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Pediatric Cardiovascular Responsoft EMS Protocols Pediatric Cardiovascular Page 74 Pediatric Cardiovascular 10/13/2020 Pediatric Bradycardia Pediatric Cardiovascular Stabilize the patient with special attention to ABC’s. Continue monitoring patient after treatment and treat underlying cause....

Pediatric Cardiovascular Responsoft EMS Protocols Pediatric Cardiovascular Page 74 Pediatric Cardiovascular 10/13/2020 Pediatric Bradycardia Pediatric Cardiovascular Stabilize the patient with special attention to ABC’s. Continue monitoring patient after treatment and treat underlying cause. Pediatric Cardiovascular Most common cause of bradycardia is respiratory insufficiency, failure. Give oxygen early. Universal Pediatric Assessment Pediatric Airway Protocol Cardiac Monitor Poor perfusion Decreased blood pressure Respiratory insufficiency Consider use of: Broselow™ Pediatric Emergency Tape No Yes Monitor and reassess IV/IO Heart rate < 60 child? / Heart rate < 60 Infant? Ensure adequate airway CPR CPR Epinephrine 1:10,000 0.1 ml/kg ml/kg IVP, IO Maximum 10 ml Repeat every 3 - 5 minutes Epinephrine 1:1,000 Atropine ET dose 0.1 ml/kg ml/kg Maximum 2 mL 0.02mg/kg mg/kg IVP, IO Minimum dose 0.1 mg / Maximum single dose 0.5 mg 0.02 No Pulse Reassess Pulse Consider ml/kg Normal Saline Bolus 2020 ml / kg Pediatric Pediatric Pulseless Pulseless Arrest Arrest Protocol for sedation Midazolam (Versed) Versed 0.1 mg/kg mg/kg IVP, IO, IN 0.1 Consider External Transcutaneous Pacing-Zoll Maximum 2 mg per dose Responsoft EMS Protocols Page 75 10/13/2020 Pediatric Pulseless Arrest Pediatric Cardiovascular Attempt Defibrillation early. Perform CPR immediately after Defibrillation. Possible Causes of Asystole / PEA:  Hypoxemia  Hypothermia  Hypoglycemia  Hypokalemia  Hyperkalemia  Acidosis  Volume Depletion  Tension Pneumothorax Universal Pediatric Assessment CPR x 2 minutes (CPR should be continued for 2 minutes after every defibrillation) Consider use of: Broselow™ Pediatric Emergency Tape Pediatric Cardiovascular Cardiac Monitor V-Fib / Pulseless V-Tach Asystole / PEA Zoll Defibrillation settings. Follow PALS Guidelines IV/IO IV/IO Defibrillation 2 2 joules/kg joules / kg Epinephrine 1:10,000 0.1 ml/kg ml/kg IVP, IO CPR x 2 min. IV/IO IV/IO Epinephrine 1:1,000 Repeat every 3 - 5 minutes ET dose 0.1 ml/kg 0.1 ml/kg Maximum 10 mL (per dose) Maximum 2.5 mL Epinephrine 1:10,000 0.1 ml/kg ml/kg IVP, IO Repeat every 3 - 5 minutes Maximum 10 mL Identify Cause: Defibrillation 4 4 joules joules/kg /kg CPR x 2 min. Amiodarone 5 mg/kg IVP, IO Maximum 300 mg May repeat x 2 for refractory vfib/VF Alternatively may substitute Lidocaine (Xylocaine) 1 mg/kg mg/kg IVP, IO 1 Hypoglycemia- Dextrose 10% 5 ml/kg ml/kg IVP, IO boluses until patient awake &/or follow up blood sugar > 60 mg/dl Maximum 100 ml Hypovolemia: 20ml/kg ml/kg NS Fluid Bolus 20 Hypoxia: Oxgenation, ventilation HypothermiaTension Pneumothorax: Chest Decompression CPR Defibrillation 4 4joules /kg joules/kg Responsoft EMS Protocols Continue CPR, Epinephrine, Defibrillation Page 76 10/13/2020 Pediatric Cardiovascular Dysrhythmias in children are uncommon. Causes are usually not cardiac related. Watch for signs of decreased cardiac output. Pediatric Tachycardia w/Pulse Universal Pediatric Assessment Identify and treat underlying cause Maintain patent airway and assist breathing as necessary. Apply Oxygen IV/IO IV/IO Access 12 Lead ECG Narrow complex < 0.09 seconds Probable Supraventricular Tachycardia Sinus tachycardia? May attempt Valsalva Maneuver Maneuver Valsalva If NO Pediatric Cardiovascular If history of heart (cardiac) problems and rate is greater than 220 bpm for infants or 180 bpm for children, then Supraventricular Tachycardia should be considered. Confirm that the child is unstable as indicated by hypotension and poor perfusion. Zoll Cardioversion settings. Follow PALS Guidelines Wide Complex Tachycardia (>0.09) Signs of cardiopulmonary compromise?  