Pediatric Population

May 2015 CECondell Medical Center

EMS SystemSite Code: 107200E-1215

Prepared by: Sharon Hopkins, RN, BSN, EMT-PRev: 5.13.15

Objectives

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

1.Recall and be able to apply the components of the Pediatric Assessment Triangle to determine if the child is sick or not sick.2. Distinguish between the patient in respiratory distress versus respiratory failure.3. Identify the components to tabulate for the GCS in the pediatric population.

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Objectives cont’d4. Distinguish the stages of shock for the pediatric population.5. Identify what could constitute an episode of apparent life-threatening event (ALTE).6. Identify the pain management plan for the pediatric patient and successfully calculate dosing.7. Actively participate in review of selected Region X SOP’s related to the topic presented.8. Actively participate in review and correct identification of a variety of EKG rhythms.

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Objectives cont’d9. Actively participate in case scenario and group discussion at your respective licensed level.10. Actively participate in calculating and drawing up pediatric doses of medications.11. Successfully complete the post quiz with a score of 80% or better.

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Assessment Steps Perform the scene size-up

◦ Safety threats◦ Try to get your snapshot of what is going on

General & primary pediatric assessment◦ Determine life threats and need for immediate interventions◦ Pediatric Assessment Triangle - PAT◦ Hands-on airway, breathing, circulation, disability, and

exposure (ABCDE) ◦ Transport decision – stay or go

◦ If transporting, determine the most appropriate destination within your transport area; inform parents of destination

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Assessment Steps cont’d

History taking◦SAMPLE, OPQRST

Secondary assessment◦Physical examination◦ Toe to head approach up to approximately 3 years of age

◦ Starting around the face is more upsetting to the very young ◦Monitoring devices◦ Pulse oximetry

◦ Clip/wrap on a fingertip, toe, earlobe◦ EKG monitor

Reassessment◦An on-going process

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Determining Sick From Not Sick

You may not know WHAT is wrong with your pediatric patient

You need to identify that SOMETHING is wrong Children have less energy reserves than the adult

◦ Children cannot compensate as long as adults◦ When children collapse/decompensate, they do so

quickly

Don’t be the one that misses the signs and symptoms being presented

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A “Crashing” Patient “They just suddenly deteriorate!”

This statement might mean that we missed the signs and symptoms

Children can only compensate for a relatively short time compared with adults

Maintain a high index of suspicion Be prepared and be proactive especially

in children!

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Pediatric Assessment Triangle - PAT

To develop a first impression of the patient’s status◦ Helps determine if the patient is sick or not sick◦ Uses only visual and auditory clues without

assistance of any equipment beyond your observational skills

Obtained on first look of the patient Helps determine level of severity of the situation Can determine the need for additional life support

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PAT cont’d Does NOT replace vital signs and the ABCDE’s hands-on assessment

Will identify general physiological problems Will identify urgency for treatment or transportation Use this technique on all pediatric patients

◦ Will help determine a sick/not sick child Most likely has been instinctively used by most care providers for a long time without thinking of naming the specific assessment process

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Pediatric Assessment Triangle - PAT

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PAT - Appearance Tone

◦ Can they sit up on their own or are they flaccid? Interactiveness

◦ How alert is the patient and interested in the environment?

Consolable by caregiver? Look – gaze

◦ Are they following activity in the room or not? Speech/cry

◦ Strong, spontaneous or weak cry?

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PAT – Work of Breathing A great indicator in peds regarding oxygenation and ventilation – more helpful than counting rates

Any abnormal sounds heard?◦ Snoring, muffled or hoarse speech

Abnormal positioning noted?◦ Sniffing position, tripoding,

unable to lie down?

Retractions evident? Nasal flaring?

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PAT – Circulation to Skin White or pale?

