Paramedic Care: Principles & Practice Volume 5 Special

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Transcript Paramedic Care: Principles & Practice Volume 5 Special

Paramedic Care: Principles & Practice Volume 5 Special Considerations/ Operations

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Chapter 2 Pediatrics

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Topics

Role of Paramedics in Pediatric Care General Approach to Pediatric Emergencies General Approach to Pediatric Assessment General Management of Pediatric Patients Specific Medical Emergencies Trauma Emergencies Sudden Infant Death Syndrome Child Abuse and Neglect Infants and Children with Special Needs Multiple Casualty Incidents Involving Children Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Introduction

Current research indicates that more than 20,000 pediatric deaths occur each year in the United States The leading causes of death are age specific – They include motor vehicle collisions, burns, drownings, suicides, and homicides Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Role of Paramedics in Pediatric Care

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Role of Paramedics in Pediatric Care

Two key concepts – Pediatric injuries have become major concerns – Children are at higher risk of injury than adults Get involved in identifying and implementing methods and mechanisms that prevent injuries Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Continuing Education and Training

Pediatric centered education – Pediatric Advanced Life Support (PALS) – Pediatric Education for Paramedic Professionals (PEPP) – Advanced Pediatric Life Support (APLS) – Prehospital Pediatric Care (PPC) Center for Pediatric Medicine (CPEM) Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Improved Health Care and Injury Prevention

Emergency Medical Services for Children (EMSC) – Federally funded program – Goal is to improve the health of pediatric patients who suffer potentially life-threatening illnesses or injuries – Coordinated effort to identify areas of concern Trauma registries and epidemiological research rely on the prehospital provider documentation Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Pediatric Health Care Concerns

Community education Data collection Quality improvement Injury prevention Access Prehospital care Emergency care Definitive care Finance Rehabilitation A systems approach to pediatric care Ongoing health care Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Improved Health Care and Injury Prevention

Take part in, or offer to organize, school or community programs in injury prevention or health care

© Craig Jackson/In the Dark Photography

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Advanced Life Support Skills in Pediatrics

85% of children treated by EMS personnel need nothing more than basic life support skills It is fairly rare that a paramedic will be called upon to perform an advanced life support (ALS) skill Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

General Approach to Pediatric Emergencies

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

General Approach to Pediatric Emergencies

Varies with the age of the patient and with the problem being treated Take into consideration the patient’s emotional and physiological development – Involve the family members or caregivers Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Communication and Psychological Support

Treatment begins with communication and psychological support – Interaction with patient and caregivers continues throughout assessment Gather information about patient history as quickly and as accurately as possible Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Responding to Patient Needs

The child’s most common reaction to an emergency is fear of: – Separation – Removal from a family place – Being hurt – Being mutilated or disfigured – The unknown Communicate honestly with the child Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Responding to Parents or Caregivers

Initial reactions to emergencies vary: – Shock, grief, denial, anger, guilt, fear, or complete loss of control Communication is essential – Allow one of the parents or caregivers to remain with the child Maintain index of suspicion for injuries that are questionable in nature Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Growth and Development

Newborns – First hours after birth – Assessed with APGAR scoring system – Treatment follows the inverted pyramid Neonate – Birth to one month – Tend to lose 10% of birth weight, but regain in 10 days – Development centers on reflexes – Personality begins to form – Mother, occasionally father, can comfort child Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Neonates

Common illnesses include: – Jaundice, vomiting, and respiratory distress Do not develop fever with minor illness – Fever may be the only sign in meningitis or other serious illness Allow patient to remain in caregiver’s lap Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Infants (1-5 months)

Double their birth weight by 5 to 6 months of age Muscle control develops in a cephalocaudal progression Focus on the parents or caregivers for information Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Infants (6 to 12 months)

May stand or walk without assistance Risk of foreign body airway obstruction (FBAO) becomes a serious concern Express themselves more readily Common illnesses and injuries Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Infants (6 to 12 months)

Examine while sitting in the lap of the parent or caregiver Toe-to-head progression of exam

© Jeff Forster

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Toddlers (Ages 1 to 3 Years)

Great strides in motor development May stray from parents more frequently – Parents remain the only ones who can comfort them Language development begins Accidents are leading cause of injury Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Toddlers (Ages 1 to 3 Years)

Examine from head to toe Avoid asking “yes” or “no” questions Allow child to hold a favorite blanket or item Tell child if something will hurt Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Preschoolers (Ages 3 to 5 Years)

Increase in fine and gross motor skills Know how to talk Fear mutilation – Avoid frightening or misleading comments Seek comfort and support from within home Distorted sense of time Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Common Preschooler Illnesses and Injuries

