Pediatric Challenges October 2012 CE Condell Medical Center EMS System Site Code: 107200E -1212 Prepared by Sharon Hopkins, RN, BSN, EMT-P 1 Objectives Upon successful completion of this module, the EMS provider will be able to: 1. Describe developmental stages in the pediatric population. 2. Describe anatomical differences in the pediatric population. 3. Describe components and purpose of the pediatric assessment triangle. 4. Describe the ABC assessment relative to the pediatric patient. 2 Objectives cont’d 5. Differentiate between respiratory distress and respiratory failure in the pediatric population. 6. Discuss a variety of pediatric challenges (ie: FBAO, asthma, RSV, meningitis, chicken pox) 7. Discuss appropriate interventions for a variety of pediatric emergencies. 8. Discuss rationale for using 250 ml IV bags in pediatric populations 9. Actively participate in scenarios of the pediatric population. 10.Successfully complete the post quiz with a score of 80% or better. 3 So, what’s a normal kid like? We know each of our own children are different We know each of our patients are different We know every call we go on is unique to itself BUT… There are similarities that can be drawn for comparison 4 Growth and Development Developmental stages Newborn – first hours after birth Neonates – birth to one month Infants – 1-12 months Toddlers – 1 – 3 years Preschoolers – 3 - 5 years School-age – 6 – 12 years Adolescents – 13 – 18 years 5 Newborn – First Hours After Birth Typical assessment tool – APGAR Helps identify newborns from those that need routine care at birth from those that need more assistance Can predict long-term survival Resuscitation, if needed, follows inverted pyramid for the newborn Drying, warming, positioning, suction, tactile stimulation are interventions are the first steps These are usually the only interventions needed for the majority of newborns 6 Inverted Pyramid of Neonatal Resuscitation 7 Neonate – Birth to 1 Month Common illnesses Jaundice Vomiting Yellow coloring from breakdown of old red blood cells called bilirubin Bilirubin is broken down by the liver for excretion in stool Lab test may be required to determine levels May lead to dehydration Respiratory distress 8 Neonate cont’d Fever may be only sign of a problem ALL infants with fevers need to be evaluated 9 Neonate Assessment Keep newborn warm Absence of tears may indicate dehydration To auscultate breath sounds, helpful to have newborn suck on pacifier Keep newborn with parent/caregiver to keep child calm Obtain history from parents/caregiver but observe child for important clues 10 Infant – 1 – 12 months Double weight by 6 months; triple by 1 year Should follow movements with their eyes Muscle development moves from head to toes and from trunk toward extremities FB obstruction risk high – this population explores their world with their mouths Increased anxiety to strangers 11 Infant cont’d Common illnesses and accidents Febrile seizures Diarrhea Bronchiolitis Croup Poisonings Airway obstruction Vomiting Dehydration Car crashes Child abuse Falls Meningitis Keep child with parent Assess toe to head to gain their trust 12 Toddler – 1 – 3 years Increase in motor development Language development begins Always seem to be on the move Becoming braver, more curious & stubborn Can understand better than they can speak Avoid questions that allow the child to say “no” EMS can ask the patient simple questions Still rely on parent/caregiver for information Perform exam toe to head approach Allow child to hold a favorite object if possible 13 Preschooler – 3 – 5 years Increase in fine and gross motor movement Language skills increase Vivid imaginations If frightened, may not speak especially to strangers “Monsters” are part of their world Fear mutilation Child can provide more information regarding the nature of the call; note the imagination factor though 14 Preschooler cont’d Allow child to hold some of the equipment Assess starting with the chest; assess the head last Watch for misleading comments – remember the wild imagination Explain what you are doing immediately before performing a task 15 School-aged – 6 – 12 years Developing personality Values peers but protective and proud of family Interview child for history but they may hold back if they were involved in forbidden activity Be respectful of child’s modesty 16 Adolescent – 13 – 18 Years This age group begins with puberty Highly variable age – can begin at various ages Typically 13 for males Typically 11 for females Physical maturity does not always equal