Pediatric Population

1. Pediatric Population May 2015 CE Condell Medical Center EMS System Site Code: 107200E-1215 Prepared by: Sharon Hopkins, RN, BSN, EMT-P Rev: 5.13.15

2. Objectives Upon successful completion of this module, the EMS provider will be able to: • 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.

3. Objectives cont’d 4. 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.

4. Objectives cont’d 9. Actively participate in case scenario and groupdiscussion 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.

5. 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

6. 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

7. 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

8. 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!

9. 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

10. 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

11. Pediatric Assessment Triangle - PAT

12. 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?

13. 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?

14. 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: Visualsigns of poor • circulation may just be a “cold” child

15. 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

16. 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

17. 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

18. 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

19. ABCDE cont’d • Disability – neurological status • Want to check the cerebral cortex and brainstem activity • Cerebral cortex • Evaluate appearance - done during the PAT • Assess level of consciousness via Alert, Voice, Pain, or Unresponsive (AVPU) scale • Brainstem • Evaluate pupillary reflex to light stimulus • Cranial nerve III • Evaluate motor activity – symmetrical movements?

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. Changes to Body Proportions

27. 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

28. 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

29. 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)

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

31. Respiratory Distress • Patient able to compensate and maintain adequate oxygenation and ventilation • Appearance relatively normal • Requires tremendous amount of energy and internal resources to compensate • Increased work of breathing • Increased respiratory rate • Use of accessory muscles • Nasal flaring

32. Respiratory Failure • Energy reserves have been exhausted • Patient unable to maintain adequate oxygenation and ventilation • Altered level of consciousness • Respiratory rate slowed • Respiratory effort decreased • Bradycardia usually present • Agitation, exhaustion, lethargy with cyanosis may be present

33. 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?

34. 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

35. 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 perfusion • PAT • Hands-on ABCDE’s

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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.

43. 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

44. 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

45. 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

46. 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)

47. 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

48. 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

49. 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

50. 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 (882.2)) • Patient weighs 130 pounds (formula 1 mg/kg) • 1302.2 = 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)