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PEDIATRIC PATIENTS Age definitions for purposes of these protocols Newly born: Up to 24 hrs Neonate: 1- 28 days Infant: 1- 12 months Child: 1 to 12 years...

PEDIATRIC PATIENTS Age definitions for purposes of these protocols Newly born: Up to 24 hrs Neonate: 1- 28 days Infant: 1- 12 months Child: 1 to 12 years Special considerations Tailor assessments & interventions to each child based on age, size, developmental, and metabolic status Communication: May be preverbal, nonverbal, or not know personal information. Age and developmental level influence responses to stressful events. Assess behaviors | Speak slowly/calmly (understandable words); don’t yell Keep small child w/ caregiver if appropriate | May assess non-critical child while being held Child/adolescent may need to be interviewed without caregiver present to gain accurate information regarding drug or alcohol use, LMP, sexual activity, or abuse/trafficking | Have 2 EMS/LEO personnel present to witness statements. Fear: Use pacifiers, toys or penlight as distractors | Make a game of assessment | Kneel down to child’s level if possible Young children may display negative behaviors (kicking/biting) due to fear or stress (May be age-appropriate behavior) Respiratory: Smaller airway diameter/shorter trachea | Infants < 6 mos obligate nose breathers | Resp arrest precedes cardiac arrest | Equipment needs vary based on pt height and weight Shock: Vigilant ongoing assessment | Children can maintain MAP until a 30% volume loss, then crash rapidly More susceptible to infections, effects of chemical, biologic, and other agents and hypothermia: Immature immune system; faster metabolism, faster RR; thinner skin/body surface area; shorter stature Cold stress & hypothermia lead to acidosis, hypoxia, bradycardia, hypoglycemia & cardiac arrest Gastric distention develops from crying and can lead to ventilatory impairment Pain: Be cautious in use of touch | Make as many observations as possible before touching and upsetting child Children do not localize pain well - defer painful part of exam to last if possible PEDS ASSESSMENT / INITIAL MEDICAL CARE Assess for causative factors of distress: Hypoxemia, acidosis, hypovolemia (dehydration), hypoglycemia, hypothermia, tension pneumothorax, cardiac tamponade, shock, poisoning/ingestion, or severe infection 1. Scene size up: Situational awareness; dynamic risk assessment | Assess/intervene as needed Scene safety; control and correct hazards; remove pt/crew from unsafe environment ASAP; if potential crime scene, make efforts to preserve integrity of possible evidence Nature of illness; scan environment for clues; POLST/DNR orders Universal blood/body secretion & sharps precautions; use appropriate personal protective equipment (PPE) # of pts; triage / request additional resources if needed | Weigh risk of waiting for resources against benefit of rapid transport to definitive care | Consider if medium or large scale MPI declaration is needed 2. While walking up to the patient, inspect for the Pediatric assessment triangle: Appearance: Awake/asleep/unresponsive | Age-appropriate behavior | Interactiveness | Abnormal look Abnormal gaze | Abnormal speech/cry | Irritable, consolable or non-consolable? Muscle tone: Good vs limp | Movement: spontaneous, purposeful, symmetrical | Sucking on a pacifier or bottle? WOB: Position: Is pt sitting up or tripoding? Is arm/head position suggestive of SCI? Accessory muscle use | Retractions, nasal flaring, head bobbing, grunting | Abnormal sounds | Apnea/gasping Circulation to skin: Pallor, mottling, cyanosis Plus: Obvious injuries, bleeding, bruising, impaled objects or gross deformities | Detect odors 3. PRIMARY ASSESSMENT/RESUSCITATION: establish rapport with patient/significant others Determine if immediate life threat exists and resuscitate as found Determine size/weight: Ask a reliable historian or use a current length/weight tape Level of consciousness using AVPU or Peds GCS | Chief complaint S&S If unresponsive, apneic or gasping, & If NO central pulse OR pulse present but < 60 in infant or child with poor perfusion: Begin high quality CPR and Resuscitate per Cardiac Arrest SOP & appendix - AIRWAY: Patency | Listen for audible airway noises, snoring, gurgling, stridor, wheezing, silence - Impaired? Reposition | Suction (size-appropriate catheter): limit 5 sec.