emotional maturity! Demanding more independence from parents/caregivers This group is body conscious and concerned over disfigurement Respect their sense of privacy 17 Common Fears of Children Fear of being separated from parents/caregivers Fear of being removed from family Fear of being hurt Fear of being mutilated or disfigured Fear of the unknown 18 Approach to the Child Children have a right to be informed Be as honest as possible but in the appropriate manner If something will hurt, tell them right before it is done and then quickly perform the task Don’t want anticipation fear to build Use plain language appropriate to the age Also helpful for the parents 19 Metabolic Differences Increasing Risk of Hypothermia Limited store of glycogen and glucose used for energy Greater body surface area by weight Volume loss due to vomiting and diarrhea Inability to shiver in newborns and neonates Unable to generate additional heat if needed when cold 20 Typical Anatomical Differences Larger body surface Tongue proportionately larger & floppier Straight blade preferred during intubation Smaller airway structures More prone to hypothermia Airway more easily blocked by minimal swelling Head heavier and neck muscles less well developed Higher incidence of head injuries 21 Anatomical Differences cont’d Head larger in proportion to body Shorter, more flexible trachea Head extension may close off trachea Abdominal breathers When flat, neck flexes; neutral alignment difficult Less developed chest muscles Not typically seen in the adult population Faster respiratory rate Muscles tire easily 22 Airway Differences Infant larynx higher which facilitates infants being nose breathers 23 Primary Assessment Pediatric assessment triangle An assessment from across the room when first observing the patient Visual assessment prior to patient contact Helps in forming your general impression Appearance Breathing Circulation 24 Pediatric Assessment Triangle Appearance Breathing Mental status and muscle tone Work of breathing Respiratory rate and effort Circulation Circulatory status Skin signs and color 25 Continuing the Assessment Level of consciousness Can still use AVPU scale “A” if eyes are open; can be alert or confused “V” if there is a response to noise or yelling when eyes are closed Response may be whimpering or crying “P” for any response to noxious/painful/tactile stimuli Technique adjusted based on child’s age This includes withdrawal or any muscle twitch “U” when they are flaccid and unresponsive 26 Assessment cont’d A-B-C’s Airway and respiratory problems are the most common causes of arrest in infants and children Is airway open? Is airway patent? Does the patient require positioning? Suctioning? Limit to <10 seconds Adjuncts? If yes, which ones??? 27 Neutral Position for Airway Control Jaw thrust with gentle support Padding under shoulders and back 28 Craniofacial Anomalies Anomalies may alter normal approaches and cause creative use of equipment This patient has Crouzon’s syndrome Malformation of the skull and facial bones How would you adjust your techniques? 29 Assessing Breathing Look at the chest Listen for breath sounds Is the chest rising and falling? Do you hear anything? Normal? Abnormal? Feel for air movement at the patient’s mouth Evaluate respiratory rate, effort, & color Cyanosis is a late sign of respiratory failure Noticed first in mucous membranes of mouth and nail beds Cyanosis of extremities more likely from shock 30 Assessing Circulation Visually check the color Check capillary refill in a central area Evaluate heart rate Bradycardia indicates hypoxia & impending arrest Evaluate peripheral pulses More reliable checking the chest or forehead area Loss of central pulses is ominous sign <1 check brachial or femoral pulses >1 check carotid pulses Evaluate end-organ perfusion – skin and brain Check mental status 31 Respiratory Distress Most notable sign is an increased work of breathing Respiratory rates often underestimated Best to count the rate for a full minute in children Note a normal mental status increasing to irritability or anxiety Respiratory rate increasing 32 Respiratory Distress Retractions Nasal flaring in infants Head bobbing – trying to inhale more oxygen Grunting – increasing peep on exhalation Wheezing Gurgling Stridor 33 Respiratory Distress Sternal retractions Nasal flaring Tripod position 34 Signs of Respiratory Distress Children use tremendous energy to maintain homeostasis When compensatory mechanisms have been exhausted, they crash fast If you were surprised the patient