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:
1Pediatric Focused Review Broselow Tape, Pediatric Codes, After Action Report Condell Medical Center EMS System May 2010 CEObjectives provided by: Mary Ann Zemla, RNPacket prepared by: Sharon Hopkins, RN, BSN, EMT-P
2ObjectivesUpon successful completion of this module, the EMS provider will be able to:Define ages for the pediatric populationDescribe 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.
3Objectives cont’dDescribe 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.
4Objectives cont’dDescribe 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.
5What is a Pediatric Patient? Newborn – first hours after birthNeonate – birth to 1 monthInfant – 1 to 12 monthsToddler – 1 to 3 years oldPreschooler – 3 to 5 years oldSchool-age – 6 to 12 years oldAdolescent – 13 to 18 years old
6Region X SOP Pediatric patient “considered under the age of 16”Patient is between the ages of 0 and 15Source: Follows guidelines of EMSC – Emergency Medical Services for Children
7Common Pediatric Fears Fear ofbeing separated from parents/caregiversbeing removed from home and not returningbeing hurtbeing mutilated or disfiguredthe unknown
8Anatomical and Physiological Differences – Peds vs Adult Tongue proportionately larger – may block airwaySmaller airway structures – more easily blockedAbundant secretions – can block airwayBaby teeth – easily dislodged, may block airwayFlat nose and face – difficult to get good seal with face mask
9Differences cont’dHeavy head with less developed neck muscles to support head – head may be propelled forward and cause more head injuriesOpen fontanelles – bulging may indicate increased ICP; shrunken may indicate dehydrationThinner, softer brain tissue – increased susceptibility to brain injuries
10Differences cont’dHead larger in proportion to body – head tips forward making neutral alignment difficultShorter, narrower, more elastic trachea – trachea can close with hyperextensionShort neck – difficult to stabilize/immobilizeAbdominal breather – difficult to evaluate breathingFaster respiratory rate – fatigued muscles leading to respiratory distress
11Differences cont’dObligate nasal breathers as newborns – may not open mouth to breathe if nose is blockedLarger body surface area relative to body mass- prone to hypothermiaSofter bones – more flexible, less easily fractured, transmitted forces may injure internal organs without rib fractures, lungs easily damagedSpleen and liver more exposed- increased risk of injury with significant force to abdomen
12Initial Pediatric Assessment Active and alert childCan spend time slowly approaching patientCan spend time making patient more comfortableCritically injured or ill childRequires quick assessment and quick intervention
13Pediatric Assessment Triangle PAT Obtain information as you enter the area and are walking towards the childUse to determine level of severity and determine urgency of situationBased on visual observation and listening skillsDoes not require equipment
14PAT Evaluate: Information gained on: AppearanceWork of breathingCirculation to skinInformation gained on:Underlying cardiopulmonary statusLevel of consciousnessIs not a replacement but an addition to the ABC assessment and vital signsWhat doyou notice about this child?Sitting up on own, If crying, are tears present?Looks malnourished. What clues do you observe in the environment?
15PAT - Appearance Appearance most important factor Reflects adequacy of Oxygenation and ventilationPerfusionHomeostasisCNS functionObserve child while in caregiver’s lapHands-on contact by caregiver may cause agitation and crying; may complicate assessment
16PAT - 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?
17What is your general impression Child sits up on their own, makes eye contact, appears content with no evidence of respiratory distress.