| Monitor ECG (bradycardia) - If obstructed: See PEDIATRIC FOREIGN BODY AIRWAY OBSTRUCTION SOP - If impaired: See PEDS AIRWAY ADJUNCTS SOP - Initiate SMR if indicated | Vomiting/seizure precautions prn BREATHING/gas exchange/adequacy of ventilations: Assess/intervene as needed: - General rate (fast or slow); rhythm | Compare to normal rate for age and situation - Air movement | Chest expansion (symmetry/retractions) | WOB (accessory muscle use) - If distress: quickly breath sounds: Present/diminished/absent, normal/abnormal; all lung fields - If apnea: See PEDS RESPIRATORY ARREST SOP NWC EMSS 2022 SOP 72 Rev. 3-11-24  PEDS ASSESSMENT / INITIAL MEDICAL CARE - SpO2 (before & after O2 if able) if possible hypoxia, CR or neuro compromise | Normal ≥ 95% Unreliable w/ poor peripheral perfusion, CO poisoning | If abnormal; move sensor to central site -reassess - EtCO2 number & waveform if possible ventilatory / perfusion / metabolic compromise Reduce anxiety if possible to decrease O2 demand & work of breathing Anticipate deterioration or imminent respiratory arrest if: Increased or decreased RR esp. if accompanied by S&S of distress, increased effort; poor chest excursion; diminished peripheral lung sounds; gasping or grunting; decreased LOC or response to stimulus; poor skeletal muscle tone; or cyanosis Correct hypoxia/assure adequate ventilations: Target SpO2: ≥ 95% O2 1-6 L/Peds NC: Adequate rate/depth; minimal distress; SpO2 92%-94% O2 12-15 L/Peds NRM: Adequate rate/depth: mod/severe distress; SpO2 < 92% O2 15 L/ Peds BVM: Apnea and/or shallow / inadequate rate/depth with mod/severe distress; unstable PPV 1 breath every 3 to 5 seconds just to see visible chest rise CIRCULATION / PERFUSION / HYDRATION / ECG: - Pulse: General rate (consider activity & stress levels), quality, & regularity of central vs. peripheral pulses - Perfusion: Mental status; skin: color, temperature, moisture; cap refill on a warm area of the body - Hydration status: General appearance (restless, irritable, lethargic, or unconscious | anterior fontanelle | breathing (normal or deep) | mucous membranes, skin turgor, tears when crying; urine output (# diapers) If actual or potential cardiorespiratory (CR) compromise (See shaded box below): - Monitor ECG. Use standard size electrodes / defib pads in children > 10 kg Use largest size that fits on chest w/o contact between pads | Prepare peds defib paddles if no pads Normal peds variants: PRI shorter | QRS wide if > 0.09 sec | T waves normally inverted V1-V3 up to 8 yrs Watch for conduction abnormalities in “normal” looking intervals / complexes in young children Peds 12 L ECG indications same as adult If ECG is run, attach/append to PCR/EHR left at, faxed or downloaded to, the receiving facility - Rx rate / rhythm / pump / volume / volume distribution disorders per appropriate SOP Vascular access: Needs volume replacement and/or IV/IO meds 0.9% NS | Catheter size, access site, & infusion rate based on pt size, hemodynamic status; SOP or OLMC IO: Same as adult + distal femur option | If responsive: LIDOCAINE 0.5 mg/kg (max 40 mg) slow IO IVF: If hypovolemic: NS 20 mL/kg up to 1 L in < 20 min based on MAP and mental status May repeat X 2 if MAP, HR, LOC, cap refill & S&S of perfusion fail to improve | Stop if S&S of fluid in lungs Do not delay transport in time-sensitive pts to establish elective IV/IO access on scene | Limit 2 attempts/route unless situation demands or OLMC order | May place peripheral line when moving; IO while stationary May use central venous access devices already placed based on OLMC *Conditions requiring rapid assessment and/or potential cardiopulmonary support Respiratory rate > 60 breaths/min Cyanosis or decreased SpO2 despite O2 Increased WOB | respiratory fatigue and/or failure Poor perfusion, dysrhythmias; chest pain HR: (Weak, thready, or absent peripheral pulses): ≤ 8 years: < 80 BPM or > 180 BPM > 8 years: < 60 BPM or > 160 BPM Altered LOC (syncope, unusual irritability or lethargy or failure to respond to parents or painful procedures) Seizures Trauma Post-exposure to toxic substance Fever with petechiae Burns >10% BSA Hypoglycemia Severe acidosis Disability: Pupil size, shape, symmetry, reactivity; peds GCS (below); ability to move all four extremities If AMS or cardiac arrest - bG l If < 70: Rx per Peds Glucose Emergencies SOP Expose and examine as indicated | Environmental control: prevent hypothermia / keep warm PEDIATRIC GLASGOW COMA SCORE Eye Opening Best Verbal Response Best Motor Response > 5 years 2-5 years < 2 years Moves purposefully; 6 Spontaneously 4 Oriented/converses 5 Oriented, words/phrases 5 Coos, babbles; words 5 obeys commands Localizes pressure/ 5 To sound 3 Confused 4 Confused 4 Irritable; cries; consolable 4 withdraws to touch Cries to pressure, 3 To pressure 2 Words 3 Words/Persistent cry 3 Withdraws from pressure 4 inconsolable None 1 Sounds 2 Sounds 2 Moans/grunts to pain 2 Abnormal flexion 3 None 1 None 1 None 1 Abnormal extension 2 None 1 NWC EMSS 2022 SOP 73 Rev. 3-11-24  PEDS INITIAL MEDICAL CARE cont. 3. SECONDARY ASSESSMENT Vital signs - BP (MAP): Obtain 1st BP manually; use size-approp. cuff (min. ⅔ length upper arm), trend PP; orthostatic changes if indicated | Pulse: rate, quality, rhythmicity (appropriate site) count HR 30-60 sec; Respirations: rate, pattern, depth | Temp if indicated If FEVER: Assess causes; hydration status | If dehydrated, may attempt IV X 1. If successful: NS 20 mL/kg IVP - Passively cool by removing all clothing