Clark County

Emergency Medical Services Pediatric

Guidelines and Procedures Manual

 

INTRODUCTION

The Clark County Emergency Medical Services Council, in cooperation with Community Hospital and Mercy Medical Center, has adopted and amended the Regional Physician Advisory Board proposed prehospital treatment guidelines for pediatric patients. This protocol closely follows others in the region, as well as the state. This insures that pediatric patients will receive quality care wherever they become ill or injured in the areas we serve.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TABLE OF CONTENTS

 

PEDIATRIC PROTOCOL

Altered Level of Consciousness (Pediatric) 1

Arrythmias 4

Pediatric Tachycardia (Unstable Patient) 11

Pediatric Bradycardia (Unstable Patient) 12

Pediatric Asystole/PEA 13

Child Abuse / Neglect 14

Fever 15

Fluid and Drug Administration 16

Multi-Trauma 18

Newborn Resuscitation 19

Pediatric Respiratory Distress 22

Lower Airway Obstruction 24

Upper Airway Obstruction 26

Pediatric Seizure 28

Pediatric Shock 31

Special Needs Children 34

Emergencies in Children with Tracheostomies 34

Emergencies in Children with In Dwelling Central Lines 35

Emergencies in Children with Gastrostomy Tubes 35

Emergencies in Children on Ventilators 36

APPENDIX

Normal Pediatric Vital Signs 38

Pediatric Coma Scoring 39

Pediatric Prehospital Medications 40

 

 

PEDIATRIC

ALTERED LEVEL OF CONSCIOUSNESS

 

FIRST RESPONDER

 

A. ABC’s Consider manual stabilization of the cervical spine as per Multiple Trauma Protocol if cause of unconsciousness is unknown.

B. If not breathing, assist ventilation via mouth to mouth using barrier device.

C. Administer 100% oxygen by NRB mask.

D. Evaluate patient's general appearance and relevant history of condition.

 

EMT-B

A. Transport IMMEDIATELY unless an advanced life support unit is enroute and has an ETA of less than 5 minutes to the scene.

B. Check blood glucose level. Consider administration of oral glucose with intact gag reflex.

EMT-I

A. Assist EMT; obtain patient condition and circumstances.

B. Apply monitor and check rhythm.

C. Determine blood sugar level by available means.

1. If blood sugar is less than 70, administer oral glucose if alert. May be repeated in 10 minutes if blood sugar remains below 70.

PATIENT MUST HAVE A GAG REFLEX.

2. If blood sugar is greater than 400, TRANSPORT.

D. If any of the following are present: patient is unresponsive, appears dry, has a low BP, poor capillary refill and/or blood sugar is above 400, IV fluid bolus 20cc/kg of saline.

E. Start IV saline, TKO, while enroute to hospital

DO NOT DELAY TRANSPORT

PARAMEDIC

 

A. Assume charge of situation and confer with EMTs about condition of patient and situation.

B. If patient does not have a secure, protective airway, intubate patient per intubation procedure.

C. Apply monitor and check rhythm.

D. Start IV/IO saline. If any of the following are present: patient is unresponsive, appears dry, has a low BP, or poor capillary refill, try a fluid challenge of 20cc/kg saline IV/IO push.

E. Determine blood sugar level by available means. Treat accordingly:

1. Blood sugar less than 70, administer IV bolus:

a. 2ml/kg of 25% dextrose (D25) for children under 50 pounds (25 kgs) or 1ml/kg of 50%

dextrose (D50) diluted with 1ml/kg of sterile water.

b. 1ml/kg of 50% dextrose (D50) for children over 50 pounds (25 kgs)

c. May be repeated in 10 minutes if blood sugar remains below 70

2. Blood sugar greater than 400 and signs of hypoperfusion are present, administer an

IV fluid bolus:

a. 20cc/kg of saline

b. May be repeated if no response in 10 minutes.

F. If blood sugar is normal, respirations are impaired, or patient does not respond to dextrose or fluid bolus, administer Narcan;

a. Patients under 5 years old: 0.1 mg/kg IV bolus

b. Patients over 5 years old or greater than 20 kg in weight: 2 mg

If patient improves somewhat with Narcan but is not fully awake, contact Medical Control for repeat dose.

G. Re-evaluate patient condition, contact Medical Control, and transport to the hospital.

H. In some cases patient may require restraint, and should not be transported until completely restrained.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PEDIATRIC

ALTERED LEVEL OF CONSCIOUSNESS

 

 FIRST RESPONDER EMT-B EMT-I PARAMEDIC

OPEN & MANAGE CONSIDER EVALUATE PT. OBTAIN MEDICAL

AIRWAY C-SPINE CONDITION HISTORY

100% 02 NRB VS,LOC,PUPILS SEIZURES

PULSE OX DIABETIC

MED ALERT DRUG ABUSE

TRANSPORT IMMEDIATELY UNLESS ADVANCED LIFE SUPPORT

UNIT IS ENROUTE WITH AN ETA LESS THAN 5 MINUTES

IV SALINE, TKO MONITOR EKG

CHECK BLOOD SUGAR UNABLE TO CHECK BLOOD SUGAR

OR

BLOOD SUGAR BETWEEN 70 & 400

BLOOD SUGAR BELOW 70 BLOOD SUGAR ABOVE 400

ADMINISTER ORAL LOW B/P NARCAN, IVP

GLUCOSE POOR CAP REFILL

IF ALERT 0.1 mg/Kg

IV BOLUS SALINE LESS THAN 5 YEARS OLD

ADMINISTER DEXTROSE 20 cc/Kg

2 mg

UNDER 25 kg OVER 25kg OVER 5 YEARS OLD or

D25 % D50 % OVER 20 kg

2 cc/Kg 1 cc/Kg

NO RESPONSE

RE-EVALUATE PT

INTUBATE IF

NEEDED

 TRANSPORT

PEDIATRIC ARRHYTHMIA

 

 

GENERAL CONSIDERATIONS

A. In the treatment of cardiac arrhythmia, current American Heart Association guidelines were referred to for protocol development.

B. Life-threatening cardiac rhythm disturbances in children are more frequently the result rather than the cause of acute cardiovascular emergencies

C. In infants and children, arrhythmia should be treated as an emergency only if:

1. the arrhythmia compromises cardiac output, or

2. the arrhythmia has the potential for degenerating into a rhythm that compromises cardiac output

D. Initial therapy in children will consist of proper ventilation and oxygenation, along with the assessment of cardiac output

E. Transport is essential when advanced cardiac life support is not available within ten minutes of receipt of the call

F. Refer to length based drug treatment guide (e.g. BROSELOW PEDIATRIC EMERGENCY TAPE) when unsure about patient weight, age and/or drug dosage.

FIRST RESPONDER

A. Per current American Heart Association Pediatric Basic Life Support guidelines, establish unresponsiveness, give two quick breaths, assess pulse and begin compressions if indicated. Immobilize cervical spine if indicated.