Croup Asthma Poisoning Auto accidents Burns Child abuse Ingestion of foreign bodies Drowning Epiglottitis Febrile seizures Meningitis Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Preschoolers (Ages 3 to 5 Years)

Treatment of preschoolers requires tact – Avoid baby talk – Do not trick or lie to the patient Allow the child to hold a piece of equipment, such as a stethoscope Start the examination with the chest and evaluate the head last Always explain what you are going to do Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

School-Age Children (Ages 6 to 12 Years)

Active and carefree age group Growth spurts are common Give responsibility of providing history Respect modesty Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Common Illness and Injuries in School-Age Children

Drowning Auto accidents Bicycle accidents Falls Fractures Sports injuries Child abuse Burns Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Adolescents (Ages 13 to 18)

Are very “body conscious” May consider themselves “grown up” Desire to be liked and included by peers Are generally good historians Relationships with parents may be strained Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Common Adolescent Illnesses and Injuries

Mononucleosis Asthma Auto accidents Sports injuries Drug and alcohol problems Suicidal gestures Sexual abuse Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Anatomy and Physiology

Children are not simply small adults They have healthier organs, a greater ability to compensate for most illnesses, and softer, more flexible tissues Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Head

Large head, small face – Difficult to maintain seal on BVM Fontanelles Heavy head relative to body size – Increases risk of trauma Airway positioning techniques – Patient < 3 Pad between shoulders – Patient > 3 Pad under occiput Sniffing position Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Anatomy and Physiology

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Airway

Pediatric patients have narrower airways – Easily blocked by secretions Infants are obligate nose breathers Large, disproportionate tongue Trachea is softer and more flexible in a child Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Airway

A child’s larynx is higher (C-3–C-4) In young children, the cricoid ring is the narrowest part of the airway Infants have an omega-shaped, floppier epiglottis Management principles: – Keep the nares clear in infants less than 6 months – Do not overextend the neck – Utilize basic maneuvers for airway maintenance May be effective without adjuncts Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Chest and Lungs

Infants and children are diaphragmatic breathers Pediatric patients are prone to gastric distention Rib fractures occur less frequently Because the chest is more compliable, energy is transmitted to organs beneath Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Chest and Lungs

Lungs are more prone than an adult’s to pneumothorax following barotrauma The mediastinum will shift more with tension pneumothorax than in an adult Breath sounds are more easily transmitted Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Abdomen

The liver and spleen, both very vascular organs, are proportionately larger Abdominal organs are closer together Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Extremities

Softer and more porous bones – Treat “sprains” and “strains” as fractures Injuries to growth plate – Keep in mind when inserting an intraosseous needle Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Skin and Body Surface Area

Three distinguishing features – Skin is thinner – Less subcutaneous fat – Increased BSA to weight ratio Children risk greater injury from extremes in temperature or thermal exposure Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Respiratory System

Tidal volume proportionately similar to that of adolescents and adults – However, metabolic needs demand double the oxygen – Proportionately smaller oxygen reserves Infants at high risk for hypoxia Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Cardiovascular System

Cardiac output is rate dependent Possess vigorous, but limited, cardiovascular reserves – Absolute blood volume is smaller They can maintain blood pressure longer than an adult but still be at risk of shock Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Nervous System

Develops continually throughout childhood – Remains very fragile Bony structures offer less protection of the brain and spinal cord – Greater force can be transmitted Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Metabolic Differences

Infants and children have a limited store of glycogen and glucose Pediatric patients are prone to hypothermia because of their greater BSA-to-weight ratio Significant volume loss can result from vomiting and diarrhea Newborns and neonates lack the ability to shiver Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Anatomy and Physiology

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

General Approach to Pediatric Assessment

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Basic Considerations

Much of the initial patient assessment can be done during visual examination of the scene Involve the caregiver or parent as much as possible Allow to stay with child during treatment and transport Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Scene Size-up

Conduct a quick scene size-up Look for clues to mechanism of injury or nature of illness – Presence of dangerous substances – Environmental hazards – Evidence of child abuse Allow child time to adjust to you before approaching Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Initial Assessment

Pediatric Assessment Triangle – A way of quickly evaluating the level of severity and the need for immediate intervention Appearance Breathing Circulation Vital Functions – Level of Consciousness – Airway – Breathing – Circulation Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Pediatric Assessment

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Evidence of Compromised Breathing

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Anticipating Cardiopulmonary Arrest

Respiratory rate greater than 60 Heart rate greater than 180 or less than 80 (under 5 years) Heart rate greater than 180 or less than 60 (over 5 years) Respiratory distress Trauma Burns Cyanosis Altered level of consciousness Seizures Fever with petechiae Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Pediatric BLS Algorithm

Click here to view the Pediatric BLS Algorithm.