18PAT – Work of Breathing Indicator of OxygenationVentilation (breathing)More accurate than counting the respiratory rate and auscultating breath soundsThese are more typically used in the adultListen for abnormal soundsObserve for increased effort of breathing
19PAT – Work of BreathingAbnormal positioning – sniffing position, tripoding, refusing to lie downAbnormal airway sounds – snoring, stridor, grunting, wheezing, hoarseRetractions – chest wall & neck muscles; head bobbing in infantsFlaring – of nares on inspiration
20Tripod PositionLeaning forward, hands placed on thighs for support, expands the lungs
21Abnormal Airway Sounds Snoring – blocked airway; usually tongueStridor – partial airway obstruction; harsh high-pitched sound on inspirationGrunting – Poor gas exchange; short, low-pitched sound at end of exhalation; helps keep airway openWheeze – whistling sound especially during exhalation
22Which infant is in more distress? Retractions noted Playful, interested
23Positioning of AirwayRolled towels under the shoulders to gently extend the neck of the infant
24PAT – Circulation to Skin Important sign of core perfusionSkin and mucous membranes non-essential and blood flow shunted away when cardiac output is inadequateExpose long enough to determine circulation statusAvoid hypothermiaIn dark skinned children, evaluate lips, mucous membranes, and nail beds
25PAT – Circulation to Skin PallorWhite or pale skin from inadequate blood flowMottlingPatchy skin discoloration due to vasoconstriction/vasodilationCyanosisBluish discoloration of skin and mucous membranesLate finding of respiratory failure or shock
26Pediatric Emergencies Are You Prepared? AirwayObstructionsInfectionsDiseasesCroupEpiglottitisAsthma
27Signs & Symptoms Respiratory Distress Irritable, anxiousTachypneaRetractionsNasal flaring (infants)Poor muscle tone as condition deterioratesTachycardiaHead bobbingGruntingCyanosis that improves with oxygen
28Signs & Symptoms Respiratory Failure Mental status deteriorating to lethargicMarked tachypnea later deteriorating to bradypneaMarked retractions deteriorating to agonal respirationsPoor muscle toneMarked tachycardia deteriorating to bradycardiaCentral cyanosis
29Pediatric Emergencies Are You Prepared? ShockInadequate tissue perfusionDehydration – vomiting or diarrheaInfection – sepsisTrauma – especially abdominalBlood loss
30Signs & Symptoms Compensated Shock Irritability or anxietyTachycardiaTachypneaWeak peripheral pulses; full central pulsesDelayed capillary refillCool, pale extremitiesSystolic B/P normalDecreased urinary output
31Decompensated Shock Lethargy or coma Marked tachycardia or bradycardia Absent peripheral pulses, weak central pulsesMarkedly delayed capillary refillCool, pale, dusky, mottled extremitiesHypotensionMarkedly decreased urinary outputAbsence of tears
32Signs & Symptoms Mild Dehydration AlertSkin normal and dryPulse normalRespirations normalBlood pressure normalCapillary refill normal
33Signs & Symptoms Moderate Dehydration IrritableSkin dry, ashen and very dryPulse increasedRespirations increasedBlood pressure normalCapillary refill 2 – 3 seconds
34Signs & Symptoms Severe Dehydration LethargicSkin dry, cool, mottled, very dry, no tearsPulse markedly increasedRespirations markedly increasedBlood pressure hypotensiveCapillary refill > 2 secondsThis thumb was accidently injected with epinephrine (Epi pen being handled during training) resulting in vasoconstriction and a delayed capillary refill time.
35Pediatric Fluid Resuscitation Formula for all persons20 ml/kgCalculate total amount based on weightAdminister one full fluid challenge, volume based on weightIf total volume greater than 200 ml, assess at every 200 ml incrementReassess to determine need for 2nd fluid challengeReassess after 2nd fluid challenge to determine need for 3rd fluid challengeTo 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.
36Are You Prepared? Neurological Emergencies SeizuresFeverHypoxiaInfections - meningitisIdiopathic epilepsy (unknown cause)Electrolyte disturbanceHead traumaHypoglycemiaToxic ingestions or exposureTumorCNS malformations
37Status Epilepticus Major emergency Involves prolonged periods of apnea Induces severe hypoxiaSeizures may causeRespiratory arrestSevere metabolic and respiratory acidosisIncreased intracranial pressureElevations in body temperatureFractures of long bones and the spineSevere dehydrationTreatment including medications are less effective when administered in an acidotic and hypoxic environment.