B. Assist ventilation with bag-valve-mask while administering 100% oxygen or provide mouth to mouth ventilation using barrier device.

 

EMT-B / EMT-I

A. If patient show signs of decreased cardiac output (decreased LOC, poor capillary refill, low blood pressure,) and a slow heart rate does not respond to oxygenation, start CPR.

Less than 60 in infants and children

B. Evaluate patient's general appearance and determine:

1. Vital signs

2. Level of consciousness

3. Cardiac output

4. Lung sounds

EMT-B / EMT-I CONTINUED

C. Obtain relevant history of current condition.

D. Establish communications with Medical Control and advise of patient condition. Transport IMMEDIATELY unless an advanced life support unit is enroute and has an ETA of less than 5 minutes

to the scene.

E. If cardiac monitor is available, and patient has an unusual and/or irregular heart rate or pulse, apply monitor and run a strip for interpretation by ED Physician, during transport only.

PARAMEDIC

A. Assume charge of situation and confer with EMTs about condition of patient and situation.

B. Assess airway adequacy and intubate only if unable to maintain with oral airway and BVM.

C. Apply monitor and determine rhythm.

D. Start IV saline, TKO using pediatric IV tubing set-up if available.

E. Treat arrhythmias as follows:

1. Bradycardia. Treat only in the presence of severe cardiopulmonary compromise.

a. Infant or Child’s heart rate < 60/min. and patient has poor systemic perfusion.

b. Airway management and 100% oxygenation does not improve patient condition.

c. With a, and/or b:

i. Begin CPR

ii. Administer Epinephrine IV, IO, or ET every three minutes or until cardiac output improves.

(a) When IV or IO routes are available, administer 0.01mg/kg (0.1mL/kg) of 1:10,000

(b) When administering through ET tube use 0.1mg/kg (0.1 ml/kg) of 1,000

ET Epinephrine must be diluted with sterile water or NS.

iii. If no response, administer Atropine 0.02mg/kg May be repeated one time.

MINIMUM DOSE: 0.1mg

MAXIMUM Single DOSES: 0.5mg-child

1.0mg-adoloscent

iv. If no response, transport.

v. Contact Medical Control for possible cardiac pacing.

 

 

 

 

PARAMEDIC CONTINUED

2. Supraventricular Tachycardia (SVT):

a. If patient is asymptomatic, do not treat. Transport immediately.

b. Consider hypovolemia and follow Hypovolemic Shock Protocol.

c. If patient is symptomatic (signs of CHF, poor capillary refill or hypotension) and rate is greater than 220:

i. Administer adenosine, 0.1mg/kg (maximum 6mg) RAPID IV bolus over 1 to 3 seconds followed IMMEDIATELY with a 5cc bolus of saline(within 5 seconds)

ii. If no conversion, repeat adenosine in 1-2 minutes, 0.2mg/kg (maximum 12mg) RAPID IV bolus followed IMMEDIATELY with a 5cc bolus of saline(within 5 seconds)

iii. If no conversion, repeat adenosine in 1-2 minutes, 0.2mg/kg (maximum 12mg) RAPID IV bolus followed IMMEDIATELY with a 5cc bolus of saline(within 5 seconds)

MAXIMUM OF 3 DOSES (30mg) OF ADENOSINE

iv. Contact Medical Control for possible synchronized cardioversion at 0.5 joules per kg

    1. If unsuccessful, repeat cardioversion at 1.0 joule per kg.

vi. Transport

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PEDIATRIC CARDIO-RESPIRATORY ARREST

 

 

GENERAL CONSIDERATIONS

 

A. Cardiac arrest in children is primarily due to the lack of an adequate airway, resulting in hypoxia.

B. All EMT personnel must concentrate on opening and maintaining the airway and providing 100% oxygenation.

C. When using BVM ventilation, gentle cricoid pressure can be applied to occlude the esophagus and prevent gastric distention. Cricoid pressure can be applied until an ET tube can be inserted.

D. Transport immediately when excessive hemorrhage or hypothermia is present. Advanced life support measures should be carried out during transportation.

E. If peripheral IV's cannot be established, venous access should be obtained by Intraosseus route (IO)

F. If IV or IO access cannot be established, administer appropriate medications through the endotracheal tube.

G. If Sudden Infant Death Syndrome (SIDS) is suspected:

1. Initiate basic and advanced life support, unless apparent rigor mortis or signs of lividity are present.

2. Be supportive of family.

3. Encourage family to have friends or neighbors accompany them to the hospital.

4. If infant is not resuscitated, refer parents to Social Services at the Emergency Department to initiate counseling.

H. Refer to length based drug treatment guide (e.g. BROSELOW PEDIATRIC EMERGENCY TAPE) when unsure about patient weight, age and/or

drug dosage.

 

FIRST RESPONDER

A. Open and maintain airway with sniffing position.

B. Ventilate with 100% oxygen, via bag valve mask with oxygen reservoir.

  1. Initiate cardiac compressions in accordance with American Heart Association guidelines.
  2. Apply and activate AED in children over 8 years of age.

 

EMT-B

A. Establish communications with Medical Control and advise of patient condition. Transport IMMEDIATELY unless an advanced life support unit is enroute and has an ETA of less than 5 minutes

to the scene.

 

 

EMT-I

A. Assume charge and confer with EMT as to patient condition and circumstances.

B. Apply cardiac monitor and check rhythm.

C. If monitor shows ventricular fibrillation or pulseless ventricular tachycardia:

1. Defibrillate 2 joules/kg

2. If no change, defibrillate 4 joules/kg

3. If no change, defibrillate 4 joules/kg

4. If no change, continue CPR and transport

D. Start IV or IO of saline with pediatric IV tubing set-up, if available, and give fluid bolus of 20cc/kg. IV should be accomplished enroute to hospital.

DO NOT DELAY TRANSPORT

 

PARAMEDIC

A. Assume charge and confer with EMTs as to patient condition and circumstances.

B. If EMT-I is in a cycle of defibrillation, complete cycle before continuing.

C. Assess airway and intubate only if airway cannot be maintained with oral airway and BVM.

D. Establish IV or IO, whichever is quickest.

E. Apply monitor. If one of the following conditions exists, treat as follows:

1. Ventricular fibrillation or pulseless ventricular tachycardia:

a. Defibrillate 2 joules/kg

b. If no response, defibrillate 4 joules/kg

c. If no response, defibrillate 4 joules/kg

d. If no response, CPR and administer Epinephrine IV, IO, or ET every 3 minutes

i. When IV or IO routes are available, administer 0.01mg/kg (0.1 ml/kg) of 1:10,000 for first dose and 0.1mg/kg (0.1 ml/kg) of 1:1,000 for additional doses

ii. When administering through ET tube use 0.1mg/kg (0.1mL/kg) of 1,000 ET Epinephrine must be diluted with 3-5mL of sterile water or saline.

e. If no response, defibrillate 4 joules/kg

f. If no response, lidocaine 1 mg/kg, IV or IO

g. If no response, defibrillate 4 joules/kg

PARAMEDIC CONTINUED

h. If no response, lidocaine 1 mg/kg, IV or IO

i. If no response, defibrillate 4 joules/kg

j. If no response, CPR and TRANSPORT.