◦ Inadequate blood flow Mottling

◦ Patchy/marbling skin discoloration◦ Vasoconstriction or vasodilation

Cyanosis◦ Bluish discoloration skin and mucous membranes

Note: Visual signs of poor circulation may just be a “cold” child

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Circulation in Dark Skinned Populations

Assess areas where skin tone is lightest and pallor and cyanosis is easiest to detect◦ Lips◦ Mucous membranes◦ Nail beds◦ Palms/soles

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Preserving Body Temperature

Children can quickly become hypothermic◦ Relative large body surface area and head◦ Can lose heat via conduction, convection, radiation,

evaporation, and via respirations Keep patient covered as much as possible Consider turning up vehicle heat as needed All patients can suffer cold stress

◦ Can increase metabolic demands; worsen effects of hypoxia and hypoglycemia; reduce response to resuscitation

◦ Increases morbidity – medical problems related to the situation

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Hands-on ABCDE Assessment

Airway◦ Open?◦ Chest rising with each breath?◦ If airway not open or compromised, what

intervention is necessary?◦ Positioning? Suctioning? Other adjuncts?

Breathing◦ Rate acceptable for the age of the patient?◦ What are the breath sounds?

◦ Smaller the chest wall listen more in the axillary line

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ABCDE cont’d Circulation

◦ Heart rate normal range for the age of the patient?◦ Pulse quality – weak or strong?

◦ Palpate in the brachial area especially under 1◦ For central pulse

◦ Check femoral in infants and young children◦ Check carotid pulse in older children

If pulse is absent or <60 with poor circulation, begin CPR per AHA guidelines

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ABCDE cont’d Disability – neurological status Want to check the cerebral cortex and brainstem activityCerebral cortex

◦ Evaluate appearance - done during the PAT◦ Assess level of consciousness via Alert, Voice, Pain, or

Unresponsive (AVPU) scaleBrainstem

◦ Evaluate pupillary reflex to light stimulus◦ Cranial nerve III

◦ Evaluate motor activity – symmetrical movements?

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AVPU Standardized, reproducible tool to evaluate level of consciousness

Results less accurate in restless or agitated states A – alert, awake, responding V – only responds after verbal stimuli provided P – only responds after pain or tactile stimuli is provided

◦ Note level of response: localizing, withdrawal, posturing

U – unresponsive and flaccid

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Glasgow Coma Scale (GCS) for Peds

Involves memorization and a numeric table Helpful to have reference table available

◦ See References in SOP page 91 May not be accurate in children with special health care needs

Motor component results appears to be best predictor of neurologic outcome

Peds component of GCS intended for non-verbal young children; no specific age limit in applying peds GCS

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GCS – Best Eye Opening

Remains unchanged from adult assessment 4 – spontaneous 3 – after verbal stimuli used 2 – after pain or tactile stimuli applied

◦ Lids may just twitch and not fully open

1 – no eye opening; no muscle twitching at all

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GCS – Best Verbal Response

5 - Coos and babbles to their norm; more playful 4 – Irritable cry 3 – Cries to pain; may be high pitched; not sustained 2 – Responds to pain but not any sustained crying 1 – no verbal response/noise at all

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GCS – Best Motor Response

Very similar to the adult response 6 – obeys commands – age appropriate 5 – Withdraws to touch 4 - Withdraws to pain 3 – Abnormal flexion/bending of extremities 2- Abnormal extension of extremities

◦ Back usually arches; wrists tend to curl inward 1 – no response; flaccid

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ABCDE cont’d Expose

◦ You can’t treat what you don’t see◦ Minimally need to view the face, chest wall, and

enough skin to evaluate circulation◦ Consider need for privacy dependent on age◦ Be careful to avoid heat loss especially in infants

◦ Infants have a larger body surface to body weight ratio than adults

◦ Greater risk than adults of cooling off rapidly ◦ “Mottling” may be response to cooler environment and not

from poor circulation

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Changes to Body Proportions

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Tips/Techniques – Obtaining Vital Signs

Can be a challenge to the healthcare provider to obtain vital signs and perform assessment on the very young

Use distraction to keep the child’s hands occupied◦ Hand them something to hold – their toy or a tongue blade

Allow the caregiver to hold the child if possible Allow the caregiver to hold stethoscope over the anatomical area being examined

Speak in a quiet, calm, even tone Get on eye level with the patient if possible Watch and interpret trends more than any one reading

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Obtaining vital signs Pulse rate