38Respirations and Status Epilepticus Patients in prolonged seizures must have respirations supported via BVMNeed to prevent hypoxia and acidosisVentilate 1 breath every 3 seconds for childrenVentilate 1 breath every 5 – 6 seconds for adultsPatients not in status and breathing on their own can be given a non-rebreather oxygen mask
39Are You Prepared? GI Emergencies NauseaVomitingDiarrheaBiggest risk – dehydration and electrolyte imbalance
42Metabolic Emergencies Severe Hypoglycemia Decreased level of consciousnessSeizuresTachycardiaHypoperfusion
43Treatment Hypoglycemia Situation develops rapidly (ie: minutes)Ages less than 1 – D 12.5% 4 ml/kg IVP/IOAges – D 25% 2 ml/kg IVP/IOAges 16 and older – D 50% 50 ml (25 Gms)Dextrose very irritating to veinsNeed diluted strength for the younger veinsNo IV accessGlucagon 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.
44Metabolic Emergencies Early Hyperglycemia Increased thirstIncreased urinationWeight loss despite increased intakeStage in which many patients are diagnosed due to the 3 P’s of signs and symptoms: polyuria, polydipsia, polyphagiaLarge 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.
45Metabolic Emergencies Late Hyperglycemia WeaknessAbdominal painGeneralized achesLoss of appetiteNausea, vomitingSigns of dehydration but with urine outputFruity odor to breathTachypneaHyperventilationTachycardiaThe 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
46Metabolic Emergencies –Hyperglycemia - Ketoacidosis Continued decrease in level of consciousness progressing to comaKussmaul’s respirations – deep, rapid, becoming slow and gaspingAn attempt to exhale excess acids (ie: CO2) produced during abnormal metabolismSigns of dehydrationSunken eyesDry skin, tentingTachycardia
47Treatment Hyperglycemia Develops over time (ie: days or weeks)Patient prone to dehydrationNeeds fluid administration20 ml/kg normal salineMonitor carefully for fluid overloadEvaluate breath sounds frequently when administering fluid challenge
48Are You Prepared? Evaluating for Poisoning Possible indicators of ingested poisoningPrevious history of swallowing a poisonChange in level of consciousnessVital sign alterationsPupils – size and reactionSkin and mucosa findingsObservation of mouth signs & odorAbdominal complaints – nausea, vomiting, diarrhea
49Toxicological Exposures Carbon monoxideWho else is ill?Headache, nausea, vomiting, sleepinessCardiac medicationsNausea and vomitingHeadache, dizziness, confusion, dysrhythmias, bradycardiaCaustic substances (Drano, liquid plumber)Burns, drooling, hoarsenessAccess to medications could be from the household medicine cabinet, purses, drawers, counter tops.
52Injury PreventionFar better to prevent the initial traumatic or medical insult than to try to treat the resultsProper immobilization in vehiclesUse of protective gear in sportsKeeping harmful products non-accessibleChildren naturally inquisitiveBeing diligent in watching children
53Case 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?
54Case Study #1You are dispatched to a local school for a 7 year old with difficulty breathingThe child is sitting upright, leaning forwardStates trouble breathing started in gym, she forgot her meds at homeAnxious, restlessTalking with frequent stops to take in a breathRespiratory rate increased, laboredSkin pale, warm, dryLips dryUnproductive cough
55Case Study #1 General impression? Initial actions? Asthma Finish hands on assessmentVital signs (96/ SpO2 91% room air)Breath sounds – bilateral wheezing – barely audibleSigns of respiratory distressOPQRST to obtain information on medical callsSAMPLE historyOPQRST 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.
56Case Study #1 Initial interventions Medications indicated Supplemental oxygenWhat route would you use?Does the patient require IV access?Monitoring equipment to applyPulse oximetryCardiac monitorBlood pressure cuffMedications indicatedAlbuterol 2.5 mg/3ml via nebulizerPatients 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.
57Case Study #1 Reassessment Airway Breathing Circulation Does it remain open?BreathingWhat is the rate, quality, and rhythm of breathingWhat are the breath sounds now?CirculationWhat is the rate, quality and rhythm of the pulse?What does the cardiac monitor show?Response to interventionWhat would you monitor specifically for asthma?For patients with asthma, reassess work of breathing and breath sounds as well as pulse rates.