Hypotension  Acutely altered mental status  Signs of shock initially and after each drug administration if indicated Probable SVT? for sedation Midazolam Midazolam (Versed) (Versed) IF YES Perform continuous cardiac monitoring and print strip Search for and treat cause Adenosine 0.1 mg/kg mg/kg IVP, IO, IN Maximum 2 mg per dose 0.1 0.1mg/kg mg/kg IVP, IO Rapid 20 mL NS flush Maximum 6 mg Cardioversion 0.5 joules / kg 0.5- -11 joules/kg nd 2 dose if needed 0.2 0.2mg/kg mg/kg IVP, IO Rapid 20 mL NS flush Maximum 12 mg Repeat Cardioversion 22 joules / kg joules/kg If rhythm changes Go to Appropriate Protocol Responsoft EMS Protocols Page 77 10/13/2020 Pediatric General Responsoft EMS Protocols Pediatric General Page 78 Pediatric General 10/13/2020 Pediatric General Pediatric Brief Resolved Unexplained Event (BRUE) Pediatric General Previously named: Pediatric Acute Life Threatening Event (ALTE) A Brief Resolved Unexplained Event (BRUE). is an episode occurring in a patient < 1 year of age that is frightening to the caretaker and includes one or more of the following features: 1. Apnea or change in breathing 2. Color change (blue, gray or red) 3. Change in muscle tone 4. Change in breathing and altered level of consciousness In some instances, the caretakers may have administered rescue breaths or chest compressions. Major risk factors associated with BRUE include: 1. Apnea 2. Pallor 3. Cyanosis 4. Feeding difficulties 5. Recent upper respiratory infections The etiology of BRUE is varied. Causes range from mild illnesses to severe, life threatening diseases. Focus history gathering on the following: 1. Complete medical history 2. Severity, nature and duration of the episode 3. Interventions provided by caretakers Treat identifiable causes as appropriate If BRUE is suspected, transport all patients to Nationwide Children’s Hospital. 1. If caretakers refuse transport, contact EMS Supervisor. Refusalof ofTreatment Treatmentor orTransport. Transport 2. Please refer to Refusal Responsoft EMS Protocols Page 79 10/13/2020 Pediatric General Pediatric Behavioral Emergencies Pediatric General Scene Safety Treat suspected medical or trauma problems per appropriate protocol If patient is sedated, use Universal Pediatric Assessment Capnography Capnography Pediatric Unconscious/ Hypoglycemic Pediatric Toxic Overdose Pediatric Head Trauma Causes of Excited Delirium Drug related, Stimulant drugs: Cocaine Amphetamines Club Drugs Attempt to remove patient from stressful environment Hallucinogens, Adverse Drug Reaction, Drug Withdrawal, Hypoglycemia, Head Trauma, Hypoxia, Hypoventilation, Shock, Psychiatric, New drug, Off Drugs, Other Medical Delirium, Infection, Dementia Verbal techniques (reassurance, calm, establish rapport) Patient Destination Guidance: All patients less than 18 years of age must be transported to NCH Behavioral Health Pavillion (The franklin county adult facilities no longer care for pediatric behavioral health patients and must transfer all patients to NCH for evaluation) If there is a medical concern in additon to the psychiatric complaint please transport to NCH main campus Explain all movements and procedures. Look for a possible cause. NCH BHP will care for pregnant patients who are less than 18 yo, are less than 20 weeks gestation and have only a non pregnancy (only behavioral) emergency Agitated & Combative Agitated Patient Restraint Patient Restraint (if necessary) Do not attempt to subdue or restrain unless adequate personnel are present and law enforcement is on the scene. Evacuate if they are not. Ketamine mg/kg 1 1mg/kg IVP, IO mg/kg IM 33 mg/kg Only try to restrain the patient if they are threatening the safety of themselves, the crew or others. If patient 12 years or Midazolam (Versed) 0.1 0.1 mg/kg mg/kg IVP, IO, IM older, co-administer Maximum 2 mg Midazolam (Versed). 