◦ Try the apical approach◦ Listen over the heart with a stethoscope◦ Tricky to listen to the “lub” or “dub” but accurate◦ Listen now to all kids you have access to for practice◦ Parent can be the one to hold the stethoscope over the heart

Respiratory rate◦ Note that the younger patient breaths uneven with short

periods of apnea – this is normal◦ Younger patients have more abdominal breathing◦ Count for a minimum of 30 seconds and multiply by 2

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Vital signs cont’d Signs of circulation

◦ Evaluate skin temperature, capillary refill time and pulse quality

◦ B/P is difficult to obtain - may need to rely on above parameters alone especially under 3 years of age

Blood pressure◦ Can be difficult to obtain

◦ Lack of patient cooperation, inappropriate cuff size◦ Minimal systolic >1 years old = 70 + (2 times the age)

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Blood Pressure Cuffs Cuff size is appropriate when the height covers 2/3 of the upper arm

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Respiratory Distress Patient able to compensate and maintain adequate oxygenation and ventilation

Appearance relatively normal◦ Requires tremendous amount of energy and internal

resources to compensateIncreased work of breathingIncreased respiratory rateUse of accessory musclesNasal flaring

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Respiratory Failure Energy reserves have been exhausted Patient unable to maintain adequate oxygenation and ventilationAltered level of consciousnessRespiratory rate slowedRespiratory effort decreasedBradycardia usually presentAgitation, exhaustion, lethargy with cyanosis may be present

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Point of Discussion EMS is called to the scene for a one year old choking

Upon arrival child is in highchair eating lunch◦ PAT?◦ Impression?◦ Interventions?

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Point of Discussion PAT –

◦ Appearance – normal◦ Work of breathing – effortless◦ Circulation – normal

Impression◦ Resolved choking issue

Interventions◦ Still perform detailed respiratory assessment

◦ Slight wheezing heard on right, left lungs clear◦ Child may have aspirated FB – encourage transport for

evaluation

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Assessing Shock in Peds

Decreased circulation will show signs of poor brain perfusion

Use multiple assessment techniques to determine child’s status and determine type of physiological problem and presence or absence of abnormal perfusionPATHands-on ABCDE’s

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Abnormal Appearance Due To Shock

Lethargic or listless Decreased motor activity Less interactivity with caregiver or others Inconsolable Poor eye contact Weak cry; lack of tears if crying Sunken fontanels – anterior (last to close) closes in most by 2½ years

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Work of Breathing in Presence of Poor Perfusion

Decreased perfusion leads to metabolic acidosis Child may increase respiratory rate without increasing work of breathing just to “blow off” excess CO2 – an acidotic by-product

Signs of increased work of breathing usually indicate presence of a respiratory problem

Can indicate poor gas exchange and hypoxia

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Abnormal Circulation to Skin

If environmental temperature is low, signs may be inaccurate◦ Vasoconstriction is a reflex to preserve body heat

Look for evidence of peripheral vasoconstriction - evidence of maintaining core circulation versus poor skin perfusion◦ Mottling◦ Pallor / paleness◦ Cyanosis

If above present with abnormal appearance in a warm environment, consider presence of shock

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Shock Inadequate tissue perfusion Insufficient oxygen delivery to maintain normal cellular function

Cardiovascular function relies on a network◦ Oxygenation and ventilation◦ Heart rate◦ Intravascular volume◦ Myocardial function◦ Vascular stability

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Shock in a Child Same physiological components as the adult Vasoconstriction and tachycardia very efficient in the child as compensatory mechanisms

Absence of sweating until adolescence◦ Children have cool, dry skin in shock

Infants in particular have high glucose needs with low energy stores

◦ Use up stores of glucose very quickly and often become hypoglycemic

◦ Check glucose levels in children under stress and with altered mental status

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Point of Discussion How would you check the blood glucose level for any patient?◦ You should be performing a “finger stick” for a

capillary sample◦ Obtaining a blood sample from an IV start has been

discouraged – this is a venous sample◦ The design of protected IV catheters does not allow

easily obtaining a sample from the used IV catheter

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Clinical Signs of Decreased Perfusion

Altered mental status Tachycardia as compensation

◦ Very effective in a child Changes in skin color and temperature due to vasoconstriction

Skin remains dry (no sweating until adolescence) Note: Adult can compensate with increased cardiac contractility; children do not. Pulse strength does not change like the adult.

