using fats creates the accumulation of ketones, the by-product of fat metabolism. Increasing ketones leads to metabolic acidosis creating the fruity breath

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
Access to medications could be from the household medicine cabinet, purses, drawers, counter tops.

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

51. Toxicology cont’d Cocaine (crack, rock)
Euphoria, dilated pupils, anxiety, hypertension, tachycardia, seizures, chest pain
Narcotics (Heroin, codeine, morphine)
CNS depression, constricted pupils, hypotension, bradycardia, coma, death
Amphetamines (Ritalin, speed)
Hyperactivity, dilated pupils, hypertension

52. Injury Prevention
Far better to prevent the initial traumatic or medical insult than to try to treat the results
Proper immobilization in vehicles
Use of protective gear in sports
Keeping harmful products non-accessible
Children naturally inquisitive
Being diligent in watching children

53. Case Studies How do you perform your initial assessment?
What is your general impression?
What is your initial action?
What your other interventions?
How would you reassess this situation?

54. Case Study #1
You are dispatched to a local school for a 7 year old with difficulty breathing
The child is sitting upright, leaning forward
States trouble breathing started in gym, she forgot her meds at home
Anxious, restless
Talking with frequent stops to take in a breath
Respiratory rate increased, labored
Skin pale, warm, dry
Lips dry
Unproductive cough

55. Case Study #1 General impression? Initial actions? Asthma
Finish hands on assessment
Vital signs (96/ SpO2 91% room air)
Breath sounds – bilateral wheezing – barely audible
Signs of respiratory distress
OPQRST to obtain information on medical calls
SAMPLE history
OPQRST assessment – onset (what were you doing at the onset), what provokes the complaint or alleviates it, what is the quality of pain, does the pain/complaint radiate, what is the severity on a 0 – 10 scale, time of onset.
SAMPLE history – signs & symptoms, allergies, medications, past pertinent medical history, last oral intake (eating or drinking anything including water), and events leading up to the call.
Expiratory wheezing is a hallmark sign of asthma. Exhaled airflow is impeded due to bronchospasm. With profound bronchoconstriction and minimal airflow through the bronchioles, wheezing may be faint or completely absent.
Mild hypoxia is evident with SpO2 of 91-94%. Normal may be considered anything over 95%.
B/P formula – age (in years) x = systolic blood pressure (this child’s is normal). Heart rate and respiratory rate indicate respiratory distress.

56. Case Study #1 Initial interventions Medications indicated
Supplemental oxygen
What route would you use?
Does the patient require IV access?
Monitoring equipment to apply
Pulse oximetry
Cardiac monitor
Blood pressure cuff
Medications indicated
Albuterol 2.5 mg/3ml via nebulizer
Patients with an asthma attack have increased respiratory rates which blow off excess moisture and contribute to dehydration. Evaluate each patient individually for the need of IV access or IV fluids.
Inhaled bronchodilators are more effective when patients are coached through their use. The patient needs to take deeper and slower breaths to get the medication down into the lungs and eventually hold in some breaths to get the medication to the target site.

57. Case Study #1 Reassessment Airway Breathing Circulation
Does it remain open?
Breathing
What is the rate, quality, and rhythm of breathing
What are the breath sounds now?
Circulation
What is the rate, quality and rhythm of the pulse?
What does the cardiac monitor show?
Response to intervention
What would you monitor specifically for asthma?
For patients with asthma, reassess work of breathing and breath sounds as well as pulse rates.

58. Case Study #1 Reassessment What action is necessary?
Patient is developing increased respiratory distress, labored breathing, barely able to auscultate bilateral wheezing, decreasing level of consciousness
RR – 38 and shallow dropping to 8; SpO2 86%
What action is necessary?
Support ventilations via BVM with Albuterol in-line
Prepare for intubation

59. Case Study #1 – In-line Albuterol
Begin bagging via BVM with nebulizer kit
After intubation is accomplished, take off BVM mask and connect to ETT with adaptor

60. Case Study #2
You are responding to a home for a 7 month-old with vomiting and diarrhea.
The mother states her child became ill this morning with several episodes of vomiting and diarrhea.
The child is listless laying in the crib
Child has a weak, whiny cry
Airway is open with rapid and unlabored respirations
Patient is pale, dry mouth, no tears are present