58Case Study #1 Reassessment What action is necessary? Patient is developing increased respiratory distress, labored breathing, barely able to auscultate bilateral wheezing, decreasing level of consciousnessRR – 38 and shallow dropping to 8; SpO2 86%What action is necessary?Support ventilations via BVM with Albuterol in-linePrepare for intubation
59Case Study #1 – In-line Albuterol Begin bagging via BVM with nebulizer kitAfter intubation is accomplished, take off BVM mask and connect to ETT with adaptor
60Case Study #2You 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 cribChild has a weak, whiny cryAirway is open with rapid and unlabored respirationsPatient is pale, dry mouth, no tears are present
61Case Study #2 Check PAT upon entering the room Appearance Work of breathingCirculation
62Case Study #2 General impression? Initial actions? Dehydrated patient Finish hands-on assessmentWarm/hot to the touch (T – F)No B/P obtained; capillary refill 4 secondsP – 190, weak radial, strong brachialRR – 50; SpO2 96%Poor skin turgorAbdomen soft, does not cry when palpatedOPQRSTSAMPLE history
63Case Study #2 Severe dehydration with signs of compensated shock ListlessTachypneaTachycardiaWeak peripheral (radial) pulse; strong central (brachial) pulseCool, pale extremitiesDelayed capillary refill
64Signs of Dehydration - Tenting Tenting seen when a child has lost at least 5% of their body water.
65Case 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 hypoxiaTachycardia is a compensatory mechanism response to severe dehydration, hypovolemia, and fever.
66Case Study #2 Interventions Supportive oxygen therapy BVM not required at this pointTry NRB or blow-by if too agitatedAgitation would be a good sign that the child is relating to stimuliIV accessCheck peripheral sitesHands, AC, ankle, feetConsider IO –proximal tibial areaContact and discuss with Medical ControlFormula is 20 ml/kgReevaluate as you are passing every 200 ml volumeIO 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.
67Case Study #2 IO insertion Do not place hand behind the site Stop placement when a “pop” or lack of resistance is felt
68Case Study #2 Rapid transport with early communication This infant is critically illShock develops much more rapidly in infants and children compared to adultsRelatively small fluid reservesIn compensated shock, peripheral blood flow is being shunted to the core of the bodyDecompensated shock will quickly follow unless the patient is treated promptlyCardiovascular collapse and death
69Case Study #3911 call from a frantic mother screaming her year-old son is not breathingUpon arrival, the child is laying on the living room floor unresponsiveMother states the child stuck a pin in the electrical outletThe child is no longer in contact with the outletThe scene is safeSmall arc-burn wound noted to left hand
70Case Study #3 Initial assessment Level of consciousness Spinal motion restriction (SMR)Is c-spine control necessary?Level of consciousnessAirwayOpen with head tilt chin lift? orOpen with modified jaw thrust?BreathingLook, listen, and feelIf not breathing, administer 2 breathsCirculationWhere do you feel for a pulse on 4 year-old?Check the carotid area after the age of oneWith 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.
71Case Study #3 Patient assessment Patient is unresponsive, not breathing, no pulseNext action?CPR for 2 minutesWitnessed arrest by mother but now over minutesPreparation during CPRApply monitor padsRun through IV tubingUse Broselow tape to prepare medications
72Case Study #3 Electrode placement Anterior/anterior Make sure electrodes do not touchAnterior/posterior
73Case 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 tapeEquipment and medicationAt 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
74Case #3 2 minutes of CPR done What is the patient’s rhythm? Ventricular fibrillationWhat is the next appropriate step?Interrupt CPR for no longer than 10 secondsDefibrillate at 2 joules per kgPatient weighs 40 poundsImmediately resume CPRTo calculate pounds to kilograms, take the pounds and divide by 2.2. (40 2.2 = 18kg)
75Case #3 What is the order of care to deliver? Secure airway Work on IV accessRepeat defibrillation after every 2 minutes of CPRInitially 2 j/kg; then 4 j/kgAlternate medications during CPREpinephrine 0.01 mg/kg 1:10,000 IVP/IORepeat every 3-5 minutesAmiodarone 5 mg/kg IVP/IO ORLidocaine 1 mg/kg IVP/IOSecure 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
76Case Study #3 How do you evaluate ETT placement? Direct visualization during placementApply cricoid pressure to control vomitusDo not let go until the cuff is inflatedObservation of bilateral rise and fall of chest5 point auscultationOver the epigastric areaUpper lobes and midaxillary approximately 4th-5th intercostal space
77Case Study #3 Peds patient positioning for ETT Need to place a small towel under the occiput to obtain neutral positionETT confirmation with ETCO2Observe for yellow colorColor can change back and forth reflecting status
78Case #3After 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 pulseWhat 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).