crashed, then you probably missed the signs 35 Respiratory Failure Uncorrected respiratory distress Irritability/anxiety deteriorating to lethargy Marked tachypnea now presenting as bradypnea Marked retractions now presenting as agonal respirations Poor muscle tone Marked tachycardia now presenting as bradycardia Central cyanosis Hypoxia 36 Respiratory Failure cont’d If immediate and appropriate interventions are not taken, the patient will respiratory arrest The pediatric patient that moves into respiratory arrest is difficult to manage Outcomes are not predictable The best treatment is prevention and avoidance of this stage 37 Pediatric Challenges Foreign bodies with airway obstruction Asthma Dehydration Meningitis Chicken pox 38 Airway Obstruction Could be from foreign body or internal swelling Typical sequence of events from aspiration Coughing Choking Gagging Wheezing Complete occlusion 39 Views of Epiglottis Normal view epiglottis and vocal cords on left Collapse of the epiglottis on right 40 Foreign Body Airway Obstruction FBAO You never know what they put in their mouths Case file: 2 year-old presents with acute airway obstruction History of noisy breathing and hoarseness for multiple months Patient presents with labored breathing, rapid respiratory rate, very anxious appearing, is drooling What intervention is required in the field? 41 FBAO If patient is able to exchange air, provide rapid transport in position of comfort If unable to breath, provide abdominal thrusts if <1 Continue thrusts until improvement or collapse If patient collapses and stops breathing, perform CPR Stop to look in mouth prior to the ventilations Prepare equipment Magill forceps Intubation equipment 42 FBAO Lateral x-ray results reveal FB Surgical intervention to remove FB swallowed by 2 y/o 43 Asthma Lower airway disease Reversible chronic inflammatory disorder Evidence of bronchospasm and excessive mucous production Can be induced by multiple triggers Symptoms represent phases of the attack 44 Asthma First phase – release of histamines Bronchoconstriction Bronchial edema May respond to inhaled bronchodilators Second phase – inflammation of bronchioles Additional edema decreasing more airflow Need anti-inflammatory agent (ie: corticosteroids) 45 Asthma Continued attack Continued swelling of mucous membranes in bronchioles Plugging of airways by mucous plugs Sputum production increases Airflow restricted in exhalation Lungs hyperinflated on exhalation Vital capacity decreased Gas exchange decreased in alveoli Hypoxemia worsens 46 Asthma Important assessment aspects Ask if the patient has ever been intubated for an attack Clue patient may deteriorate quickly What is their posture/positioning? Sitting up & leaning forward (tripod) indicates respiratory distress Are they able to speak in full sentences? 2-3 word sentences indicate respiratory distress 47 Asthma Diagnosis Differentiated usually by history taking History of previous episodes Use of inhalers Usually sitting up, leaning forward, tachypneic Unproductive cough Use of accessory muscles Bilateral wheezing Silence is ominous – exchange of air is limited 48 Asthma Management Goals: Correct hypoxia Provide supplemental oxygen Reverse bronchospasm Administer nebulized bronchodilator medications Decrease inflammation Medication added at the hospital 49 Bronchodilator DuoNeb Albuterol 2.5 mg / 3 ml Atrovent (Ipratropium) 0.5 mg / 2.5 ml Document by name of meds used and dosage May repeat Albuterol neb treatment if no improvement In severe cases, prepare for intubation with in-line treatment May bag the patient forcing medication into the airway while preparing the intubation equipment 50 Nebulizer Need to be able to assemble the various parts Aerosol mask versus mouthpiece 51 Aerosol Mask Used when the patient cannot tolerate putting their lips around the mouthpiece Aerosol mask designed for nebulizer use Specific exhalation port hole size No rubber valves Aerosol mask Non-rebreather mask not the same device!!! 