61. Case Study #2 Check PAT upon entering the room Appearance
Work of breathing
Circulation

62. Case Study #2 General impression? Initial actions? Dehydrated patient
Finish hands-on assessment
Warm/hot to the touch (T – F)
No B/P obtained; capillary refill 4 seconds
P – 190, weak radial, strong brachial
RR – 50; SpO2 96%
Poor skin turgor
Abdomen soft, does not cry when palpated
OPQRST
SAMPLE history

63. Case Study #2 Severe dehydration with signs of compensated shock
Listless
Tachypnea
Tachycardia
Weak peripheral (radial) pulse; strong central (brachial) pulse
Cool, pale extremities
Delayed capillary refill

64. Signs of Dehydration - Tenting
Tenting seen when a child has lost at least 5% of their body water.

65. Case Study #2 Cardiac rhythm observed:
Does the cardiac rhythm match the presentation?
In infants, tachycardia <220 almost always sinus tach especially in presence of fever, pain, hypovolemia, or hypoxia
Tachycardia is a compensatory mechanism response to severe dehydration, hypovolemia, and fever.

66. Case Study #2 Interventions Supportive oxygen therapy
BVM not required at this point
Try NRB or blow-by if too agitated
Agitation would be a good sign that the child is relating to stimuli
IV access
Check peripheral sites
Hands, AC, ankle, feet
Consider IO –proximal tibial area
Contact and discuss with Medical Control
Formula is 20 ml/kg
Reevaluate as you are passing every 200 ml volume
IO indications: arrest or near arrest, 2 attempts or 90 seconds, there is a need for the IV.
IO site – 2 fingers below the patella to the tibial tuberosity and 1 finger breadth medially.
Confirmation of insertion: feel lack of resistance or pop when through the bone marrow, needle stands up on its own, marrow is aspirated, IO flushes easily, no infiltration, fluids flow with pressure bag.

67. Case Study #2 IO insertion Do not place hand behind the site
Stop placement when a “pop” or lack of resistance is felt

68. Case Study #2 Rapid transport with early communication
This infant is critically ill
Shock develops much more rapidly in infants and children compared to adults
Relatively small fluid reserves
In compensated shock, peripheral blood flow is being shunted to the core of the body
Decompensated shock will quickly follow unless the patient is treated promptly
Cardiovascular collapse and death

69. Case Study #3
911 call from a frantic mother screaming her year-old son is not breathing
Upon arrival, the child is laying on the living room floor unresponsive
Mother states the child stuck a pin in the electrical outlet
The child is no longer in contact with the outlet
The scene is safe
Small arc-burn wound noted to left hand

70. Case Study #3 Initial assessment Level of consciousness
Spinal motion restriction (SMR)
Is c-spine control necessary?
Level of consciousness
Airway
Open with head tilt chin lift? or
Open with modified jaw thrust?
Breathing
Look, listen, and feel
If not breathing, administer 2 breaths
Circulation
Where do you feel for a pulse on 4 year-old?
Check the carotid area after the age of one
With electrocutions, there is a high likeliness of c-spine injury so take precautions until injury ruled out.
Check blood sugar levels on all patients with an altered level of consciousness.

71. Case Study #3 Patient assessment
Patient is unresponsive, not breathing, no pulse
Next action?
CPR for 2 minutes
Witnessed arrest by mother but now over minutes
Preparation during CPR
Apply monitor pads
Run through IV tubing
Use Broselow tape to prepare medications

72. Case Study #3 Electrode placement Anterior/anterior
Make sure electrodes do not touch
Anterior/posterior

73. Case Study #3 Broselow Tape
How do you measure the Broselow tape?
From top of head to heel (not end of toes)
Information on both sides of tape
Equipment and medication
At one end of the tape, the calculation formulas are provided. The medications are calculated for the weight in each colored section. Equipment sizing is listed on one of the sides.
Note: Valium listed as Diazepam; Narcan listed as Naloxone; Normal saline listed as crystalloid

