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

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.

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.

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.

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

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

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

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

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

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

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

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

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

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?

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

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?

What is your general impression Child sits up on their own, makes eye contact, appears content with no evidence of respiratory distress.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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.

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

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.

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

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

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

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

Metabolic Emergencies Severe Hypoglycemia Decreased level of consciousness Seizures Tachycardia Hypoperfusion

Treatment Hypoglycemia Situation develops rapidly (ie: minutes) Ages less than 1 – D 12.5% 4 ml/kg IVP/IO Ages 1 -15 – 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.

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.

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

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

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

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

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.

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

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

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

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?

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

Case Study #1 General impression? Initial actions? Asthma Finish hands on assessment Vital signs (96/56-130-30-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 2 + 70 = systolic blood pressure (this child’s is normal). Heart rate and respiratory rate indicate respiratory distress.

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.

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.

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

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

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

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

Case Study #2 General impression? Initial actions? Dehydrated patient Finish hands-on assessment Warm/hot to the touch (T – 101.50F) 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

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

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

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.

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.

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

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

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

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.

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 4 - 5 minutes Preparation during CPR Apply monitor pads Run through IV tubing Use Broselow tape to prepare medications

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

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

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)

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

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

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

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).

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

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.

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

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.

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

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

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?

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.

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

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)

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)

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

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?

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

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

Case Study #6 Abdominal Thrusts

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

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

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

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

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?

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

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

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?

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

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)

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

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:

Bibliography American Academy of Pediatrics. Pediatric Education for Prehospital Professionals. 2nd edition. Jones & Bartlett. 2006. Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices. 3rd Edition. Brady. 2009. Dietrich, A., Shaner, S., Ohio Chapter ACEP. Pediatric Trauma Life Support. 3rd Edition. ITLS. 2009. Rahm, S. Pediatric Case Studies for the Paramedic. AAOS. 2006. Region X SOP’s, March 2007, Amended version implemented May 1, 2008.