52 Nebulizer Kit vs In-line Kit Standard Neb treatment In-line set-up pieces to add 53 Increasing Success Rate of Nebulizer Use Assist patient in sitting upright Coach patient through procedure with calm, quiet, firm tone of voice Coach patient into slowing respiratory rate Coach patient into inhaling deeper Coach patient into holding their breath and eventually increasing the timing Need to get the medications into the lungs to have any effect 54 RSV Respiratory syncytial virus A common virus In older healthier persons produces mild, cold-like symptoms Can be serious in young babies Causes lung infection Infections begin in fall and run into spring Spread by tiny droplets Coughing, sneezing, blowing nose 55 RSV Transmission Exposure to the tiny droplets Touching, kissing, shaking hands with infected person Touching contaminated surface (i.e.: doorknob, phone) and then touching your mucous membranes Virus lives ½ hour plus on hands Virus lives several hours on used tissues Virus lives up to 5 hours on countertops 56 RSV Symptoms appear 4-6 days after contact Infants <1 have more severe symptoms Cyanosis Dyspnea Cough Fever Nasal flaring Tachypnea Shortness of breath Stuffy nose Wheezing 57 RSV Treatment Antibiotics do not help (this is a virus) Humidified oxygen IV fluids Prevention Frequent hand washing especially before touching infants Avoid direct contact with infants if you have a cold or fever 58 Meningitis Inflammation of the protective covering of the brain and spinal cord Bacterial form – the more deadly Transmission – droplets with close contact Prevention – immunization Routine in childhood since 1980’s Treatment – antibiotics High mortality rate if untreated 59 Meningitis Typical presentation Severe headache Stiff neck – unable to flex forward without pain Fever Confusion Vomiting Light sensitivity Sometimes a rash If suspected, then EMS provider to put on N95 mask and then place a surgical mask on the patient 60 Chicken Pox Viral infection with development of itchy blisters – varicella zoster virus Transmission Contagious until all lesions have crusted over Airborne with coughing and sneezing or with direct contact with secretions from the blisters Infectious starting 1-2 days before rash develops Rarely fatal but can include more severe complications in adults Late complication in adults is shingles 61 Chicken Pox If you are caring for a patient with chicken pox, is there concern for transporting the virus home to your family? NO! The virus does not live long out of it’s host and is only a risk to the ones directly exposed to respiratory droplets or the moist blisters You are at risk of contracting chicken pox if you have never had the disease or been vaccinated Handwashing remains a very important part of infection control practices 62 Chicken Pox In children, first sign is usually the rash Small red dots on face, scalp, torso, upper arms, upper legs In older persons, early signs present Nausea Loss of appetite Aching Headache 63 Chicken Pox Prevention Isolate cases Virus easily killed with disinfectants (ie: chlorine bleach Antiviral meds if started soon after rash noticed Shingles – herpes zoster Affects 1 in 3 adults Can be very painful Causes nerve and skin inflammation 64 Shingles Painful, blistering skin rash from varicellazoster virus Same virus as chicken pox Virus dormant in body for years after incident of chicken pox Vulnerable persons Age over 60 Having chicken pox under the age of 1 Less developed immune system Immunocompromised person 65 Shingles Pain may last for months or years 66 Shingles If you are in contact with lesions you can develop chicken pox; not shingles First symptoms usually one-sided pain More likely if you have never had chicken pox or have not been vaccinated Rash develops after the pain Treatment Antiviral medications if started soon enough Anti-inflammatory (corticosteroids) for comfort Pain medications 67 Trauma Trauma is the number one cause of deaths in infants and children Most injuries are from blunt forces Pediatric differences Thinner cavity walls –forces more easily transmitted More trauma to the underlying organs than there are to bony ribs Ribs more pliable in the peds population than adult 68 Cardiac Contusion Similar to any other muscle that has been bruised BUT… This injury may reduce cardiac contractile strength and reduce cardiac output Electrical conduction system may be disrupted Carefully monitor cardiac rhythm 69 Commotio Cordis Rare event VF induced by a blow to the chest wall Leading cause of death in young athletes Average age 13 years Only 15% of victims successfully resuscitated Condition usually unrecognized initially or misdiagnosed leading to a delay in CPR and defibrillation GOAL: CPR and immediate defibrillation Treat like VF from any other cause 70 Pediatric VF SOP Prepare to defibrillate as soon as possible CPR if any delay 1 man CPR peds 30:2 2 man CPR peds 15:2 Once intubated, asynchronous compressions; ventilate once every 6-8 seconds Defib 2 j/kg or equivalent biphasic Resume chest compressions immediately after each defib attempt Successful defib