 

2. Asystole / pulseless electrical activity (PEA)

a. Confirm asystole by two different lead positions.

b. If rhythm is unclear and possibly ventricular fibrillation, follow Pediatric Tachycardia Unstable Patient Protocol.

c. TREAT CAUSE: consider hypovolemia or hypothermia, cardiac tamponade, tension pneumothorax, pulmonary embolism, hypoxemia or acidosis, hypoglycemia.

d. CPR and administer epinephrine IV, IO, or ET every 3 minutes.

i. When IV or IO routes are available, administer 0.01mg/kg (0.1 ml/kg)of 1:10,000 for first dose and 0.1mg/kg (0.1 ml/kg)of 1:1,000 for additional doses

ii. When administering through ET tube use 0.1mg/kg of 1,000. ET epinephrine must be diluted with 1-2cc of saline.

e. If no response, IV fluid bolus, 20 cc/kg of saline.

f. Check blood sugar and if less than 70 administer:

i. 2 ml/kg 25% dextrose for children under 25 kg

ii. 1 ml/kg 50% dextrose for children over 25 kg

g. If no response, CPR and TRANSPORT.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PEDIATRIC ARRHYTHMIA

FIRST RESPONDER EMT-B EMT-I PARAMEDIC

ASSESS HISTORY, PLACE ON MONITOR CONTACT

RESPONSIVENESS MEDICAL

AIRWAY, BREATHING, CONTROL

CHECK PULSE

PATIENT ALERT WITH ADEQUATE PATIENT WITH DECREASED LOC,

BREATHING, PULSES, AND PERFUSION INADEQUATE AIRWAY, BREATHING

PULSES, OR PERFUSION

SUPPORT AS NECESSARY:

100% OXYGEN

TRANSPORT MAY INCLUDE 100% OXYGEN, BVM VENTILATION, INTUBATION, CHEST COMPRESSIONS, IV/IO ACCESS

 IF HEART RHYTHM IS:

C TTTOO FASTRDIOVERSION.5 JOULES/TOO SLOWKG

TOO FAST-WITH OR TOO SLOW NO PULSE PRESENT

WITHOUT PULSE-SEE SEE BRADYCARDIA SEE ASYSTOLE/PEA

TACHYCARDIA ALGORITHM ALGORITHM

ALGORITHM

 

 

 

 

 

 

 

 

 

 

PEDIATRIC TACHYCARDIA (UNSTABLE PATIENT)

 

SUPPORT ABCs AS NECESSARY

IDENTIFY RHYTHM

 

VF/VT SVT

DEFIBRILLATE PROCEED DIRECTLY TO

1ST 2 J/KG CARDIOVERSION IF

2ND 4 J/KG PATIENT HAS SEVERE

3RD 4 J/KG DECREASE IN CARDIAC

OUTPUT (i.e.: UNRESPONSIVE,

ABSENCE OF PERPHERIAL PULSES, CYANOTIC)

EPINEPHRINE FIRST DOSE

IV/IO 0.01 MG/KG

(0.1CC/KG. 1;10,000

ET 0.1 MG/KG ADENOSINE O.1 MG/KG

(0.1 CC/KG) 1:1,000

SUBSEQUENT DOSES MAX DOSE 6 MG

EPINEPHRINE IV/IO/ET

0.1 MG/KG (0.1 CC/KG)

1:1,000 ADENOSINE 0.2 MG/KG

MAY REPEAT EVERY 3-5 MAX DOSE 12 MG 12 MG

MINUTES AS NECESSARY

SYNCRONIZED

DEFIBRILLATE 4 J/KG CARDIOVERSION

AFTER EACH DOSE OF 0.5 J/KG

EPINEPHRINE

SYNCRONIZED

LIDOCAINE 1 MG/KG IV/IO/ET CARDIOVERSION

1.0 J/KG

DEFIBRILLATE 4 J/KG TRANSPORT

CONTACT MEDICAL

LIDOCAINE 1 MG/KG IV/IO/ET CONTROL

DEFIBRILLATE 4 J/KG

TRANSPORT

CONTACT MEDICAL

CONTROL

 

 

 

PEDIATRIC BRADYCARDIA (UNSTABLE PATIENT)

 

SUPPORT ABCs AS NECESSARY

 

 

IV/IO EPINEPHRINE 0.01 MG/KG

(0.1 CC/KG 1:10,000)

ET EPINEPHRINE 0.1 MG/KG

MAY REPEAT EVERY 3 MINUTES

AS NECESSARY

ATROPINE 0.02 MG/KG IV/ET

MINIMUM DOSE 0.1 MG

MAXIMUM DOSE: CHILD 0.5 MG

ADOLESCENT 1.0 MG

MAY BE REPEATED ONCE

TRANSPORT

CONTACT MEDICAL CONTROL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PEDIATRIC ASYSTOLE/PEA

 

 

SUPPORT ABCs AS NECESSARY

 

 

 

ATTEMPT TO FIND AND

CORRECT ANY OF THE

FOLLOWING:

HYPOVOLEMIA, HYPOXIA,

HYPOTHERMIA, PNEUMOTHORAX

EPINEPHRINE FIRST DOSE

0.01 MG/KG IV/IO

(0.1 CC/KG 1:10,000)

0.1MG/KG ET

(0.1 CC/KG 1:1,000)

 

EPINEPHRINE 2ND & SUBSEQUENT

DOSES

0.1 MG/KG IV/IO/ET

(0.1 CC/KG 1:1,000)

REPEAT EVERY 3-5 MINUTES

IV FLUID BOLUS

20 CC/KG NS OR LR

MAY REPEAT AS NECESSARY

TRANSPORT

CONTACT MEDICAL CONTROL

 

 

 

 

CHILD ABUSE / NEGLECT

 

 

GENERAL CONSIDERATIONS

 

  1. Child abuse/neglect are widespread enough that nearly all EMTs and Paramedics will see these problems at some time. The first step in recognizing abuse or neglect is to accept that they exist.
  2. Initiate treatment as necessary for situation using established protocols.
  3. EMS is required to report any suspicion of child abuse or neglect. You may discharge this duty in one of three ways:
  1. Transport the child to the hospital. Remove the child from the scene even if there is no medical reason for the transport. The hospital will notify Family and Children’s Services. Keep to a minimum the number of times the child must relate the incident events as multiple interviews alone can leave emotional scars.
    1. Advise parents to go to the hospital. AVOID ACCUSATIONS as this may cause a delay in transport. The adult with the child may not be the abuser.
    2. Document your findings and report to the physician at the hospital.

 

  1. Notify the police. If you believe the child to be I immediate danger and can not make a removal, the police have the right to make an investigation and remove the child if deemed necessary.