74. Case #3 2 minutes of CPR done What is the patient’s rhythm?
Ventricular fibrillation
What is the next appropriate step?
Interrupt CPR for no longer than 10 seconds
Defibrillate at 2 joules per kg
Patient weighs 40 pounds
Immediately resume CPR
To calculate pounds to kilograms, take the pounds and divide by 2.2. (40  2.2 = 18kg)

75. Case #3 What is the order of care to deliver? Secure airway
Work on IV access
Repeat defibrillation after every 2 minutes of CPR
Initially 2 j/kg; then 4 j/kg
Alternate medications during CPR
Epinephrine 0.01 mg/kg 1:10,000 IVP/IO
Repeat every 3-5 minutes
Amiodarone 5 mg/kg IVP/IO OR
Lidocaine 1 mg/kg IVP/IO
Secure airway – use whatever method to allow ventilation of the patient. Evaluate chest rise and fall, SpO2 monitor, ETCO2 detector. Immediate intubation is not necessary if the airway can otherwise be secured.
Epinephrine is used for its vasopressor qualities to vasoconstrict blood vessels and improve blood flow.
Antidysrhythmics used to reduce irritability in the ventricles.
Do not mix antidysrhythmics – this makes the heart more irritable

76. Case Study #3 How do you evaluate ETT placement?
Direct visualization during placement
Apply cricoid pressure to control vomitus
Do not let go until the cuff is inflated
Observation of bilateral rise and fall of chest
5 point auscultation
Over the epigastric area
Upper lobes and midaxillary approximately 4th-5th intercostal space

77. Case Study #3 Peds patient positioning for ETT
Need to place a small towel under the occiput to obtain neutral position
ETT confirmation with ETCO2
Observe for yellow color
Color can change back and forth reflecting status

78. Case #3
After several rounds of medication and several defibrillation attempts next rhythm check:
What do you need to do now?
Check for pulse now that you observe a rhythm that should generate a pulse
What is the perfusion status of the patient with this rhythm (sinus rhythm with PVC’s)?
Rare to occasional PVC’s are not treated. Evaluate oxygenation status – hypoxia may be contributing to the ventricular irritability.
If antidysrhythmics were given during VF, consider the need for a drip (contact Medical Control).

79. Case #4 You are responding to a call for a 3 year old with a seizure
Your patient is sitting in mom’s lap crying and clinging to mom
Patient has been “ill” for the past 12 hours
Respirations are increased and unlabored
Patient is flushed

80. Case #4 General impression Febrile seizure
Avoid tunnel vision; get history
Recent head trauma
Medical history
Initial actions
Finish hands-on assessment
Skin hot and dry
Radial pulse rapid & regular
Capillary refill 2 seconds
VS: B/P 80/50, P – 140; RR - 40
Think of all the reasons a child may have a seizure. Check blood sugar if they have an altered level of consciousness upon your arrival.

81. Case #4
While transporting to the ED, the child begins to have a seizure
What are your interventions?
Protect the airway
Turn the child onto their side
Turn on suction
Administer blow-by oxygen
If the seizure lasts for any length of time you will need to bag the patient to oxygenate and ventilate them

82. Case #4 SOP for seizures Obtain blood glucose level
If result < 60, administer Dextrose
<1y/o – D 12.5% 4 ml/kg
1-15 y/o – D 25% 2 ml/kg
Current, active seizure
Valium 0.2 mg/kg IVP titrated to seizure activity
No IV access – Valium 0.5 mg/kg rectally (max 10 mg)
Valium stops a current seizure but does not prevent future seizure activity.

83. Case Study #5
Called to the scene for a 6 year-old struck by a car while riding his bike
Scene is safe
Child flickers eyelids to pain, is occasionally moaning, and withdraws to pain
Blood flowing from mouth
Respirations rapid, gurgling, irregular
Radial pulse slow, bounding
Skin warm and dry

84. Case Study #5 Rapid trauma assessment
Hematoma right side of head with abrasions
Trachea midline, no JVD, c-spine normal
Abrasions to left lateral chest, chest wall stable & symmetrical
Breath sounds clear bilaterally
Abdomen soft & nondistended; pelvis stable
Closed fx left femur; abrasions upper extremities
No signs of trauma when rolled over

85. Case Study #5 Baseline vital signs and SAMPLE
VS: 140/90; P -66; RR – 36 and shallow; SpO2 91%
SAMPLE – unknown
History of events – child ran out in front of car
What interventions need to be performed?
What category trauma is this?
Where is this patient transported to?