0.2mg/kg mg/kg IN Maximum 5 mg 0.2 An alternative to Ketamine is: Midazolam. Midazolam should be used in patients in which Ketamine is contraindicated or ineffective or if there is suspicion that the agitation may be related to underlying seizure activity. Responsoft EMS Protocols Page 80 10/13/2020 Pediatric Fever Pediatric General Fever in children is most often caused by viral infections (URI, bronchiolitis, some cases of pneumonia or meningitis), some are caused by bacterial infections (strep, otitis media, life-threatening pneumonia or meningitis, UTI) Pediatric General Obtain history: Feeding, Previous illnesses, Degree of temperature, Medications or therapies administered, Immunizations. Universal Pediatric Assessment Strongly encourage transport for all patients under 6 months of age. Note that all infants less than 29 days with a fever require admission to the hospital. Infants 30-60 days require a more extensive workup and are often admitted. Appropriate Protocol by Complaint Temperature greater than 100.4 F Children 6 months of age or older Ibuprofen mg/kg PO 1010mg/kg Maximum 600 mg Responsoft EMS Protocols Page 81 10/13/2020 Pediatric General Pediatric Hypovolemic Shock Delay in recognizing and quickly treating a state of shock results in a progression from compensated reversible shock to widespread multiple system organ failure to death. Obtain history. If vomiting, diarrhea, or fever present, assess for hypovolemic shock secondary to dehydration. Remember, early signs of hypovolemia in children include the following: Tachycardia Tachypnea Agitation, restlessness Poor peripheral perfusion (capillary refill > 2 seconds, mottled cool skin) Hypotension is a LATE and ominous sign Universal Pediatric Assessment Cardiac Monitor IV/IO IV/IO Pediatric Multiple Trauma Protocol Yes Pediatric General Evidence or history of trauma? No Blood Glucose < 60 mg/dl Dextrose 10% > 60 mg/dl Normal Normal Saline Saline Bolus 55ml/kg ml/kg IVP, IO boluses until patient awake &/or follow up blood sugar > 60 mg/dl Maximum 100 ml 20 20ml/kg ml/kg 60mL/kg ml/kg May repeat 2x to Maximum 60 Responsoft EMS Protocols Page 82 10/13/2020 Pediatric Pain Control Pediatric General Pain assessment should be frequently evaluated using: Pediatric General Universal Pediatric Assessment FLACC-Revised Scale Patient care according to Protocol based on Specific Complaint Assess Pain severity May offer IN fentanyl earlier, for treatment of pain in appropriate patients. See below. Pulse Oximetry Fentanyl IV/IO IV/IO If necessary No Contraindication to sedation? Patient may have additional Fentanyl in 100 mcg doses to total additional Maximum of 200 mcg. In case of major trauma, major thermal injuries and intubated patients, Maximum cumulative total dose of fentanyl permitted is 400 mcg. 100 mcg per bolus dose for all cases except first dose for RSI. 1 1mcg/kg mcg/kg IVP, IO Maximum single dose 100 mcg 1.5 mcg/kg mcg/kg IN Yes May repeat original dose every 3 – 5 minutes Maximum total 200 mcg Monitor and reassess For severe / excruciating / painful discomfort caused from a fracture / dislocation / subluxation Consider, if Fentanyl is not sufficient or ineffective: Monitor and reassess Ketamine (Ketalar) 0.2 0.2mg/kg mg/kg IVP, IO Maximum 30 mg Responsoft EMS Protocols Page 83 10/13/2020 Pediatric General Pediatric Unconscious/Hypoglycemic View surroundings for reason patient is unconscious. Look for medication bottles, cleaning supplies, alcohol, etc. consider also possibilities due to fever, seizure, trauma, headache, etc. Obtain any previous medical history also. Pediatric General Universal Pediatric Assessment Spinal Injury Assessment Cardiac Monitor IV/IO Blood Glucose No Glucose < 60 mg/dl Glucose 60 - 250 mg/dl Dextrose 10% IVP, IO Consider Naloxone if signs or symptoms of opiate ingestion. 