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General Classes of Shock

Hypovolemic◦ Volume loss

Distributive◦ Decreased vascular tone with problems distributing

blood volume usually related to peripheral vasodilation

Cardiogenic◦ Heart failure – usually in child with congenital problem

Obstructive◦ Physical obstruction to blood flow

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Etiology Pediatric Shock Hypovolemic

◦ Vomiting – most common◦ Diarrhea – most common◦ Blunt trauma◦ Excessive blood loss

Distributive◦ Sepsis – massive infection most common in 2-3 years old◦ Anaphylaxis – multisystem response to an antigen◦ Unintentional drug overdoses – B-blockers, barbiturates◦ Neurogenic shock - spinal cord injury with interruption of

sympathetic nerves - particularly above T6 level

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Etiology Shock cont’d Cardiogenic

◦ Uncommon in children◦ Usually a congenital condition

Obstructive shock◦ Pericardial tamponade◦ Tension pneumothorax

◦ More common in children with cystic fibrosis◦ A bleb may rupture spontaneously and turn into tension

pneumothorax

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Point of Discussion You are unable to establish a peripheral IV in a child who needs IV access

What do you do?◦ Establish an IO◦ Palpate the site to determine the length of needle used

◦ If you can feel the bone (similar to over your radial area) then use the pink shortest needle (15 G 15mm)

◦ If the site feels fleshy use the blue medium needle (15G 25mm)◦ Reserve the yellow needle (15G 45mm) for extremely obese sites and

the humeral insertion (Medical Control permission for this site in peds)

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Point of Discussion What are the landmarks for the proximal tibial site?

◦ Leg needs to be straight◦ Palpate 2 fingers below bottom edge (distal) of patella

◦ May not palpate the tibial tuberosity in the very young◦ Identify site 1 finger width in from tibial tuberosity (medial)

MUST stay away from growth plate◦ Needle insertion into the growth

plate could stunt future growth of the extremity

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Point of Discussion How do you know your IO needle insertion is successful?◦ Feel the pop through to the marrow◦ Needle stands up on its own◦ Able to aspirate bone marrow – doesn’t always

happen◦ Line flushes easily◦ Line runs with pressure bag applied to IV bag

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Point of Discussion Your peds patient is unconscious You have successfully inserted an IO needle How would you know the infusion is causing pain?

◦ Agitation, restlessness, trying to move extremity◦ Facial grimacing, moaning◦ Increased heart rate, respiratory rate, B/P

What would your response be?◦ Lidocaine 1 mg/kg IO over 60 seconds, wait 60

seconds then restart infusion

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Point of Discussion – Lidocaine Dose For IO Pain Control

Patient weighs 88 pounds (formula 1 mg/kg)◦ Check the SOP reference charts◦ Notice the dosage in the heading is for 1.5 mg/kg

◦ This is the dose used for drug assisted intubation◦ This patient should get 40mg (they are 40 kg (882.2))

Patient weighs 130 pounds (formula 1 mg/kg)◦ 1302.2 = 59 kg

◦ Max adult dose is 50 mg! Patient weighs 50 pounds (formula 1 mg/kg)

◦ 50 2.2 = 23 kg (kg will equal mg to give)

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Compensatory (“Early”) Shock

Signs and symptoms begin to show at fluid loss equal to 5% of body weight

Goal compensated shock◦ To sustain cardiac output to maintain adequate perfusion

to core organs◦ Supported via stimulation of sympathetic nervous

system

Compensatory mechanisms most evident in peds◦ Vasoconstriction◦ Increased heart rate

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Compensatory Shock Effects of vasoconstriction

◦ Delayed capillary refill time > 2seconds◦ Poor skin color – pale or mottling◦ Dry, cool skin◦ Systolic B/P NORMAL

◦ Minimal systolic over 1 year old = 70 + 2 times the age◦ Appearance normal or slightly agitated