86. Case Study #5 Interventions
Spinal motion restriction (SMR) – c-spine control
Supportive ventilations with oxygenation
Ventilate at 20 breaths per minute
60 (seconds)  20 (breaths/minute) = 1 breath every 3 seconds
Suctioning is limited to 10 seconds alternated with 2 minutes of ventilation
Think: IV – O2 - monitor
Ventilation per “Head/spinal injury” SOP. Respirations that are too rapid, too slow, too shallow, or irregular will not produce adequate tidal volume.
Intubation is the ultimate method to secure the airway but you must start with basic techniques first.
Suctioning must be limited to less than 10 seconds. This patient must be managed for oral bleeding and inadequate respirations.

87. Case Study #5 Typical injury pattern for child versus auto
Waddell’s triad
Initial impact blunt abdominal trauma, pelvic fractures and/or femur fractures (bumper)
Seconds impact thoracic trauma (grill or hood of car)
Third impact closed head trauma (thrown from car to ground)
Brain injury associated with highest mortality rates

88. Case Study #5 Category trauma patient Transport decision
Category I
Transport decision
Highest level within 25 minutes
Closely monitor ventilations
Ventilation rate for head injury if needed:
Adult 10 breaths per minute (if deteriorated 20/min)
Children 20 breaths per minute (if deteriorated 30/min)
Infants 25 breaths per minute (if deteriorated 35/min)

89. Case Study #5 Fluid Resuscitation
Formula 20 ml/kg all patients
Monitor vital signs and breath sounds closely
Administer in 200 ml increments reassessing as you pass each 200 ml mark
Goal to get B/P to 90 systolic
Max fluid challenge for peds is 60ml/kg
3 separate fluid challenges (each dose 20 ml/kg)

90. Case Study #5 Why the abnormal vital signs for this patient?
Increased intracranial pressure due to closed head trauma and cerebral edema
Acute rise in systolic B/P
Reflex bradycardia (from parasympathetic tone)
Abnormal respiratory pattern based on pressure in various levels in the brain stem
Inadequate ventilatory volume requiring ventilatory support
Cushing’s triad -  B/P, bradycardia, abnormal respirations

91. Case #6
You respond to a local food establishment for a child (7 year old) choking
Child was eating a piece of candy running around the store
Child conscious, panicked, weak audible cough
Perioral cyanosis, radial pulse present
What is your immediate response?

92. Case Study #6 Immediate intervention Equipment to prepare
Abdominal thrusts
Continue until object expelled or child passes out
Equipment to prepare
Intubation equipment
Magill forceps
Suction
Broselow tape in case of medication dosing

93. Case Study #6
Clinical findings of inadequate airway or poor air exchange:
Weak, ineffective audible cough
Faint inspiratory stridor
Perioral cyanosis
Minimal to no air movement via nose or mouth
No audible sounds, unable to talk

94. Case Study #6 Abdominal Thrusts

95. Case Study #6
If failed abdominal thrust and person collapses, begin steps of CPR
Open airway
Look in mouth
If you see the object, pull it out
No blind finger sweeps
Have Magill forceps ready to retrieve object

96. Case Study #6 Continue normal steps of CPR if obstructed airway
Before attempting 2 ventilations, open airway and look into mouth and remove object if visualized
CPR 1 man for child and infant
30 compressions to 2 ventilations
CPR 2 man for child and infant
15 compressions to 2 ventilations

97. Case Study #6 You are able to remove an object with the Magill forceps
Now what?
Open airway
Look, listen, feel for breathing
If not breathing, administer 2 ventilations
Check 5 – 10 seconds for pulse
If no pulse, begin chest compressions

98. Case Study #7
You have responded to the scene for a 6 year-old with an altered mental status
Child is unconscious and breathing rapid and deep
Skin is pale
Radial pulse present, rapid and weak

99. Case Study #7
What could cause an altered mental status in a 6 year-old?
What else would you need to obtain for your baseline assessment?
What interventions are required?