55 ml/kg ml/kg Naloxone (Narcan) Maximum 100 ml 0.1mg/kg mg/kg IVP, IO, ET 0.1 Until patient awake &/or glucose 60 mg/dl 0.2mg/kg mg/kg IN 0.2 Glucagon Glucose > 250 mg/dl signs of dehydration Normal Saline bolus 20 ml/kg 20 ml/kg Maximum 2 mg Consider other causes: Head injury, Overdose Hypoxia 25mcg/kg mcg/kg IM, IN 25 Maximum 1 mg Return to baseline? Yes Reassess and monitor Responsoft EMS Protocols Page 84 10/13/2020 Pediatric General Universal Pediatric Assessment Pediatric General The Universal Patient Care Protocol should be used as primary guide to patient assessment. Scene Safety & BSI (body substance isolation) Pediatric Primary Assessment Pediatric Assessment-Medical Pediatric Assessment-Trauma Consider use of the: Broselow™ Pediatric Emergency Tape Pediatric Pulseless Arrest Protocol Pediatric Airway Airway Protocol Pediatric Spinal Injury Assessment Documentation of Vitals Signs per guideline (Temperature if appropriate) Consider Pulse Oximetry & Capnography Ondansetron (Zofran) ODT (oral) Nausea & Vomiting Ondansetron (Zofran) (Zofran) Ondansetron 0.1 mg/kg IVP 0.1 mg/kg or 12 – 17 years of age >40 kg (88 lbs.) 4 mg No dosage for <40 kg Maximum 4 mg Consider Cardiac Monitor Maximum 8 mg Consider administering Zofran en route to hospital to avoid refusal of transport Appropriate Protocol Responsoft EMS Protocols Page 85 10/13/2020 Pediatric Neonatal Responsoft EMS Protocols Pediatric Neonatal Page 86 Pediatric Neonatal 10/13/2020 Pediatric Neonatal Pediatric Neonatal Care Taking care of a neonate appears complicated due to the many steps needed. However, upon study of this algorithm, the steps are simple and can be carried out in a timely manner. Pediatric Neonatal Newborns are 28 days or less Universal Universal Patient Patient Assessment Assessment (for mother) Dry infant and keep warm Bulb syringe suction mouth / nose Stimulate infant and note APGAR Score Targeted SpO2 per minute of life: 1 minute: 60 - 65% 2 minutes: 65 - 70% 3 minutes: 70 - 75% 5 minutes: 80 - 85% 10 minutes: 85 - 95% Respirations present? No Yes Cardiac Monitor / Heart rate HR < 100 HR > 100 Reassess heart rate and APGAR Score BVM 30 seconds at 40-60 breaths per minute with 100% Give report to receiving Hospital Oxygen HR < 60 HR > 100 HR 60 - 100 Pediatric Airway Pediatrics Airway Protocol / CPR CPR Monitor and reassess Pediatric Airway Airway Protocol Pediatric HR < 60 IV/IO IV/IO Reassess heart rate HR > 100 Appropriate Dysrhythmia Protocol HR 60 - 100 Continue Oxygen IV/IO IV/IO Responsoft EMS Protocols Page 87 10/13/2020 Pediatric Neurological Responsoft EMS Protocols Pediatric Neurological Page 88 Pediatric Neurological 10/13/2020 Pediatric Seizures Pediatric Neurological Seizures can be largely classified into 2 types, generalized and partial seizures. Generalized seizures involve both cerebral hemispheres, while partial seizures involve only one cerebral hemisphere. Possible causes for seizures in children include: Noncompliance with medication(s) for treating epilepsy febrile seizure hypoglycemia anoxia meningitis or encephalitis lead intoxication poisoning or overdose brain tumor head trauma Reyes Syndrome Universal Pediatric Assessment Spinal Injury Assessment If necessary If patient is having active seizure on EMS arrival Position on side to prevent aspiration Midazolam (Versed) (Preferred) IN dose see: MAD