79Case #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 momPatient has been “ill” for the past 12 hoursRespirations are increased and unlaboredPatient is flushed
80Case #4 General impression Febrile seizure Avoid tunnel vision; get historyRecent head traumaMedical historyInitial actionsFinish hands-on assessmentSkin hot and dryRadial pulse rapid & regularCapillary refill 2 secondsVS: B/P 80/50, P – 140; RR - 40Think of all the reasons a child may have a seizure. Check blood sugar if they have an altered level of consciousness upon your arrival.
81Case #4While transporting to the ED, the child begins to have a seizureWhat are your interventions?Protect the airwayTurn the child onto their sideTurn on suctionAdminister blow-by oxygenIf the seizure lasts for any length of time you will need to bag the patient to oxygenate and ventilate them
82Case #4 SOP for seizures Obtain blood glucose level If result < 60, administer Dextrose<1y/o – D 12.5% 4 ml/kg1-15 y/o – D 25% 2 ml/kgCurrent, active seizureValium 0.2 mg/kg IVP titrated to seizure activityNo IV access – Valium 0.5 mg/kg rectally (max 10 mg)Valium stops a current seizure but does not prevent future seizure activity.
83Case Study #5Called to the scene for a 6 year-old struck by a car while riding his bikeScene is safeChild flickers eyelids to pain, is occasionally moaning, and withdraws to painBlood flowing from mouthRespirations rapid, gurgling, irregularRadial pulse slow, boundingSkin warm and dry
84Case Study #5 Rapid trauma assessment Hematoma right side of head with abrasionsTrachea midline, no JVD, c-spine normalAbrasions to left lateral chest, chest wall stable & symmetricalBreath sounds clear bilaterallyAbdomen soft & nondistended; pelvis stableClosed fx left femur; abrasions upper extremitiesNo signs of trauma when rolled over
85Case Study #5 Baseline vital signs and SAMPLE VS: 140/90; P -66; RR – 36 and shallow; SpO2 91%SAMPLE – unknownHistory of events – child ran out in front of carWhat interventions need to be performed?What category trauma is this?Where is this patient transported to?
86Case Study #5 Interventions Spinal motion restriction (SMR) – c-spine controlSupportive ventilations with oxygenationVentilate at 20 breaths per minute60 (seconds) 20 (breaths/minute) = 1 breath every 3 secondsSuctioning is limited to 10 seconds alternated with 2 minutes of ventilationThink: IV – O2 - monitorVentilation 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.
87Case Study #5 Typical injury pattern for child versus auto Waddell’s triadInitial 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
88Case Study #5 Category trauma patient Transport decision Category ITransport decisionHighest level within 25 minutesClosely monitor ventilationsVentilation 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)
89Case Study #5 Fluid Resuscitation Formula 20 ml/kg all patientsMonitor vital signs and breath sounds closelyAdminister in 200 ml increments reassessing as you pass each 200 ml markGoal to get B/P to 90 systolicMax fluid challenge for peds is 60ml/kg3 separate fluid challenges (each dose 20 ml/kg)
90Case Study #5 Why the abnormal vital signs for this patient? Increased intracranial pressure due to closed head trauma and cerebral edemaAcute rise in systolic B/PReflex bradycardia (from parasympathetic tone)Abnormal respiratory pattern based on pressure in various levels in the brain stemInadequate ventilatory volume requiring ventilatory supportCushing’s triad - B/P, bradycardia, abnormal respirations
91Case #6You respond to a local food establishment for a child (7 year old) chokingChild was eating a piece of candy running around the storeChild conscious, panicked, weak audible coughPerioral cyanosis, radial pulse presentWhat is your immediate response?