attempts at 4 j/kg Establish IV/IO access 71 Peds VF cont’d Meds Epinephrine 1:10,000 - 0.01 mg/kg IVP/IO Repeat every 3-5 minutes Amiodarone 5 mg/kg IVP/IO Adult max is 300 mg first dose Repeat dose in 3-5 minutes at 5 mg/kg IVP/IO Alternate the above 2 drug categories during rounds of CPR Search for treatable causes (i.e.: H’s and T’s) Consider causes of arrest as soon as situation identified 72 Resources for Pediatric Arrest Broselow tape to determine size of child and recommended size of equipment to use SOP drug reference charts Use charts in the SOP’s for specific drug dosing following Region X SOP’s Broselow tape may follow a different schedule of dosing based on weight when range of dosing is listed Suggest use of TB syringe for dosages under 1 ml Suggest use of 3 ml syringe for doses 1-3 ml 73 Fluid Challenges in the Pediatric Population Remember Total blood volume is relative to body size Total blood volume typically 85 ml/kg An infant has approximately 350 ml total blood volume Equivalent to 1 can of soda A child has approximately 2 L total blood volume Equivalent to a large bottle of soda 74 Total Blood Volume Probably less volume per the unique population than you would visualize 75 Blood Loss – Typical 6 year old Average weight 62 pounds = 28 kg Total blood volume 85 ml/kg = 2380 ml Class I shock - <15% (<357 ml) Class II shock – 15-30% (357 – 714 ml) Class III shock – 30-40% (714 - 952 ml) Class IV shock - >40% (>952 ml) Compensated shock in Class I & II Decompensated shock by Class III Falling blood pressure is the key Falling blood pressure is also a LATE sign 76 Pediatric Fluid Challenges IF a patient needs fluid replacement, the formula is 20 ml per kg for all ages Monitor the adult as every 200 ml is infused Monitor smaller patients as often as necessary Example: 6 y/o (62# = 28 kg) would get 560 ml A runaway IV of 1 liter of fluid could fluid overload the small patients EMS must control fluid infusion by careful observation along with hanging small sized IV bags IV bags may need to be changed more often but child won’t be in failure due to fluid overload 77 Drug Calculation and Preparation Practice Work in small groups Prepare meds used for VF for various age groups as you would on the call Draw up Epinephrine and Amiodarone as you would on a call 10 pound patient 18 pound patient 36 pound patient 42 pounds 58 pound patient 62 pounds 78 Scenario Practice Read the following scenarios Describe the pediatric assessment triangle Determine your general impression Decide which SOP to follow Discuss treatment options determined to be necessary 79 Scenario #1 You are called to the scene for an 18 month old child choking Upon arrival the child is on the mother’s lap Child anxious, frightened looking Coughing, drooling High pitched stridor heard from doorway Retractions evident Appears dusky 80 Scenario #1 Pediatric assessment triangle General impression? Appearance? Work of breathing? Circulation? Airway obstruction SOP to follow 2010 AHA obstructed airway guidelines if obstruction is complete CPR with pause to look into airway prior to ventilations resuming 81 Scenario #1 What assessments would be important in this case? History If sudden onset think FB If gradual onset consider a medical problem A positive history should never be ignored BUT… A negative history may be misleading Auscultation of breath sounds Visualization of oral area with out use of probing instruments 82 Scenario #1 Removal of FB in the ED Your goal – try not to excite child; allow patient to dictate best position to maintain open airway – they often do this instinctively 83 Scenario #2 You are called to the scene for a 5 y/o child found unresponsive in the backyard Upon arrival, the child is unconscious, not breathing and there is no pulse Parents state that other children were in backyard playing with patient What is your first action after scene survey/scene safety? Begin CPR while preparing to apply the cardiac monitor 84 Scenario #2 What is the rhythm strip? NO PULSE!!! PEA What is your next intervention? Resume CPR Search for treatable causes – H’s and T’s 85 Scenario #2 What is the ratio of chest compressions to ventilations? 1 man CPR all patients 30:2 2 man CPR in infant and child 15:2 Once advanced airway in place, compressions with out stopping, ventilations performed once every 6-8 seconds (same for all persons except neonate) Have you asked/considered why this child would have arrested? Have you checked the environment? 