Procedure MAD Pediatric Neurological Cardiac Monitor 0.3 mg/kg IM Max. 2 mg per dose Maximum 6 mg Total IV/IO IV/IO Temperature greater than 100.4 Consider undressing patient. Febrile? Yes No If not postictal, older than 6 months, and protecting airway: Blood Glucose Ibuprofen 10 mg/kg 10 mg/kg PO Maximum 600 mg Blood Glucose < 60 mg/dl Dextrose 10% 55ml/kg ml/kg IVP, IO boluses until patient awake &/or follow up blood sugar > 60 mg/dl Maximum 100 ml Active Seizure? Yes Midazolam (Versed) Midazolam (Versed) No Preferred: IN dose (see MAD MAD ) OR Midazolam (Versed) 0.3 0.3 mg/kg mg/kg IM to Max 6 mg Evidence of Shock / Trauma? If recurrent seizures and patient unable to protect airway proceed to: Pediatric Pediatric Airway Airway Responsoft EMS Protocols OR Midazolam (Versed) 0.2 0.2 mg/kg mg/kg IVP, IO to Max 4 mg If seizure persists repeat in 5 min x 1 NOTE: IN preferred unless IV/IO previously obtained, in which case give IV/IO Appropriate Protocol Repeat Seizures or status? Page 89 If patient continues to have persistent seizures after two doses of midazolam contact medical control Yes 10/13/2020 Pediatric Respiratory Responsoft EMS Protocols Pediatric Respiratory Page 90 Pediatric Respiratory 10/13/2020 Pediatric Airway Pediatric Respiratory Assessment is the same evaluating ABC’s including respiratory rate, and effort. Breath sounds and levels of respiratory distress if noticed. Infants and children can easily obstruct the upper airway due to causes including foreign bodies, croup, or epiglottitis, or EMS interventions. Crying can also increase work of breathing. Assess ABC’s, respiratory rate, effort, & adequacy Inadequate Pulse Oximetry & Capnography Adequate Oxygen Pulse Oximetry Supplemental Oxygen Oxygen Positive respirations positive gag reflex Oxygenate, Ventilate, Position, Reassess Cardiac Monitor Basic airway maneuvers: Manual, oral airway. Consider Spinal Injury Assessment if necessary. Ventilate with bag mask device. If airway needs controlled continue below: Pediatric Respiratory NOTE: Be aware of the differences between the infant, child and the adult patients. In the pediatric patient, the larynx is located more anterior and cephalad. The angle formed between the epiglottis and vocal cords is more acute in the infant and child. The tongue is relatively larger. Care must be taken not to hyper-extend the neck as the trachea can collapse during intubation. The occiput (back of the head) in children is larger and this will affect airway management and Cspine control. Padding under the shoulders will help with airway control and not compromise the C-spine. Also, baby teeth are poorly anchored and are easily dislodged. Assess breath sounds bilaterally If necessary Suction Obstruction Obstructed airway per AHA guidelines Pulseless & Apneic Intubation-Pediatric Oral (2 attempts only) Direct laryngoscopy Apneic Continue Ventilation & Transport Intubation-Pediatric Oral (2 attempts only) Facial Trauma or swelling? (Avoid cricothyrotomy if possible, with most medical patients) Unsuccessful Cricothyrotomy-Needle Supraglottic Airway Responsoft EMS Protocols Page 91 (Pediatric) Patients < 10 years old 10/13/2020 Pediatric Respiratory Pediatric Allergic Reaction Allergic reaction can occur quickly in children due to the small size of the airway. Causes of an allergic reaction can include food, medications, insect stings, pollens and molds. Mild Rash only. No respiratory component. No tongue, lip, facial swelling, or hives Universal Pediatric Assessment Pediatric Airway Protocol Anaphylaxis Evidence of impending respiratory distress or shock and GI involvement Diphenhydramine Diphenhydramine(Benadryl) (Benadryl) Epinephrine 1:1,000 mg/kg 11mg/kg ml/kg IM 0.01 ml/kg SLOWLY IVP, IO, IM, PO