Reproduced with permission from “2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care,” Circulation 2005, Volume 112, IV-158. © 2005 American Heart Association.

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Transport Priority

Urgent – Rapid trauma assessment – Transport immediately Non-urgent – Complete the focused history and physical exam at the scene Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Transitional Phase

Depends on seriousness of patient’s condition Intended for the non-acutely ill patient Phase of care that allows patient to become familiar with you and your equipment Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Focused History and Physical Exam

If the patient has a medical illness: – History will precede the physical exam If the patient is suffering from trauma: – Physical exam will take precedence Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

History

Nature of illness/injury Length of time ill or injured Presence of fever Effects of illness/injury on behavior Bowel/urine habits Presence of vomiting/diarrhea Frequency of urination Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

History

Identify chronic illnesses, use of medications, and allergies If under a doctor’s care, obtain the name of the physician With trauma, reconsider the mechanism of injury Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Physical Exam

Focused Exam – For trauma: Rapid trauma exam – Use the toe-to-head approach with the younger child – If minor illness or injury, perform a physical exam that is focused on the affected areas and systems Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Physical Exam

Focused exam (cont.) – Pupils – Capillary refill Valuable in pediatric patient < 6 – Hydration Skin turgor, presence of tears and saliva, and the condition of the fontanelles – Pulse oximetry Information regarding peripheral oxygen saturation Shock and hypothermia can effect reasons Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Glasgow Coma Scale

Scoring determines severity: – GCS 13–15 = Mild – GCS 9–12 = Moderate – GCS < 8 = Severe Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Vital Signs

Pulse Respirations Blood pressure (children over 3 years of age) Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Obtaining the Pediatric Pulse

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Non-Invasive Monitoring

Includes – Pulse oximeter – Automated blood pressure devices – Self-registering thermometers – ECGs

© Ken Kerr

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Ongoing Assessment

Reassess the patient since conditions can change rapidly – Every 15 minutes in stable patients – Every 5 minutes in unstable patients Monitor the patient’s respiratory effort, skin color, mental status, temperature, and pulse oximetry Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

General Management of Pediatric Patients

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

General Management of Pediatric Patients

Your top priorities in treating an infant or child are airway, breathing, and circulation Maintain skills through practice Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

BLS Maneuvers: Infants and Children

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Foreign Body Airway Obstruction

Responsive Child – Perform a series of abdominal thrusts Responsive Infant – Five back blows followed by five chest thrusts – Visually inspect Unresponsive Child/Infant – Never use blind finger sweeps – Attempt ventilation and chest compressions Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Suctioning

Decrease suction pressure to less than 100 mm/Hg in infants Avoid excessive suctioning time Avoid stimulation of the vagus nerve Check the pulse frequently Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Oxygenation

Adequate oxygenation is the hallmark of pediatric patient management Methods of oxygen delivery – Masks – “Blow-by” Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Airway Adjuncts

Airway adjuncts may create greater complications in children than in adults – Soft-tissue damage, vomiting, and stimulation of the vagus nerve – Use if prolonged ventilations necessary – Infants and children often improve quickly through the administration of 100% oxygen Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Airway Adjuncts

Oropharyngeal – Utilize a tongue blade for insertion – Inserted with the tip pointing toward the tongue and pharynx Nasopharyngeal – Do not use them on any child with midface or head trauma Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Ventilation

Avoid excessive bag pressure and volume Obtain chest rise and fall Allow time for exhalation Flow-restricted, oxygen-powered devices are contraindicated Do not use BVMs with pop-off valves Avoid hyperextension of the neck Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Ventilation

Use a properly sized mask to ensure a good fit Apply cricoid pressure through application of the Sellick maneuver Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Advanced Airway and Ventilatory Management

Success of these techniques requires knowledge of the procedures that set pediatric skills apart from the ALS skills used on adults Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Foreign Body Airway Obstruction

If a child’s airway cannot be cleared by basic airway procedures, visualize the airway with the laryngoscope – Once visualized, use the Magill forceps to remove it – If unable to remove, intubate around object Needle Cricothyrotomy Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Endotracheal Intubation

Allows direct visualization of the lower airway through the trachea The most effective method of controlling a patient’s airway Mistakenly sized or misplaced tube can quickly lead to hypoxia and death Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Anatomical and Physiological Concerns