3. Notify Family and Children’s Services. An investigation must be initiated within one hour of the notification if the situation is deemed an emergency. If you are unsure of you suspicions of abuse or neglect, discussion of the circumstances with this agency is encouraged.

DOCUMENT THIS NOTIFICATION

 

DO NOT JEOPARDIZE YOUR SAFETY

 

FEVER

 

GENERAL CONSIDERATIONS

 

  1. If febrile, remove excess clothing, but take great care to avoid shivering. Consider environment and temperature of vehicle.
  2. DO NOT sponge child unless treating for heat exposure. (This includes use of moist towels to "cool" the child)
  3. Suggest transport or urgent medical attention for all infants < 8 weeks of age with a reported temperature > 100.4F (38C) or < 96F(35.5C).

  4. Obtain history:
    1. Feeding
    2. Previous Illnesses
    3. Degree of Temperature
    4. Medications or Therapies Administered

5. Immunizations

PEDIATRIC

FLUID AND DRUG ADMINISTRATION

INTERMEDIATE

A. Peripheral venous access lines will be the first route for fluid and drug administration for any life or

limb threatening emergency situation.

B. Unless there are compelling factors, no more than two attempts at peripheral access should be made

in the pediatric patient.

C. In life threatening situation where venous access appears futile, immediately establish Intraosseous access.

D. Intraosseous Infusion

1. The following are guidelines for the UNSTABLE child requiring alternative vascular access AFTER ensuring airway and ventilation are established:

a. Indications: Route of choice for fluid and/or drug administration when peripheral IV access cannot be obtained with two quick attempts in < 90 seconds and child is unstable (severely altered vital signs, markedly decreased level of consciousness).

b. Contra-indications: Recently fractured bone, known bone disorder, unsuccessful prior attempt. Relative Contra-indication: cellulitis or infected burn at site

c. Equipment: Bone marrow aspiration needle, iodine and alcohol preps, 5cc syringe. Local anesthetic optional.

2. Procedure:

a. Select site (Tibia preferred)

Tibia - anteromedial aspect of proximal tibial shaft, 1-3 cm below tibial tuberosity.

Femur - distal 1/3 of femur, midline, 3 cm above condyle

b.. Prep skin with iodine and alcohol.

c. After penetration of the skin, direct the needle at 90 degree angle OR at a slight 10-15 degree vertical angle away from knee, while applying gentle pressure, using a twisting motion.

d. After penetration through the cortex, as marrow cavity is entered, operator may feel a 'pop' or less resistance. Remove the inner stylet and attach a 10cc syringe. Attempt aspiration of bone marrow and inject 5cc of normal saline.

e. Placement usually confirmed by successful fluid administration without edema or swelling.

f. Connect to conventional IV tubing and infuse fluids, blood or drugs as per protocol. If infusion fails to run, or runs slowly, flush needle with 5 mls. of isotonic solution.

g . Secure as needed, immobilize extremity and observe site frequently for extravisation of fluid.

h Infusion may require pressure bag to maintain patency or 60 cc syringe to provide bolus dosing.

i . Document procedure and child’s response.

E. Fluid of choice is Normal Saline or lactated ringers, utilizing a macrodrip administration set. If child is less than 2 years old a microdrip set should be used if available.

PARAMEDIC

A. When peripheral or IO access is not available for administering medications:

1. If an ET tube is in place, the ET tube should be the route of administration for

Lidocaine

Atropine

Narcan

Epinephrine

2. Intramuscular (IM) route may be used for versed or morphine.

3. Rectal route may be used for Valium (diazepam).

 

 

Multi-trauma

 

GENERAL CONSIDERATIONS

 

A. Pediatric Trauma care should primarily follow the Adult Protocol.

B. Areas where special focus should occur:

1. May involve both respiratory failure and shock.

2. Assessment and support of cardiopulmonary function is fundamental.

C. Common errors of pediatric trauma resuscitation are:

1. Failure to open and maintain the airway.

2. Failure to provide appropriate fluid resuscitation to children with head injury.

3. Failure to recognize and treat internal hemorrhage.

D. IO infusion is indicated in the trauma setting when shock needs to be treated and rapid venous access is unobtainable.

E. The proper size equipment is very important to resuscitation care. Refer to length based drug treatment guide (e.g. BROSELOW PEDIATRIC EMERGENCY TAPE) when unsure about patient weight, age and/or drug dosage and when choosing equipment size.

F. MAST devices are not indicated except for the treatment of shock associated with unstable pelvic fractures.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEWBORN RESUSCITATION

 

GENERAL CONSIDERATIONS

A. Body heat must always be maintained. As soon as the baby is born, wipe the baby dry and place in a warm environment. The following are ways to maintain body heat:

1. Cover infant's head, place infant against mother's skin, and cover both.

2. Use child seat with heat packs under and beside infant. Be sure to place towels between heat packs and infant.

    1. Use indirect, heated, humidified oxygen if available.

4. Turn up the heat in the ambulance. Uncomfortable for you is just fine for baby.

B. Always position infant in the sniffing position (1" towel under shoulders). This will allow for an adequate open airway and drainage of secretions.

C. Intermittently suction infant until airway is clear of all secretions. Prolonged deep suction may cause bradycardia.

1. Meconium aspiration is a major cause of death and morbidity among infant. If thick meconium is present and not removed adequately a high percentage (60%) of these infant will aspirate the meconium.

2. If meconium is present, suction the mouth and nose thoroughly. It may also be necessary to visualize the trachea and suction the lower airway. Lower airway suction is achieved by

intubating the infant and suctioning directly through the ET tube. Each time this suctioning is done the infant will have to be reintubated with a new tube. This lower airway suction is only done when thick meconium is present; watery or thin meconium does not require routine endotracheal intubation.

a. Mechanical suction may be used on infant but only if the suction pressure does not exceed -100 mmHg or -136 cmH2O. Bulb suctioning is preferred.

D. If drying and suction has not provided enough tactile stimulation, try flicking the infant's feet and/or rubbing the infant's back. If this stimulation does not improve the infant's breathing, then BVM may be necessary.

E. Avoid direct application of cool oxygen to infant's facial area as this may cause respiratory depression due to a strong mammalian dive reflex immediately after birth

F. American Heart Association standards will be used as a guideline for both Basic and Advanced Life Support procedures.

G. Refer to length based drug treatment guide (e.g. BROSELOW PEDIATRIC EMERGENCY TAPE) when unsure about patient weight, age and/or drug dosage.

 

 

 

A. After delivery of the newborn’s head, but prior to delivery of the body, quickly and thoroughly suction mouth, oropharynx, then nose with a bulb syringe.

B. After delivery of the infant, assess airway and breathing while drying and positioning head down. If amniotic fluid NOT clear, continue to suction PRIOR to ventilating and stimulating.