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Decompensated Shock Compensatory mechanisms of vasoconstriction and increased heart rate unable to maintain adequate perfusion to core organs

Blood pressure drops with approximate 25% loss of intravascular (blood) volume

Hypotension is hallmark sign of decompensated shock

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Decompensated Shock Appearance is abnormal – inadequate brain perfusion

◦ FYI - may still be assigned “A” under AVPU

Restless, agitated Poorly responsive Hypotension Tachypnea Extreme tachycardia with weak palpable pulse Pale, mottling, or cyanosis with cold skin

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Cardiac Failure Develops when decompensated shock is not reversed◦ Bradycardia◦ Respiratory failure◦ Cardiac arrest

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Interventions For Shock Determine type of shock patient is exhibiting Begin routine pediatric care Establish IV/IO access with normal saline

◦ The use of minidrip tubing allows for better control of fluid volume infused◦ Avoids inadvertent over-hydration of patient

Formula is 20 ml/kg◦ May be repeated to a total volume of 60 ml/kg

◦ Allows for total of 3 fluid challenges for the peds patient

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Point of Discussion – Comparing Fluid Challenges Your 200# adult patient requires a fluid challenge How will you deliver this?

◦ Administer in 200 ml increments◦ Formula is 20 ml/kg for all persons◦ Total for this patient would be 1820 ml (91 kg x 20 ml/kg)

◦ Do not stop infusion but as you pass each 200 ml increment, you would reassess patientLevel of consciousnessSkin parametersLung sounds

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Point of Discussion Your 60 pound peds patient requires a fluid challenge How will you deliver this? Resources

◦ Do the math: 60# 2.2 = 27 kg; 27kg x 20 ml = 540ml◦ Check the back of the SOP’s

◦ Choose closest and next less weight 57# = 520 ml How are you going to administer this volume? Child requires their total calculated volume

◦ Administer as close to 20 minute time frame as possible◦ Assess as you pass a reasonable volume of fluid

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Apparent Life Threatening Event - ALTE

Defined as an episode involving significant behavioral or physical changes in a child

Often witnessed by the parents only◦ Usually resolved prior to arrival of healthcare provider

Involves some combination ApneaColor changeMarked change in muscle toneChoking or gagging

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ALTE If child appears “normal” upon exam, encourage transport in case of occult or hidden illness

If child is symptomatic, perform appropriate intervention for the physiological or anatomical problem

Most cases are limited to transport only◦ Continue reassessments watching for a change in the

patient◦ Don’t be lulled into a false sense of security

Expect the worse, hope for the best!!!

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ALTE Use scene size-up to obtain any clues Perform ABCDE assessment

◦ Airway unobstructed?◦ Breathing rate, depth, and quality?◦ Circulation status?

◦ Pulse rate, regularity, and quality?◦ Capillary refill; skin color and temperature?

Thorough history◦ SAMPLE, OPQRST

Vital signs – B/P, P, R, pulse ox, pain scale, glucose Hands-on toe-to-head or head-to-toe assessment

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OPQRST Assessment O – what where you doing at the onset? P – what makes it better/worse (palliation/provocation)? Q – in patient’s words, what is the quality? R – does the pain radiate? S – on the appropriate pain scale, what is the severity? T – what time did this start?

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ALTE Possible problem listSepsisCongenital heart diseaseMetabolic abnormalitySeizureGastroesophageal refluxBrain injury

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Pain Management in Peds

Contact Medical Control for patients under 2 Pain often under-recognized in the peds population

◦ Therefore, often undertreated in this population

Indications a person may be experiencing pain◦ Verbalizes – only if old enough to do so!