Maximum 25 mg PO Maximum 50 mg Diphenhydramine (Benadryl) Pediatric Respiratory Signs & Symptoms Hives, rash, itching, nasal congestion, sneezing, throat tightness, hoarseness, coughing, nausea/vomiting, dizziness, tachycardia. Severe Reaction (Anaphylaxis) Shortness of breath, chest pain, stridor, syncope, hypotension, unconsciousness, death. mg/kg 1 mg/kg SLOWLY IVP, IO, IM Maximum 25 mg May repeat in 10 minutes Albuterol / Ipratropium (Atrovent) 2.5 mg & 0.5 mg / 5.5 ml saline Nebulized. May repeat x 2 Dexamethasone (Decadron) 0.6 mg/kg IVP, IO, IM, PO 0.6 mg/kg Maximum 10 mg (Only administer if airway symptoms) Assist with Pt’s prescribed Epinephrine Auto-Injector If wheezing Ipratropium (Atrovent) Albuterol/Ipratropium Albuterol Reassess patient 2.5 mg & 0.5 mg / 5.5 ml saline Nebulized. May repeat x 2 Cardiac Monitor Respiratory Distress Hypotension Dysrhythmia Pediatric Hypovolemic Shock Protocol Appropriate Cardiac Protocol Pediatric Respiratory Distress (Lower Airway) Responsoft EMS Protocols Page 92 10/13/2020 Pediatric Respiratory Pediatric Respiratory Distress (Lower Airway) Lower Airway includes the trachea below the vocal cords, lungs and bronchioles. Universal Pediatric Assessment Pediatric Respiratory Common Lower Airway Problems include: Asthma, Bronchiolitis, Pneumonia. Cardiac Monitor Yes Respiratory insufficiency No Pediatric Airway Protocol Position of patient comfort Respiratory Distress (Wheezing) If received nebulized medications within previous 1 hour. Epinephrine and MgSO4 can be given concurrent with EMS nebulized medications. If age 2 or younger, position and clear airway with nasal suction. Albuterol 2.5 mg in 3 ml Saline mixed with 0.5 mg 2.5 ml Saline Ipratropium May repeat in 10 minutes Dexamethasone 0.6 mg/kg IVP, IO, IM, PO 0.6 mg/kg Maximum 10 mg If unresponsive to Albuterol / Ipratropium Epinephrine 1:1,000 0.01ml/kg ml/kg IM 0.01 Maximum 0.3 ml EPINEPHRINE should be withheld in the following situations: 1. No previous history of Wheezing 2. Pulse rate greater than 180 If given ET 0.1 0.1mg/kg ml/kg Max. 0.3 ml If unresponsive to Epinephrine 20 ml/kg 0.9 NS Fluid Bolus 20 ml/kg For further reference see: Magnesium Sulfate Pediatric Lower Airway Disorders mg/kg in 100 ml NS over 20 minutes, 50 mg/kg IV Infusion. Maximum 2 grams Responsoft EMS Protocols Page 93 10/13/2020 Pediatric Respiratory Pediatric Respiratory Distress (Upper Airway) Upper Airway includes the oral and nasal cavities, pharynx, and trachea. If child is ventilating obtain complete history prior to a medical intervention*. Keep child with parent, if possible, place child in sitting position. Keep lights and noise to an absolute minimum. If child is showing signs of hypoxia (agitated, restless, etc.) administer OXYGEN Universal Pediatric Assessment Cardiac Monitor Respiratory insufficiency Decreased Level of consciousness Yes Pediatric Respiratory usually by placing O2 connecting tubing directly by their face or through a disposable paper cup. DO NOT cause further agitation or start IV. No Position of patient comfort Suction nose if necessary Pediatric Airway Protocol Cause of upper airway known? Is child CALM? Normal Saline Saline Aerosol Aerosol 3 ml Saline Normal Croup Racemic Epinephrine 2.25% Dexamethasone(Decadron) (Decadron) Dexamethasone Maximum 10 mg administer OXYGEN usually by placing O2 connecting tubing directly by their face or through a disposable paper cup. DO NOT cause further agitation or start IV. 0.5 ml nebulized In 3 ml saline May repeat once Must be transported 0.6 mg/kg IVP, IO, IM, PO 0.6 mg/kg If child is ventilating obtain complete history prior to a medical intervention*. Keep child with parent, if possible, place child in sitting position. Keep lights and noise to an absolute