FIRST RESPONDER CONTINUED

C. If infant not breathing, assist ventilations via mouth to mouth using barrier device.

D. If no pulse or pulse below 60, begin CPR.

E. Keep infant warm. Wrap in dry blankets.

EMT-B / EMT-I

A. If heart rate is < 100 after oxygenation, BVM ventilation is necessary to increase heart rate.

B. If heart rate is < 80 despite adequate ventilation, cardiac compressions should be initiated.

C. BVM ventilation is also indicated for apnea and persistent central cyanosis.

 

D. BVM ventilation rate should be between 40 and 60 breaths per minute. Cardiac compression rate should be at a rate of 120 times per minute.( COMPRESSION TO BREATH RATIO OF 3:1)

E. Establish communications with Medical Control and advise of patient condition. Transport IMMEDIATELY unless an advanced life support unit is enroute and has an ETA of less than 5 minutes to the scene.

PARAMEDIC

A. Assume charge of situation and confer with EMTs about condition of patient and situation.

B. Intubate patient if thick meconium is present in lower airway; suction through ET tube using a meconium aspirator and reintubate with new tube.

C. Apply monitor and check rhythm.

D. If asystole or spontaneous heart rate is less than 80 despite adequate ventilation:

1. Administer epinephrine 0.01-0.03 mg/kg (0.1-0.3 ml/kg)of 1:10,000.via IV or ET

2. If no response, repeat every 3-5 minutes.

E. Establish IV or IO.

F. If infant shows signs of hypovolemia, administer saline 10 cc/kg over 5 minutes

G. Consider Narcan administration if respirations are depressed and narcotic dependence is suspected

1. 0.1mg/kg repeated every 3 minutes until respirations improve.

H. Transport to hospital.

 

 

 

 

 

 

 

 

 

 

 

 

 

NEWBORN RESUSCITATION

FIRST RESPONDER EMT-B EMT-I PARAMEDIC

SUCTION AS CHECK FOR DRY INFANT TACTILE

HEAD PRESENTS MECONIUM STIMULATION

CONTACT MEDICAL CONTROL

 Heart rate > 100 Heart rate <100 Heart rate < 100

Resp present No respirations

 NO STIMULATE & SUCTION

INTERVENTION POSITION

AIRWAY

TRANSPORT INFANT RESPONDS

SUPPORT WITH

WARM, INDIRECT

 OXYGEN YES NO

BVM 100% 02

40-60 VENT/MIN

CHECK RATE & RHYTHM

HR < 100

INTUBATE, CLEAR

MECONIUM IF PRESENT

HR < 80

CARDIAC COMPRESSIONS 120/MIN

EPINEPHRINE, ET 1:10,000

0.02 MG/KG, 0.2 ML

EVERY 3 MINUTES

TRANSPORT

 HYPOVOLEMIA ESTABLISH IV OR IO

FLUID BOLUS NS 10ML/KG

SUSPECT NARCOTIC USE

NARCAN 0.1 ML /KG EVERY 3 MIN

 

PEDIATRIC RESPIRATORY DISTRESS

GENERAL CONSIDERATIONS

A. In children, open airway by using the sniffing position.

B. In suspected cases of upper airway obstructions, unless a foreign body is suspected, DO NOT attempt to visualize the airway. Keep patient calm and transport in position patient seeks to maintain airway.

C. If BVM ventilation is necessary, cricoid pressure can be applied to minimize gastric distention until

airway is secured.

D. Refer to length based drug treatment guide (e.g. BROSELOW PEDIATRIC EMERGENCY TAPE) when unsure about patient weight, age and/or drug dosage.

E. Evaluate patient's general appearance and relevant history of condition.

UPPER AIRWAY OBSTRUCTION

Stridor, gagging or choking in the breathing patient with respiratory distress may indicate upper airway obstruction.

 

FIRST RESPONDER

A. Quickly obtain history and non-invasive respiratory assessment.

1. History of foreign body airway.

a) Manual clearing only if foreign body is visible - NO BLIND FINGER SWEEP

b) Backblows and chest thrust in children less than 1 yr.

c) Abdominal and/or chest thrusts in children over 1 yr.

d) If airway cannot be cleared in 60 seconds:

I) Transport immediately to nearest hospital.

ii) Do not take history.

iii) Do not make further physical assessment.

2. Other cause of upper airway obstruction.

a) DO NOT AGITATE CHILD, DO NOT EXAMINE THROAT.

b) Administer oxygen by NRB if tolerated or by "blow-by".

B. Allow the child to assume a position of comfort. The child may assume the tripod position. Encourage parent to hold the child upright. Keep child and parent (or caregiver) CALM. Do not agitate child.

 

EMT-B

A. Transport in an upright position immediately to the nearest appropriate hospital.

EMT-I

A. Assume charge of situation and confer with EMTs about condition of patient and situation.

B. Reassess breath sounds and treat as follows:

1. Attempt to obtain IV access if child is in or approaching extremis.

2. If foreign body in airway is suspected in unconscious patient with complete obstruction and basic procedures are unsuccessful, try to visualize obstruction with laryngoscope.

PARAMEDIC

A. Assume charge of situation and confer with EMTs about condition of patient and situation

B. Reassess breath sounds and treat as follows:

 

1. If cause of upper airway obstruction is unknown and child is calm, a normal saline aerosol may be administered. DO NOT further agitate child.

2. Do not attempt invasive airway unless child has respiratory arrest. Bag-valve mask ventilation is acceptable.

3. If foreign body in airway is suspected in unconscious patient with complete obstruction, and basic procedures are unsuccessful, try to visualize obstruction with laryngoscope and remove with Magill forceps.

4. If airway is completely obstructed a needle, or surgical cricothyrotomy may be life saving. Contact medical control.

 

 

 

PEDIATRIC RESPIRATORY DISTRESS

LOWER AIRWAY OBSTRUCTION

Wheezing in the breathing patient with respiratory distress indicates lower airway disease, which may come from a variety of causes. The patient with severe lower airway disease may have altered LOC, be unable to talk, may have absent or markedly decreased breath sounds and severe retractions with accessory muscle use.

 

FIRST RESPONDER

A.. Place child in position of comfort, encourage parent to hold child upright. Keep child and parent CALM.

B. Quickly obtain history and non-invasive respiratory assessment.

C. Administer 100% Oxygen in the least threatening manner.

D. If respiratory effort is insufficient or patient is becoming unconscious, assist ventilations with bag-valve-mask.

1. If allergic reaction is suspected:

a) Secure airway and support with oxygen.

b) Ask patient or bystanders if epinephrine by auto-injector has been prescribed for these situations, administer medication as per protocol, then transport patient immediately.

2. For other causes of wheezing:

a) Ask patient or bystanders if a bronchial dilator by inhaler has been prescribed for these situations. If they have the medication with them, administer medication as per protocol, then transport patient.