100. Case Study #7
Most likely causes of altered mental status in the pediatric patient
Alcohol (regardless of age)
Endocrine (Diabetic), electrolytes
Opiates/narcotics
Trauma
Intracranial problems, infection (meningitis)
Poisoning, psychiatric
Seizures

101. Case Study #7 Further assessment
VS: 88/56; P – 130; RR – 10; SpO2 – 94%
Monitor – Sinus Tachycardia
SAMPLE history
Any reason for the altered mental status?
Any recent trauma?
Any evidence around the environment for poisonings?
Neurological assessment

102. Case Study #7 Neurological assessment Level of consciousness AVPU GCS
Pupils
Pinpoint
CMS
Circulation – peripheral and distal
Motion – if able, ask patient to wiggle fingers/toes
Sensation – can patient feel a finger or toe being touched or do you get a response when extremities pinched?

103. Case Study #7 Interventions IV-O2-monitor Check blood glucose level
Support respirations via BVM
1 breath every 3-5 seconds
12 – 20 breaths per minute
Check blood glucose level
Onset of diabetes often presents with increased thirst (polydipsia), increased urination (polyuria), and increased hunger (polyphagia)
Consider Narcan for potential narcotics

104. Case Study #7 Narcan Narcotic antagonist Evidence of narcotic overdose
Pinpoint pupils
Slurred speech
Uneven gait
Depressed respirations
< 20 kg – 0.1 mg/kg IVP/IO/IM
>20 kg – 2 mg IVP/IO/IM
Maximum calculated dose 2 mg (adult dose)

105. After Action Report
Completed individually or as a group at the completion of all multiple patient incidents
Provides an opportunity for critique of the incident
Return form to the EMS Resource Hospital as soon as possible
To be used as a learning tool

106. REGION X AFTER-ACTION REPORT Name: MULTIPLE PATIENT MANAGEMENT PLAN
Date of Incident: ________ Time of Incident: ________ Primary Fire/Rescue Agency: ___________________
Description of Incident: ______________________________________________________________________
Check One:
CLASS 1 : Total # patients: ____ (Specific # Trauma: Cat I___ Cat II___ Cat III___ Medical: Cat I___ Cat II ___ Cat III ___)
CLASS 2  / CLASS 3 : Total # patients: _____ (Specific #: Red _____ Yellow _____ Green _____ Deceased _____)
Please answer the following questions. Use the reverse side for additional comments (take note when faxing form).
Which hospital was first contacted by field personnel?______________________________________________
Mode of communication between field and hospital: Cell phone  Telemetry  MERCI  Other:_______
Any difficulties with initial communication? No  Yes:__________________________________________
Was it difficult to determine the ‘Class’ of the incident? No  Yes:________________________________
Any difficulties with triage? No  Yes:_______________________________________________________
Receiving Hospitals / # pts to each hospital: ______________________________________________________
Any difficulties with patient disbursement? No  Yes:___________________________________________
Any difficulties with ambulance to hospital communication (Class 1 only): No  Yes:_________________
Was the two-sided Multiple Patient Management Plan REFERENCE CARD used? Yes  No 
If yes, was it helpful? Yes  No  Comments: _________________________________________
Was a Region X Multiple Patient Management Plan LOG FORM used? Yes  No 
Overall, how effective was Region X Multiple Patient Management Plan in successfully disbursing patients from the scene to area-wide hospitals?
Very Effective  Effective  Ineffective  Very Ineffective 
The success of the plan depends on your detailed comments. Please provide us with any additional information that may be helpful:
_________________________________________________________________________________________
__________________________________________________________________________________________
Hospital Personnel – Submit this form and Emergency Department Log form to your hospital EMS Coordinator.
Field Personnel – Fax this form and Field Provider Log Form to the Resource Hospital EMS Office.
Name:
FD or Hosp:

107. Bibliography
American Academy of Pediatrics. Pediatric Education for Prehospital Professionals. 2nd edition. Jones & Bartlett
Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices. 3rd Edition. Brady
Dietrich, A., Shaner, S., Ohio Chapter ACEP. Pediatric Trauma Life Support. 3rd Edition. ITLS
Rahm, S. Pediatric Case Studies for the Paramedic. AAOS
Region X SOP’s, March 2007, Amended version implemented May 1, 2008.