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Pediatric Focused Review Broselow Tape, Pediatric Codes, After Action Report Condell Medical Center EMS System May 2010 CE Objectives provided by: Mary.

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Presentation on theme: "Pediatric Focused Review Broselow Tape, Pediatric Codes, After Action Report Condell Medical Center EMS System May 2010 CE Objectives provided by: Mary."— Presentation transcript:

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

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

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

17 What is your general impression

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

46 Metabolic Emergencies – Hyperglycemia - Ketoacidosis Continued decrease in level of consciousness progressing to coma Kussmaul’s respirations – deep, rapid, becoming slow and gasping –An attempt to exhale excess acids (ie: CO 2 ) produced during abnormal metabolism Signs of dehydration –Sunken eyes –Dry skin, tenting –Tachycardia

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

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

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

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

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? –Asthma Initial actions? –Finish hands on assessment Vital signs (96/ SpO 2 91% room air) Breath sounds – bilateral wheezing – barely audible Signs of respiratory distress –OPQRST to obtain information on medical calls –SAMPLE history

56 Case Study #1 Initial interventions –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

57 Case Study #1 Reassessment –Airway 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?

58 Case Study #1 Reassessment –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; SpO 2 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? –Dehydrated patient Initial actions? –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

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

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

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 4 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 –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

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

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

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

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

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 4 th -5 th 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 ETCO 2 –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)?

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

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)

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; SpO 2 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 – O 2 - monitor

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 –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 –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; SpO 2 – 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-O 2 -monitor 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 Name: FD or Hosp: REGION X MULTIPLE PATIENT MANAGEMENT PLAN AFTER-ACTION REPORT 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  If yes, was it helpful? Yes  No  Comments: _________________________________________ 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.

107 Bibliography American Academy of Pediatrics. Pediatric Education for Prehospital Professionals. 2 nd edition. Jones & Bartlett Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices. 3 rd 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.


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