minimum. If child is showing signs of hypoxia (agitated, restless, etc.) Isolate Epiglottitis Croup Foreign Body Site of Obstruction Above vocal cords Below vocal cords Varies Cause Bacterial Infection Viral infection Varies Age range Generally older child (>2 yrs) but can occur at any age Younger child (6 months-3 years) Any (usually under 5 years and in adult years) Onset Sudden (6-24 hours), fever may be first sign 24-72 hours Sudden if upper airway Toxicity Child appears very ill; often has high fever Mild to moderate, low-grade fever Not ill appearing, no fever Drooling Common Infrequent May be present Rare “barky” or “seal-like” Common, distinctive, choking, gagging Cough Responsoft EMS Protocols Page 94 10/13/2020 Pediatric Toxicology Responsoft EMS Protocols Pediatric Toxicology Page 95 Pediatric Toxicology 10/13/2020 Pediatric Toxic Overdose Pediatric Toxicology Universal Pediatric Assessment Perform scene size-up and ensure crew safety. Be careful of potential violent situation and be aware of biohazards. Pediatric PediatricAirway Airway Protocol IV/IO Pediatric Toxicology Contact Poison Control for information as needed. POISON CONTROL 228-1323 or 1-800-222-1222 ENCODE NUMBER – 101 9 POISON Cardiac Monitor Dextrose 10% IVP, IO 5 5 ml/kg ml/kg Maximum 100 ml < 60 mg/dl Blood Glucose Yes Respiratory depression? Until patient awake &/or glucose 60 mg/dl Make every effort to contact Poison Control if you feel that the patient does not need to transported. Note the instructions of Poison Control on the run sheet. Consider Naloxone if signs or symptoms of opiate ingestion. Naloxone 0.1 0.1mg/kg mg/kg IVP, IO, 0.2 mg/kg mg/kg IN Maximum 2 mg EMT may administer via IN only Naloxone Naloxone 0.2 mg/kg mg/kg IN Max. 2 mg Immediately transport and notify receiving facility of concern for cyanide toxicity. Appropriate Protocol Responsoft EMS Protocols Yes Yes Smoke Inhalation / CO Poisoning Cyanide toxicity, closed space fire, smoke inhalation with decreased LOC and inadequate response to oxygen therapy? Carboxyhemoglobin Monitor If concern for CO poisoning, place on Oxygen and transport. Hypotension, Seizures, Ventricular dysrhythmias, or Mental status changes? Page 96 10/13/2020 Pediatric Trauma Responsoft EMS Protocols Pediatric Trauma Page 97 Pediatric Trauma 10/13/2020 Pediatric Burns Pediatric Trauma Burns many times are not lifethreatening, but cause a significant amount of pain. Some types of burns are flame, scalds, steam, electrical, flash, tar and chemical burns. Consider transporting patient to burn center. Pediatric Trauma Burns can be thermal, or chemical. Types of burns are First degree ( red and painful), Second degree (Skin blisters) and Third degree (Necrosis). Use the Lund and Browder to estimate body surface percentage affected. Universal Pediatric Assessment Pediatric PediatricAirway Airway Protocol Signs of other injuries: Remove rings, bracelets, and any other constricting items Pediatric Multiple Trauma Protocol Thermal Chemical Eye involvement? Continuous Normal Saline flush in affected eye Cover the burn area with dry dressings. Consider transport for patients with burns involving the hands, face and genitalia (critical burns). Remove clothing or expose area Flush area with water or Normal Saline for 10-15 minutes IV/IO Pediatric PediatricPain PainControl Control Protocol Smoke inhalation / CO Poisoning? Carboxyhemoglobin Monitor Pediatric Toxic Overdose For sedation Consider Midazolam (Versed) mg/kg IVP, IO, IN 0.1 mg/kg Maximum 2 mg per dose For sedation due to significant 2nd and 3rd degree burns. May consider MAD dosing if unable to establish IV and patient requires sedation. Please see MAD dosing page. Responsoft EMS Protocols Page 98 10/13/2020 Pediatric Chest