Pediatric Focused Review

Broselow Tape, Pediatric Codes, After Action Report

Condell Medical Center EMS SystemMay 2010 CE

Objectives provided by: Mary Ann Zemla, RNPacket 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/caregiversbeing removed from home and not returningbeing hurtbeing mutilated or disfiguredthe 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 TrianglePAT

• 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:AppearanceWork of breathingCirculation 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

PAT - Appearance

• Appearance most important factor• Reflects adequacy of

Oxygenation and ventilationPerfusionHomeostasisCNS 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

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

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

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

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)

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

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

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

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?– Asthma

• Initial actions?– 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

Case Study #1

• Initial interventions– Supplemental oxygen

• What route would you use?

– Does the patient require IV access?– Monitoring equipment to apply

• Pulse oximetry• Cardiac monitor• Blood pressure cuff

• Medications indicated– Albuterol 2.5 mg/3ml via nebulizer

Case Study #1• Reassessment

– Airway• Does it remain open?

– Breathing• What is the rate, quality, and rhythm of breathing• What are the breath sounds now?

– Circulation• What is the rate, quality and rhythm of the pulse?• What does the cardiac monitor show?

– Response to intervention• What would you monitor specifically for asthma?

Case Study #1

• Reassessment– Patient is developing increased respiratory

distress, labored breathing, barely able to auscultate bilateral wheezing, decreasing level of consciousness

– RR – 38 and shallow dropping to 8; 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?

– Dehydrated patient

• Initial actions?– 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

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

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

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

– 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

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

• Electrode placement– Anterior/anteriorMake sure

electrodes do not touch

– Anterior/posterior

Case Study #3

Case Study #3Broselow 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

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

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

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)?

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

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)

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 #5Interventions

• 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

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– 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– 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 coughFaint inspiratory stridorPerioral cyanosisMinimal to no air movement via nose or

mouthNo 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

• 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

Name:FD or Hosp:

REGION X MULTIPLE PATIENT MANAGEMENT PLAN

AFTER-ACTION REPORTDate of Incident: ________ Time of Incident: ________ Primary Fire/Rescue Agency: ___________________Description of Incident: ______________________________________________________________________Check One:

CLASS 1 : Total # patients: ____ (Specific # Trauma: Cat I___ Cat II___ Cat III___ Medical: Cat I___ Cat II ___ Cat III ___)

CLASS 2 / CLASS 3 : Total # patients: _____ (Specific #: Red _____ Yellow _____ Green _____ Deceased _____)

Please answer the following questions. Use the reverse side for additional comments (take note when faxing form).

Which hospital was first contacted by field personnel?______________________________________________

Mode of communication between field and hospital: Cell phone Telemetry MERCI Other:_______

Any difficulties with initial communication? No Yes:__________________________________________

Was it difficult to determine the ‘Class’ of the incident? No Yes:________________________________

Any difficulties with triage? No Yes:_______________________________________________________Receiving Hospitals / # pts to each hospital: ______________________________________________________

Any difficulties with patient disbursement? No Yes:___________________________________________

Any difficulties with ambulance to hospital communication (Class 1 only): No Yes:_________________

Was the two-sided Multiple Patient Management Plan REFERENCE CARD used? Yes No

If yes, was it helpful? Yes No Comments: _________________________________________

Was a Region X Multiple Patient Management Plan LOG FORM used? Yes No

If yes, was it helpful? Yes No Comments: _________________________________________Overall, how effective was Region X Multiple Patient Management Plan in successfully disbursing patients from the scene to area-wide hospitals?

Very Effective Effective Ineffective Very Ineffective The success of the plan depends on your detailed comments. Please provide us with any additional information that may be helpful:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Hospital Personnel – Submit this form and Emergency Department Log form to your hospital EMS Coordinator.Field Personnel – Fax this form and Field Provider Log Form to the Resource Hospital EMS Office.

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.