92Case Study #6 Immediate intervention Equipment to prepare Abdominal thrustsContinue until object expelled or child passes outEquipment to prepareIntubation equipmentMagill forcepsSuctionBroselow tape in case of medication dosing
93Case Study #6Clinical findings of inadequate airway or poor air exchange:Weak, ineffective audible coughFaint inspiratory stridorPerioral cyanosisMinimal to no air movement via nose or mouthNo audible sounds, unable to talk
95Case Study #6If failed abdominal thrust and person collapses, begin steps of CPROpen airwayLook in mouthIf you see the object, pull it outNo blind finger sweepsHave Magill forceps ready to retrieve object
96Case Study #6 Continue normal steps of CPR if obstructed airway Before attempting 2 ventilations, open airway and look into mouth and remove object if visualizedCPR 1 man for child and infant30 compressions to 2 ventilationsCPR 2 man for child and infant15 compressions to 2 ventilations
97Case Study #6 You are able to remove an object with the Magill forceps Now what?Open airwayLook, listen, feel for breathingIf not breathing, administer 2 ventilationsCheck 5 – 10 seconds for pulseIf no pulse, begin chest compressions
98Case Study #7You have responded to the scene for a 6 year-old with an altered mental statusChild is unconscious and breathing rapid and deepSkin is paleRadial pulse present, rapid and weak
99Case Study #7What 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?
100Case Study #7Most likely causes of altered mental status in the pediatric patientAlcohol (regardless of age)Endocrine (Diabetic), electrolytesOpiates/narcoticsTraumaIntracranial problems, infection (meningitis)Poisoning, psychiatricSeizures
101Case Study #7 Further assessment VS: 88/56; P – 130; RR – 10; SpO2 – 94%Monitor – Sinus TachycardiaSAMPLE historyAny reason for the altered mental status?Any recent trauma?Any evidence around the environment for poisonings?Neurological assessment
102Case Study #7 Neurological assessment Level of consciousness AVPU GCS PupilsPinpointCMSCirculation – peripheral and distalMotion – if able, ask patient to wiggle fingers/toesSensation – can patient feel a finger or toe being touched or do you get a response when extremities pinched?
103Case Study #7 Interventions IV-O2-monitor Check blood glucose level Support respirations via BVM1 breath every 3-5 seconds12 – 20 breaths per minuteCheck blood glucose levelOnset of diabetes often presents with increased thirst (polydipsia), increased urination (polyuria), and increased hunger (polyphagia)Consider Narcan for potential narcotics
104Case Study #7 Narcan Narcotic antagonist Evidence of narcotic overdose Pinpoint pupilsSlurred speechUneven gaitDepressed respirations< 20 kg – 0.1 mg/kg IVP/IO/IM>20 kg – 2 mg IVP/IO/IMMaximum calculated dose 2 mg (adult dose)
105After Action ReportCompleted individually or as a group at the completion of all multiple patient incidentsProvides an opportunity for critique of the incidentReturn form to the EMS Resource Hospital as soon as possibleTo be used as a learning tool
106REGION 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:
107BibliographyAmerican Academy of Pediatrics. Pediatric Education for Prehospital Professionals. 2nd edition. Jones & BartlettBledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices. 3rd Edition. BradyDietrich, A., Shaner, S., Ohio Chapter ACEP. Pediatric Trauma Life Support. 3rd Edition. ITLSRahm, S. Pediatric Case Studies for the Paramedic. AAOSRegion X SOP’s, March 2007, Amended version implemented May 1, 2008.