Trauma Pediatric Trauma Injury Signs & Symptoms Tension PneumothoraxSevere respiratory distress, hypotension, tachycardia, decreased level of consciousness (LOC), cyanosis, absent breath sounds on affected side, distended external jugular veins Universal Pediatric Assessment Open Pneumothorax-Respiratory distress, sucking wound Oxygen should be administered to maintain SpO2 >94% Hemothorax-Profound hypovolemic shock, decreased LOC, pallor, flat external jugular veins, respiratory distress Flail segment-Severe respiratory distress, unequal chest movement, cyanosis, decreased LOC Pediatric Trauma Do not remove any impaled or foreign object. Stabilize impaled object for transport. Carefully assess for and treat a life-threatening thoracic injury. Pediatric Airway Protocol If evidence of other injuries? Pediatric Multiple Trauma Protocol Spinal Injury Assessment Vital Signs / Perfusion Abnormal IV/IO IV/IO Normal Rapid Transport Focused history and physical exam Evaluate chest for the following injuries Tension pneumothorax Hemothorax Flail segment Open pneumothorax Transport Open Pneumothorax Nonporous dressing with pressure vent Children presenting with significant chest trauma should, ideally, be transported directly to a Level I Pediatric Trauma facility. Signs & Symptoms of Hypovolemic Shock Normal Saline Bolus 20 20ml/kg ml/kg Repeat as needed Reassess Pediatric Airway Protocol Tension pneumothorax? Chest Decompression Responsoft EMS Protocols Page 99 10/13/2020 Pediatric Trauma Pediatric Head Trauma Children are more likely to experience head injuries, because their heads are proportionally larger, and heavier, in comparison to the rest of their bodies. Universal Pediatric Assessment Isolated head trauma? Yes Pediatric Trauma Younger children frequently fall and injure their face, because of being clumsy when they first start walking. Older children suffer dental injuries from bike and skateboard accidents. Spinal injuries are not as common in children, but because of their larger head, are vulnerable to c-spine injury. Pediatric Airway Protocol No If necessary Pediatric Multiple Trauma Spinal Injury Assessment Protocol IV/IO IV/IO Do not restrict fluids in a patient who is hypotensive or has shock signs and symptoms Indications for transport include loss of consciousness, change in state of consciousness, profuse vomiting, children under 2 years of age with large hematomas, gait disturbances, seizures, and pupillary changes. Monitor and reassess Responsoft EMS Protocols Page 100 10/13/2020 Pediatric Trauma Pediatric Multiple Trauma Perform a trauma assessment. Expose patient. Attempt to keep scene time to a minimum. Treat life threatening injuries as priority. REMEMBER, shock in children is primarily recognized by: TACHYCARDIA - anxiety, restlessness POOR PERIPHERAL PERFUSION (cool, clammy skin with slow capillary refill, weak pulses) Pediatric Trauma Universal Pediatric Assessment Pediatric PediatricAirway Airway Protocol Spinal Injury Assessment IV/IO IV/IO If no improvement or vital signs deteriorate, repeat bolus as necessary. Inform hospital of responses to treatment and recommunicate any change. NS Fluid Bolus 20 ml/kg ml/kg If blood pressure is less than expected or shock symptoms present Cardiac Monitor Assess for tension pneumothorax or flail chest. Evaluate for neurological deficit. Do not restrict fluids in a child that has an inadequate BP or shock symptoms. For Sedation Consider Midazolam Midazolam (Versed) (Versed) 0.1mg/kg mg/kg IVP, IO, IN 0.1 Maximum 2 mg per dose Pediatric Pain Control Protocol For fractures, burns, etc. See: Mucosal Atomizer Device (MAD) for IN dose May repeat in 10 minutes For sedation with severe burns or fractures. Responsoft EMS Protocols Page 101 10/13/2020