A straight blade is preferred for greater displacement of the tongue Proper sizing of the endotracheal tubes is crucial – Use a resuscitation tape – Estimate the correct tube size by using the diameter of the patient’s little finger – (Patient’s age in years + 16) ÷ 4 = Tube size Depth of insertion Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Depth of Insertion

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Anatomical and Physiological Concerns

Cuffed or uncuffed endotracheal tubes can be used in children (but not in neonates) Infants and small children may have greater vagal response than adults Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Indications

Need for prolonged artificial ventilation Inadequate ventilatory support with a BVM Cardiac or respiratory arrest Control of an airway in a patient without a cough or gag reflex Providing a route for drug administration Access to the airway for suctioning Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Ventilate the Child

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Prepare the equipment

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Insert the laryngoscope

Visualize the larynx and insert the tube

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Ventilate and auscultate

Confirm tube placement

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Secure the tube

Reconfirm proper tube placement

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Confirmation of Tube Placement

Visualization – Tube passing through the vocal cords – Equal rise and fall of the chest – Condensation inside the tube Auscultation – Lung sounds in the axilla – Absence of sounds over the epigastrium – Lack of phonation (inability to speak) Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Adjuncts to ETT Confirmation

Esophageal detection devices – May be inaccurate in pediatrics Pulse oximetry – Useful in trending the patient’s oxygenation Capnography – Preferred method of continuous tube confirmation Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Endotracheal Intubation

Be extremely vigilant about repeatedly or continuously monitoring proper endoctracheal tube placement DOPE – Displacement – Obstruction – Pneumothorax – Equipment failure Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Rapid Sequence Intubation

Indicated in pediatric patients when intubation is difficult due to combativeness or clenched teeth Neuromuscular compliance is gained by the use of a paralytic – Succinylcholine (Anectine) 1 –2 mg/kg IV push Sedative administration – Includes midazolam (Versed), diazepam (Valium), thiopental, and fentanyl Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Rescue Airways

Laryngeal Mask Airway (LMA) is now routinely used in several EMS systems

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Nasogastric Intubation

Indications: – Inability to achieve adequate tidal volume during ventilation due to gastric distention – Presence of gastric distention in an unresponsive patient Measure the tube from the tip of the nose, over the ear, to the tip of the xiphoid process Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Oxygenate and continue to ventilate, if possible

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Measure the NG tube from the tip of the nose, over the ear, to the tip of the xiphoid process.

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Lubricate the end of the tube. Then pass it gently downward along the nasal floor to the stomach.

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Auscultate over the epigastrium to confirm correct placement. Listen for bubbling while injecting 10 –20 cc of air into the tube.

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Use suction to aspirate stomach contents.

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Secure the tube in place.

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Circulation

Two problems lead to cardiopulmonary arrest in children: – Shock – Respiratory failure End-organ changes indicate the effectiveness of respiratory and cardiovascular function Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Vascular Access

Neck veins Scalp veins Arms Hands Feet Intraosseous infusion Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Intraosseous Infusion

Large volumes of fluid may be administered Drugs can be administered intraosseously Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Intraosseous Infusion Indications

Primary indications for intraosseous access – Existence of shock or cardiac arrest – An unresponsive patient – Unsuccessful attempts at peripheral IV insertion Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Intraosseous Infusion Contraindications

The primary contraindications for IO infusion include: – Presence of a fracture in the bone chosen for infusion – Fracture of the pelvis or extremity fracture in the bone proximal to the chosen site Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Drugs Administered by IO Route

Epinephrine Atropine Dopamine Lidocaine Sodium bicarbonate Dobutamine Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Intraosseous Infusion

Placement of the needle into the marrow cavity can be determined by noting a lack of resistance Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Intraosseous Infusion

Click here to view a video on intraosseous infusion.

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Fluid Administration

The accurate dosing of fluids in children is crucial Initial dosage of 20 mL/kg of an isotonic solution – Reassess and repeat as necessary Minidrip administration sets, flow limiters, or infusion pumps should be routinely used in pediatric cases Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Medications

The major aim in pediatric resuscitation is airway management and ventilation Medications may need to be administered Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Electrical Therapy

Initial dose of 4 joules per kilogram of body weight If still unsuccessful, focus on correcting hypoxia and acidosis Transport to a pediatric critical care unit, if possible Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

C-Spine Immobilization

Because of a child’s disproportionately larger and heavier head, the cervical spine (C spine) is vulnerable to injury Use the appropriate-sized pediatric immobilization equipment Use appropriate amounts of padding Minimize the emotional stress Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

Transport Guidelines

Consider three factors: – Time of transport – Specialized facilities – Specialized personnel Reassure the child

© Ken Kerr

Bledsoe et al.,

Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.