 

EMT-B

A. IF MEDICATION IS NOT AVAILABLE- Transport immediately, unless ALS unit is enroute and has an ETA of less than 5 minutes

EMT-I

A. Assume charge of situation.

B. Reassess breath sounds.

C. DO NOT establish IV access unless child is in arrest. Do not agitate child.

1. If allergic reaction is suspected.

a) Give 0.01 mg/kg (0.01 ml/kg) of 1:1000 epinephrine by subcutaneous injections MAX Dose 0.3mg (0.3mL)

 

PARAMEDIC

A. Assume charge of situation and confer with EMTs about condition of patient and situations.

B. Reassess breath sounds and treat as follows

1. If allergic reaction is suspected:

a) Give 0.01 mg/kg (0.01 ml/kg) of 1:1000) epinephrine by subcutaneous injection. MAX dose 0.3mg (0.3mL)

2. For other causes of wheezing:

a) Administer 2.5 mg albuterol aerosol with 6 L/min oxygen over 10-15 minutes. Observe and document child’s response. If no improvement, notify receiving facility or Medical Control.

b) DO NOT attempt invasive airway unless child has respiratory arrest.

 

 

 

 

PEDIATRIC RESPIRATORY DISTRESS

UPPER AIRWAY OBSTRUCTION

 

FIRST RESPONDER EMT-B EMT-I PARAMEDIC

OPEN AIRWAY CLEAR OBSTRUCTION CONTACT

CHECK FOR BY MANUAL METHODS MEDICAL

BREATHING CONTROL

 

AIRWAY BLOCKED UNABLE TO CLEAR

IN LESS THAN 60 SECONDS

TRANSPORT IN POSITION OF COMFORT

AIRWAY CLEARED AIRWAY BLOCKED

DURING TRANSPORT

PROVIDE OXYGEN VISUALIZE WITH PROVIDE

NRB LARYNGOSCOPE OXYGEN

REMOVE IF FB PRESENT

ASSESS AIRWAY

& NEEDLE OR SURGICAL

LUNG SOUNDS CRICOTHYROTOMY

 

 

 

 

 

TRANSPORT

 

 

 

 

 

 

 

 

 

 

PEDIATRIC RESPIRATORY DISTRESS

LOWER AIRWAY DISEASE

 

FIRST RESPONDER EMT-B EMT-I PARAMEDIC

OPEN AIRWAY EVALUATE PT. OBTAIN HISTORY CONTACT

PROVIDE OXYGEN CONDITION & MEDICAL

NRB/BVM PULSE OX, LUNG SOUNDS MEDICATIONS CONTROL

TRANSPORT IN

POSITION OF COMFORT

PEDIATRIC SEIZURE

 

GENERAL CONSIDERATIONS

A. The seizure has usually stopped by the time the EMS personnel arrive. The patient will normally be in the postictal state.

B. The basic rule with seizures is to "protect and support" the patient.

C. Aspiration precautions should include:

1. Coma position: a left side-lying position with the head lowered 15 to 30 degrees.

2. Suction readily available.

3. Clear mouth of foreign bodies (food, gum, etc.)

D. Febrile Seizures (seizures with fever) are common in children and should be treated like other seizures.

 

FIRST RESPONDER

A. Place patient away from objects on which they might injure themselves; protect but do not restrain them.

B. Clear and maintain airway; consider C-spine injury.

C. Administer 100% oxygen with NRB as needed for ventilation.

D. Obtain history from family and/or bystanders:

1. Seizure history

2. Description of onset of seizure

3. Medication

4. Other known medical history, especially fever, head trauma, diabetes, drugs

E. Evaluate any evidence of injury, especially head trauma.

EMT-B

 

A. Bring any medications with child to the hospital.

B. Establish communications with Medical Control and advise of patient condition. Transport IMMEDIATELY unless an advanced life support unit is enroute and has an ETA of less than 5 minutes

to the scene.

 

EMT-I

A. Assist EMTs, obtain patient condition and circumstances.

B. Apply monitor and check rhythm.

 

 

 

 

 

PARAMEDIC

A. Assume charge of the situation and confer with EMTs about patient and situation

B. Make sure patient has good airway. In some cases intubation may be necessary.

C. If seizure activity persists:

1. Establish airway

2. Start IV per Fluid and Medication Procedure

D. If seizure activity persists, determine blood sugar level and treat accordingly

1. Blood sugar less than 70, administer IV bolus:

a) 2ml/kg of 25% Dextrose for children under 50 pounds (25 kg)

b) 1ml/kg of 50% Dextrose for children over 50 pounds (25 kg)

2. Administer midazolam (versed) 0.1mg/kg IM or,

3. Administer Valium, 0.2 mg/kg, slow IV push over three minutes, to a maximum dosage of 5 mg.

a. If no IV is available, administer Valium rectally, 0.5 mg/kg, to a maximum dose of 10 mg.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PEDIATRIC SEIZURES

 

FIRST RESPONDER EMT-B EMT-I PARAMEDIC

OPEN & MANAGE EVALUATE PT. OBTAIN MEDICAL CONTACT

AIRWAY CONDITION: HISTORY MEDICAL

100% 02 NRB VS, LOC, SEIZURES CONTROL

CONSIDER PUPILS DIABETES

C-SPINE MED ALERT DRUG ABUSE

TRANSPORT

IV, SALINE, TKO MONITOR EKG CHECK BLOOD SUGAR

STILL SEIZING

MAINTAIN AIRWAY

ENSURE ADEQUATE VENTILATION

BLOOD SUGAR < 70

ADMINISTER DEXTROSE

UNDER 25 kg OVER 25 kg

25 % 50%

2cc/Kg 1cc/Kg

MIDAZOLAM (VERSED)

0.2mg/kg IM or IV

OR

ADMINISTER VALIUM

0.2mg/kg IV

OVER 3 MINUTES

MAXIMUM DOSE 5 mg

0.5mg/kg RECTALLY

MAXIMUM DOSE 10 mg

 

 

 

 

 

 

 

PEDIATRIC SHOCK

GENERAL CONSIDERATIONS

 

A. Shock is not only caused by blood loss. The EMT must evaluate for fluid loss from other causes such as excessive vomiting and/or diarrhea, heat exposure, severe infection, severe allergic reaction (anaphylaxis), spinal trauma, and heart failure.

B. Do not use only the patient's blood pressure in evaluating shock; also look for lower body temperature, poor capillary refill, decreased level of consciousness, increased heart rate, and/or poor skin color or turgor. Tachycardia is often the first sign of shock.

NOTE: DO NOT depend on blood pressure.

C. Transport should not be delayed. The airway must be secured and then transport immediately. It is preferable IVs and/or IOs be done during transportation.

 

FIRST RESPONDER

A. Open and maintain the airway with sniffing position and the use of an oral airway if needed.

B. Control all external bleeding and evaluate for internal hemorrhage and/or dehydration.

C. Provide 100% oxygen through NRB mask, and if needed assist ventilations with a BVM.

D. Obtain vital signs: pulse and respirations.

 

EMT-B

A. Transport IMMEDIATELY unless an advanced life support unit is enroute and has an ETA of less than 5 minutes to the scene.