◦ Use age appropriate assessment tool (0-10 pain scale, Wong-Baker FACES, FLACC pain scale)

◦ Increased pulse rate◦ Increased agitation, restlessness, moaning◦ Sweating – usually not present until adolescence

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Pediatric Pain Management

Pain and anxiety can both be present Need to identify one from the other

◦ Interventions are different

Morphine – opioid◦ Can cause vasodilation and a drop in blood pressure◦ Indicated for control of pain related to burns

Fentanyl – synthetic opioid◦ Faster acting and shorter duration than morphine◦ Does not affect cardiovascular status (B/P)

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Pediatric Pain Management

Fentanyl 0.5 mcg/kg IVP/IN/IO May repeat in 5 minutes – same dose Reminder: adult max total dosing is 200 mcg

◦ 220 pound patient would get 100 mcg with one dose

Watch for respiratory depression What should you do if respiratory depression is noted?◦ Reverse the response with Narcan◦ Consider need to support ventilations via BVM

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Pediatric Medication Medication is based on patient weight in kilograms Parents will often provide information in pounds What are your resources for dosing calculations?

◦ The Region X SOP for calculation formula◦ Back of the SOP’s for dosing charts

◦ Check “how supplied” for equivalency of calculation

Precaution◦ Broselow tape may not follow same formula calculation as

Region X SOP’s◦ Many drugs listed as total mg, not ml to put into syringe

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Case Scenario Discussion

Review the following cases Discuss as a group Information gathered from the PATGeneral impression formedNecessary interventions to performWhat you will do for reassessment

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Case Scenario #1 EMS is called for a 13 year old who was injured at school A non-parental adult has volunteered to drive him to the hospital

How would you respond to this suggestion?◦ Only the patient’s parents/legal guardians can authorize a

medical release or alternative transportation◦ An authorized school representative can authorize a

medical release into the school representative’s custody◦ Encourage ambulance transport if appropriate

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Case Scenario #1 PAT

◦ Patient is sitting up, in obvious pain◦ Respiratory rate is slightly elevated ; in no distress◦ Skin is pale (what might this mean???)

VS: B/P 122/78; P – 98; R – 16; pain 9/10 Deformity present to right leg; no other injuries What is the mechanism of injury (MOI)? What is your priority of care? What interventions will you provide?

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Case Scenario #1 Perform full head to toe assessment

◦ One injury is obvious; don’t want to miss another one

Immobilize injured extremity◦ Splint includes joint above and below the injured site◦ Assess CMS/PMS before and after splinting

Address pain intervention◦ Splinting (rest), elevation if able◦ Ice applied indirectly to site◦ Pain medication for 132 pound patient

◦ Fentanyl 0.5 mcg/kg IVP/IN/IO

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Case Scenario #1 How much Fentanyl would you give?

◦ 132# 2.2 kg = 60 kg◦ 60 kg x 0.5 mg/kg = 30 mcg◦ 30 mcg = 0.6 ml

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Formula #1 Formula #2

30 mcg = 100 mcg X ml 2 ml100 X = 30 x 2100 X = 60 100 100 X = 60 100X = 0.6 ml

X ml = Vol x desired dose Dose on hand (mg)

Xml = 2 ml x 30 mcg 100 mcg

X ml = 60 100

X ml = 60 100X ml = 0.6 ml

Case Scenario #2 A 3 year-old patient was found drinking a caustic product Upon your arrival, you notice the child is not interactive You hear stridor You notice tissue damage around lips PAT? Impression? Product involved? Intervention?

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Case Scenario #2 PAT – sick child Impression – airway compromise Intervention

◦ Secure airway◦ How would you do this?

◦ Positioning◦ Intubation; Quick trach (size 2mm for 22-77# or 10-35 KG)

◦ Consider need for oxygen support ◦ How would you administer blow-by oxygen?

◦ Hold oxygen source so O2 blows across mouth area

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Case Scenario #3 You arrive on the scene for a patient who is less responsive Mother reports 35 pounds PAT

◦ Child is limp, not interactive◦ Respiratory rate is shallow and rapid

◦ No noises are heard◦ Circumoral cyanosis – cyanosis around mouth

Impression? Is this a respiratory or cardiac problem?

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Case Scenario #3 Impression

◦ Sick child◦ Needs rapid intervention and transport

Consider IV – O2 – monitor How fast should you bag the infant & child?

◦ Check the SOP’s ◦ 1 breath every 3 - 5 seconds (12-20/minute) (up to puberty)◦ Adult over puberty – 1 breath every 5-6 seconds (10-12 per minute)

How much Lidocaine would be indicated if necessary after IO insertion?◦ 35# = 16 kg = 16 mg = 0.8 ml

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Case Scenario #3 How do pediatric patients compensate?