86 Scenario #2 What is the treatment for PEA? A vasopressor is the only drug given Use epinephrine 1:10,000 IVP/IO Stimulates vasoconstriction to improve blood flow Also stimulates heart which is not needed in this situation but comes with the use of this medication Dose repeated every 3-5 minutes No limit to epinephrine 87 Scenario #2 When do you check pulses during CPR? Pulses are checked on all patients when first assessed If patient remains in VF or asystole, pulses will never be rechecked If patient presents with VT or any rhythm that should produce a pulse, then pulses will be checked every 2 minutes during 10 second pause in CPR 88 Scenario #2 Why would this child be in PEA? Consider the H’s and T’s Follow-up: Child was shot in chest with a BB gun The other children were too frightened to confess BB was lodged in the heart The small entrance wound on the chest wall was overlooked 89 Endotracheal Tubes With/Without Cuffs Newer investigations question old practices Children can be intubated with cuffed ETT There is little evidence to indicate that cuffed tubes are more dangerous than uncuffed tubes in children The volume in the cuff can be regulated to avoid undue pressure on the tracheal wall A cuffed airway device better protects the airway from aspiration 90 Cuffed versus Uncuffed ETT Cuffed ETT are appropriate in all patients Are no more dangerous than uncuffed tubes More secure airway with cuff in place Cuffs are adjustable so pressure against wall of trachea can be controlled and regulated Uncuffed tubes often too small or too large Too small and airway is not secured and aspiration not as well controlled Too large and there is too much pressure against 91 the wall of the trachea causing tissue damage Scenario #3 You are called to the scene for a 6 year old with history of asthma having an asthma attack Sudden onset of wheezing Anxious, sitting up leaning forward Using accessory muscles Audible wheezing What’s your impression? Asthma attack 92 Scenario #3 What else needs to be done for assessment? Auscultate breath sounds Obtain pulse oximetry reading Hear wheezing on the right, clear on the left SpO2 92% What is your interpretation of the breath sounds and pulse ox? Asthma should produce bilateral wheezing Consider FB if wheezing is only unilateral If oxygen sat is low – administer supplemental oxygen 93 Scenario #3 History of asthma confuses the presentation This is most likely a FBAO; not asthma Unilateral wheezing Sudden onset without likely provocation Be careful of tunnel vision and being swayed by history 94 Scenario #3 Peanut in bronchus found on exam at hospital Inspiratory film on left Expiratory film – trapped air on patient’s left 95 Scenario #3 Progression of disease process of FB Child aspirates Will display signs of obstruction immediately or become asymptomatic Complications develop due to the lodged FB Coughs, chokes, gags, wheezes Adjacent structures can erode There is formation of granular tissue to wall off the FB Child may develop a change in health (i.e.: noisy breathing, snoring, coughing) that wasn’t previously present Surgical procedure required to remove the FB 96 Scenario #4 You are called to the scene for a 16 year-old child ill with fever Upon arrival the child is pale with flushed cheeks, listless, no evidence of respiratory distress Skin is hot to the touch They complain of body aches all over Patient complains of increased pain when neck is moved 97 Scenario #4 What is your general impression? Consider bacterial infection Bacterial meningitis What precautions need to be observed? Consider transmission routes via respiratory droplets First mask yourself with the Hepa filter mask or N95 Then mask the patient with a surgical mask Inform Medical Control of suspicions ASAP 98 Scenario #4 If patient is diagnosed with a contagious disease, the EMS providers will be notified Appropriate interventions will be discussed based on nature of exposure If exposure is to meningitis, exposed persons will be treated prophylactically with oral antibiotic therapy Remember to complete the exposure form, if indicated, based on nature of call 99 100 Bibliography Bledsoe, B., Porter, R., Cherry, R. Essentials of Paramedic Care 2nd edition Update. Brady. 2011. Limmer, D., O’Keefe, M. Emergency Care 12th Edition. Brady. 2012. Region X SOP’s IDPH Approved January 6, 2012 Walraven, G., Basic Arrhythmias 7th Edition. Brady. 2011. http://www.meddean.luc.edu/lumen/meded/elective/ent/lecture 2/img065.htm http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2231400/ www.spine.org/Documents/NATA_Prehospital_Care.pdf http://www.cdc.gov/vaccines/vpd-vac 101