 

EMT-I

A. Assist EMT, obtain patient condition and circumstance.

B. Hypovolemic, Neurogenic or Septic Shock:

1. Start IV saline during transport to the hospital.

DO NOT DELAY TRANSPORT FOR IV

 

2. Administer IV fluid bolus of 20cc/kg of saline if signs of hypoperfusion or dehydration are present

3. Transport. Repeat bolus during transport if patient does not respond to first bolus.

 

 

 

 

 

 

 

 

EMT-I CONTINUED

C. Anaphylaxis from an insect bite or sting:

1. If breathing difficulty with low blood pressure establish IV saline during transport.

a. Give 0.01cc/kg (0.01 ml)1:1000, maximum 0.3mg (0.3mL) epinephrine by injection subcutaneously.

2. Hives, itching, and/or swelling:

a. Give 0.01cc/kg (0.01 ml)1:1000, maximum 0.3mg (0.3mL) epinephrine by injection subcutaneously.

D. Apply monitor and check rhythm.

 

PARAMEDIC

A. Assume charge of situation and confer with EMTs about condition of patient and situation.

B. Apply monitor and follow protocol for Arrhythmias.

C. Identify type of shock and treat as follows:

1. Hypovolemic, Neurogenic, Septic:

a. Start IV or IO saline and administer fluid bolus of 20cc/kg if sign of

hypoperfusion or dehydration are present (low BP, poor capillary refill, poor skin turgor)

b. Repeat bolus during transport

c. Check blood sugar; if less than 70, administer IV bolus:

i. 2ml/kg of 25% Dextrose for children under 25 kg.

ii. 1ml/kg of 50% Dextrose for children over 25 kg.

2. Anaphylactic:

a. Respiratory distress

i. Give 0.01cc/kg (1:1000) epinephrine by injection subcutaneously.

Maximum dose 0.3mg.

ii. Administer Benadryl (Diphenhydramine) to be administered 1mg/kg IM or IV

NOTE: This is especially indicated when drug reactions are suspected.

iii. When wheezes are present and not cleared by epinephrine, provide albuterol breathing treatment: 1 unit dose, 2.5mg (3cc), by child aerosol mask over 10-15 min.

b. Hives, itching, and/or swelling with normal B/P:

i. Give 0.01cc/kg 1:1000 epinephrine by injection subcutaneously.

Maximum dose 0.3ml.

ii. Administer Benadryl (Diphenhydramine) to be administered 1mg/kg IM or IV. NOTE: This is especially indicated when drug reactions are suspected.

PEDIATRIC SHOCK

 

 

FIRST RESPONDER EMT-B EMT-I PARAMEDIC

OPEN & MANAGE DETERMINE OBTAIN MEDICAL CONTACT

AIRWAY TYPE & CAUSE HISTORY & MEDICAL

100% 02 NRB/BVM OF SHOCK VITAL SIGNS CONTROL

TRANSPORT WITHOUT DELAY, UNLESS ENTRAPMENT, THEN ADVISE MED CONTROL

IV SALINE, TITRATE TO B/P OF 90 SYSTOLIC MONITOR EKG

ANAPHYLACTIC HYPOVOLEMIC, SEPTIC

NEUROGENIC

RESPIRATORY HIVES, ITCHING TRANSPORT

DISTRESS SWELLING

EPINEPHRINE NORMAL B/P

0.01 mg/Kg 1,000 IV FLUID BOLUS 20cc/Kg

SUB Q INJECTION

BENEDRYL EPINEPHRINE NO RESPONSE

1 mg/Kg IM/IV 0.01 mg/kg REPEAT FLUID BOLUS

1: 1,000 SUB. Q

WHEEZES PRESENT

BLOOD SUGAR < 70

ALBUTEROL AEROSOL BENEDRYL

 1mg/Kg IM/IV

ADMINISTER DEXTROSE

2.5 mg (3cc) O2 FLOW

VIA MASK @ 8 LPM UNDER 50 LB OVER 50 LB

D25 % D50 %

2 cc/Kg 1 cc/Kg

TRANSPORT

 

 

 

 

 

 

 

CHILDREN WITH SPECIAL NEEDS

 

SPECIAL CONSIDERATIONS

 

A. Children formerly cared for in hospitals or chronic care facilities are often cared for in homes by parents or other caretakers. These children may have self limiting or chronic diseases. Many are often unstable and may frequently involve the EMS system for evaluation, stabilization, and transport.

B. Knowing which children in a given area have special needs and keeping a logbook can be very useful.

C. Parents and caretakers are usually trained in emergency management and can be of assistance to EMS personnel.

D. Special needs children include children with tracheostomy tubes with or without assisted ventilation, children with gastrostomy tubes, and children with indwelling central lines. Most serious complications of these devices are related to tracheostomy problems.

EMERGENCIES IN CHILDREN WITH TRACHEOSTOMIES

 

FIRST RESPONDER

A. Examine the child quickly for possible causes of distress which may be easily correctable, such as a detached oxygen source.

B. Try to establish the child’s baseline: the child may never look normal.

C. If on a ventilator, remove the child from the ventilator and bag the child with a secure oxygen source; there may be a problem with the ventilator or oxygen source.

EMT-B & EMT-I

A. Suction the child as accumulation of debris is a common cause of obstruction; if the tracheostomy tube has a cannula, remove it; if it is the cause of obstruction there should be immediate improvement.

B. If still no improvement immediately transport to the nearest medical facility;

initiate appropriate resuscitation as needed.

PARAMEDIC

A. If there is no improvement and the child is in severe respiratory distress, the tube should be removed, attempt a bag-valve mask ventilation; if another tube is available, insert into the stoma and resume ventilation (a standard endotracheal tube may be used or the used tracheostomy tube after being cleaned.)

B. If there is still no improvement see the respiratory distress protocol.

 

 

 

 

 

 

 

 

 

 

 

 

EMERGENCIES IN CHILDREN WITH IN DWELLING CENTRAL LINES

 

GENERAL CONSIDERATIONS

A. Children may have central lines in several locations and some complications are due to location; some central lines are located under the skin and can be felt but not seen.

B. The most common emergencies with central lines include, blockage of the line, complete or partial accidental removal, or complete or partial laceration of the line.

FIRST RESPONDER

A. Always evaluate child for cardiovascular stability as some complications may be life threatening.

B. Children may be experiencing complications from their underlying medical condition; ask caretakers about the child’s condition.

 

EMT-B, EMT-I & PARAMEDIC

A. If line is blocked, do not attempt to force the catheter open, transport to a facility capable of managing central lines.

B. For complete removal, do not attempt to reinsert; transport to the nearest emergency department.

1. Infections are a common complication; don’t try to push a line back in, even if it is only slightly out.

C. For complete removal, maintain pressure on site until bleeding has stopped; transport child and catheter to nearest emergency department (part of the catheter may have broken off.)

1. Always bring the line with you to the hospital.

D. For partial or complete laceration of the line, clamp proximally to laceration and transport child and catheter to nearest emergency department.