◦ Tachycardia and vasoconstriction are the most powerful responses a peds patient can have to support perfusion◦ Peds patients do not increase cardiac contraction strength like

adults do for compensation◦ Vasoconstriction will change skin parameters to cool and

pale◦ Often see definite line of demarcation of coloring and mottling

◦ Sweating does not usually occur until adolescence◦ Most children in shock have cool, dry skin

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Case Scenario #4 The mother states the child hasn’t been eating well for the past 2 days

Child has been vomiting PAT? Impression? Interventions?

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Case Scenario #4

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Child is awake, does not object to you approaching them, weak cry

Respirations non-labored, no noises Skin dry Impression?

◦ Sick◦ Looks emaciated and dehydrated◦ This looks like it has been a longer term problem

What would you do if you suspect child neglect?

Case Scenario #4

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Consider need for IV access Need cardiac monitoring If you suspect child abuse/neglect

◦ Objectively document findings◦ Report verbally your suspicions to ED staff◦ Report to DCFS 24/7 via hot line 1-800-252-2873◦ Follow-up phone report with written report filed

with DCFS within 48 hours

Small Group Practice Small groups are to respond to the “call” Perform as realistically as possible Perform your assessments – PAT, ABCDE, OPQRST, SAMPLE

Form a general impression Determine interventions required Perform skills as you would in the field

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Group Practice #1 13 year-old patient (90 pounds) found unresponsive with shallow breathing at a rate of 4 per minute

Weak radial pulse Pinpoint pupils History of insulin dependent diabetes

Perform as a small group with this scenario

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Group Practice #1 Skills Positioning Airway control IV/IO access Blood glucose monitoring Medication calculation

◦ Narcan◦ Dextrose 25%◦ Lidocaine for drug assisted intubation◦ Lidocaine for pain control of IV infusion

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Group Practice #2 5 year-old (45 pounds) with persistent vomiting Listless No eye contact Sunken eyes Tachypnea, tachycardia

Cool, dry skin

Perform as a small group with this scenario

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Group Practice #2 Skills Positioning Airway control

◦ BVM 1 breath every 3-5 seconds (12-20 per minute)◦ Advanced procedures

IV/IO access◦ Calculating fluid challenge 20 ml/kg

Blood glucose monitoring Medication

◦ Lidocaine for pain control of IO infusion

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Group Practice #3 2 year-old unresponsive; 23 pounds Limp Shallow, slow respiratory rate Circumoral cyanosis No radial pulse; slow, weak carotid

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Group Practice #3 Skills Positioning Airway control – BVM, advanced airway device IV/IO access

◦ Fluid challenge 20 ml/kg

Cardiac monitoring CPR for child Medications

◦ Epinephrine 1:10,000◦ Drug assisted intubation: Atropine, Etomidate, Versed

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Group Practice #4 8 year-old (60 pounds) with a severe asthma attack Agitated; having hard time sitting up Pale, diaphoretic Looks exhausted, minimal accessory muscle use SpO2 92% Lung sounds: diminished and hard to hear

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Group Practice #4 Skills Positioning Airway control – O2, BVM assist Medications

◦ Duoneb via nebulizer◦ Duoneb via in-line set-up

IV/IO access

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Group Practice #5 15 year-old patient (128 pounds) found unresponsive

Diaphoretic; shallow, snoring respirations Weak, rapid pulse Medic alert tag - diabetic

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Group Practice #5 Skills Positioning Airway control – BVM, oro/nasopharyngeal airway IV access Medications

◦ Glucagon IM/IN◦ Dextrose 25%

◦ Calculated from 25% and 50% concentrations◦ Narcan considered

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Bibliography American Academy of Pediatrics. Pediatric Education for Prehospital Professionals 3rd Edition. Jones and Bartlett. 2014

Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th edition. Brady. 2013.

Mistovich, J., Karren, K. Prehospital Emergency Care 9th Edition. Brady. 2010.

Region X SOP’s; IDPH Approved April 10, 2014.

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