E. For children with sudden deterioration begin basic resuscitation and transport to nearest emergency facility (child may have pneumothorax or internal bleeding.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMERGENCIES IN CHILDREN WITH GASTROSTOMY TUBES

GENERAL CONSIDERATIONS

A. Children with gastrostomy tubes may have complications of obstruction or dislodgment; obstruction is usually not an emergency but the child may require transport; dislodgment is not life threatening but the tube should be replaced as soon as possible. Both conditions are easily recognized.

B. The child should be examined for any other possible problems.

 

 

 

 

FIRST RESPONDER

A. Children who have problems with their tubes may have problems with regurgitation or aspiration.

B. Be aware of and address any other possible problems from their underlying medical condition.

 

EMT-B, EMT-I & PAREMEDIC

A. Transport the child and the tube to the nearest facility capable of replacing the tube; this is not an emergency transport.

1. Do not attempt to replace the tube; it is not as easy as it seems and there may be other complications.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMERGENCIES IN CHILDREN ON VENTILATORS

 

GENERAL CONSIDERATIONS

A. Children on mechanical ventilation may exhibit sudden or gradual deterioration, cardiac arrest, increased oxygen demand, increased respiratory rate, retractions, change in mental status.

B. Examine the child quickly for possible causes of distress which may be easily correctable (e.g. detached oxygen source) the caretakers will often have done this but double check.

C. Medications the child is presently taking may be the cause of deterioration.

D. Try to establish the child’s baseline; the child may never look normal.

FIRST RESPONDER

A. Remove the child from the ventilator and bag the child with a secure oxygen source; if the child improves there may be a problem with the ventilator or oxygen source.

EMT-B & EMT-I

A. Suction the child as accumulation of debris is a common cause of obstruction; if the tracheostomy tube has a cannula, remove it; if it is the cause of obstruction, there should be immediate improvement.

PARAMEDIC

A. If there is no improvement the tube should be removed; attempt bag-valve mask ventilation; if another tube is available insert into the stoma and resume ventilation (a standard endotracheal tube may be used or the used tracheostomy tube after being cleaned.)

B. If there is no improvement immediately transport to the nearest medical facility; initiate appropriate resuscitation as needed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHILDREN WITH TRACHEOSTOMIES

 

 

FIRST RESPONDER EMT-B EMT-I PARAMEDIC

CHECK FOR ESTABLISH IF ON VENTILATOR

DETACHED BASELINE REMOVE AND BAG

OXYGEN WITH OXYGEN

SOURCE

SUCTION

REMOVE CANNULA IF IT IS

CAUSE OF OBSTRUCTION

IF NO IMPROVEMENT, TRANSPORT

REMOVE TUBE IF CHILD IS

IN RESPIRATORY DISTRESS

ATTEMPT A BAG-VALVE

MASK VENTILATION

INSERT NEW OR CLEANED

TUBE INTO STOMA

IF NO IMPROVEMENT, SEE

RESPIRATORY DISTRESS

ALGORITHM AND TRANSPORT

 

 

 

 

 

 

 

 

 

 

Normal Pediatric Vital Signs

Age

Pulse

Respiration

Blood Pressure

Newborn

120-160

30-60

Systolic = 60-70

<1 year

120-140

30-50

1-2 years

100-140

30-40

systolic = 70+(2 x age)

3-5 years

100-120

20-30

diastolic = 2/3 systolic

6-10 years

80-100

16-20

 

 

Pediatric Coma Scoring

Glasgow

Infant

 
       

Eye

Spontaneous

Spontaneous

4

Opening

To voice

To voice

3
 

To pain

To pain

2
 

None

None

1
       

Verbal

Oriented

Coos, babbles

5

Response

Confused

Irritable cry, inconsolable

4
 

Inappropriate

Cries to pain,

3
 

Garbled speech

Moans to pain

2
 

None

None

1
       

Motor

Obeys commands

Normal movements

6

Response

Localizes pain

Withdraws to touch

5
 

Withdraws to pain

Withdraws to pain

4
 

Flexion

Flexion

3
 

Extension

Extension

2
 

Flaccid

Flaccid

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PEDIATRIC PREHOSPITAL MEDICATIONS

Medication

Dose

Route

Remarks

       
       

• Activated charcoal

1 gm/kg

PO

Do not give to child with altered level of consciousness
       

• Adenosine

0.1 mg/kg

IV, IO

Indicated for SVT. May double second dose; max. dose 6 mg
       

• Albuterol

2.5 mg

Aerosol

Indicated for wheezing as per protocol
       

• Atropine

0.02 mg/kg

IV, IO, ET

Minimum dose 0.1 mg; max. dose for child 0.5 mg; max. dose for adolescent 1.0 mg; may repeat x1; Also useful before intubating children < 5 years old, blocks bradycardia due to vagal nerve stimulation
       

• Bretylium

5 mg/kg

IV

May be indicated for refractory ventricular fib; double second dose

       

• Dextrose 25%

2 ml/kg

IV, IO

Try to obtain bedside glucose level before administering ----administer if blood glucose < 70; consult Medical Control if infant < 1 month as solution may need to be further diluted.

       

• Diazepam (Valium)

0.2-0.3

IV

Indicated for uncontrolled seizure mg/kg activity; anticipate respiratory depression. Max. dose 10 mg.

       

• Diazepam (Valium)

0.5 mg/kg

Rectal

Indicated for uncontrolled seizure activity; anticipate respiratory depression. Max. dose 10 mg.

       

• Diphenhydramine (Benadryl)

1 mg/kg

IV

Useful in allergic reactions and anaphylaxis
       

• Epinephrine

0.1 ml/kg

IV, IO

Commonly used in cardiac arrest rhythms as first dose.

(1:10,000)

(0.01 mg/kg)

  

Increase second dose 10 X (may use 1:1,000 solution).
       

• Epinephrine

0.1 ml/kg

ET,IV, IO

Commonly used in cardiac arrest rhythms.

(1:1,000)

(0.1 mg/kg)

Use for all ET doses, and second and subsequent IV/IO doses.

*The ET route has limited absorption, use IV/IO route whenever possible

0.01ml/kg

SubQ

Used for anaphylaxis. Max dose is 0.3ml
       

• Lidocaine

1 mg/kg

IV, IO, ET

Can repeat once. If successful start continuous infusion at 20-50 mcg/kg/min.

Also useful before intubating for cerebral protection and decreases airway reactivity.
       

• Morphine

0.1 mg/kg

IV/IM

Useful for moderate pain, may cause respiratory depression. Hypotension and reflex bradycardia may develop from histamine release
       

• Midazolam (Versed)

0.1 mg/kg

IV/IO/IM

Indicated for uncontrolled seizure activity; anticipate respiratory depression Useful to facilitate advanced airway management in combative patients
       

• Naloxone (Narcan)

0.1 mg/kg

IV, IO, ET

Useful for unknown unconscious, known narcotic overdoses
       

• Nalbuphine (Nubain)

0.1 mg/kg

IV

Useful for mild or moderate pain, minimal respiratory depression

IV = Intravenous ET = endotracheal IO = Intraosseous

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