but diaper/ underwear. Cover lightly. Do not induce shivering. - Do not give OTC anti-fever meds unless ordered by OLMC. ASA contraindicated. Chief complaint; Hx of present illness; SAMPLE history - S&S: OPQRST (symptom onset, provocation/palliation, quality, region/recurrent/radiation, severity, time); quantify pain using a pain scale that is consistent with the pt's age, condition, and ability to understand Age ≤ 7 yrs or unable to communicate their pain: Observational scale such as FLACC (see appendix) Age 8-12 yrs: Self-report scale such as Wong-Baker Faces, numeric or verbal scales - Allergies (meds, environment, foods) - Medications (prescription/over-the-counter – bring containers to hospital if possible) - PMH (medic-alert jewelry; advance directives; medical devices/implants) - Last oral intake/LMP - Events leading to illness. In pts with syncope, seizure, AMS, cardiac arrest, or acute stroke: bring witness to hospital or obtain their contact phone number to provide to ED. Review of systems based on chief complaint; S&S; practitioner scope of practice, and pt level of acuity - Head, eyes, ears, nose, throat/neck; jugular veins - Chest: Breathing w/ diaphragm only is normal up to 3 yrs | Abnormal S&S: Nasal flaring; grunting, head bobbing; see-saw breathing; assess normal, abnormal, adventitious lung sounds: stridor, wheezing, crackles - Abdomen/pelvis/GU/reproductive organs: Inspect contour, symmetry; discoloration; pain; changes in function; auscultate bowel sounds; palpate (light) for point tenderness, guarding/rigidity; assess for rebound tenderness if S&S peritonitis - Extremities: Edema, pulses, discoloration; warmth, pain, motor/sensory changes/deficits - Back/flank: pain, discoloration - Neurologic: Affect, behavior, cognition, memory/orientation; select cranial nerves (see stroke screen); motor/sensory; balance/ataxia - Skin: color (variation), moisture, temp, texture, turgor, lesions/breakdown; hair distribution; nails 4. Position: Semi-Fowler's or position of comfort unless contraindicated or otherwise specified AMS: Place on side or elevate head of stretcher 10-30° unless contraindicated, to minimize aspiration 5. Nausea: ONDANSETRON 0.15 mg/kg (max 4 mg) ODT [BLS] or slow IVP over no less than 30 sec [ALS] May repeat once in 10 min to a max of 8 mg. 6. Peds PAIN - See Pain Mgt SOP: Non-pharmacologic options: parental presence, distraction, cold packs, Buzzy All should reflect a child-centered approach based on specific needs regardless of transport interval Consider pt status, responder scope of practice, risks/benefits of each strategy STANDARD DOSING for CHILDREN: ACETAMINOPHEN PO (See drug appendix) | IV If >2 yrs: 15 mg/kg IV (max dose 750 mg); IV pump required FENTANYL: If > 2 yrs: 1 mcg/kg (See dose chart in appendix - round to closest 5 mcg -max single dose 100 mcg) IVP/IN/IM/IO. May repeat once in 5 min: 0.5 mcg/kg (max 50 mcg). Max total dose per SOP: 150 mcg (1.5 mcg/kg) Additional doses require OLMC: 0.5 mcg/kg q. 5 min up to a total of 3 mcg/kg (300 mcg) if indicated & available KETAMINE 0.3 mg/kg slow IVP (over 1 min) or IN/IM. Max initial dose 50 mg slow IVP or infusion in 100 mL NS/LR. May repeat X 1 in 20 minutes (max cumulative dose 100 mg). See appendix for dosing chart. Caveat on Peds sedation: Children < 6 yrs (esp. < 6 mos) may be at greater risk for an adverse event from sedation and/or opioid pain medication. They are particularly vulnerable to medication’s effects on ventilatory drive, airway patency and protective airway reflexes – See below NWC EMSS 2022 SOP 74 Rev. 3-11-24  PEDS INITIAL MEDICAL CARE cont. Safe sedation of children requires a systematic approach that includes the following: - Close supervision by qualified EMS practitioner(s) - Pre-sedation evaluation for underlying medical conditions that would place child at risk from sedating meds - Airway exam for loose teeth; large tonsils or anatomic airway abnormalities that may ↑ risk from sedating meds - Clear understanding of medication actions, side effects, and drug interactions - Appropriate training and skills in peds sedation and airway/ventilator mgt to allow rescue of the pt - Age and size-appropriate equipment for airway mgt and vascular access - Appropriate medications and reversal agents (per local policy/procedures) - Sufficient staff to provide medication and monitor patient - Appropriate physiologic monitoring and continuous observation before, during, and after the procedure - Practitioners must have the skills and age and size-appropriate equipment based on their scope of practice to rescue a child from a level of sedation that is deeper than desired, apnea, laryngospasm, and/or airway obstruction. This includes the ability to open the airway, suction secretions, perform successful bag-mask ventilations, insert an oral airway, a nasopharyngeal airway, an extraglottic airway, and rarely perform tracheal intubation per local policy/procedures. (Am Acad of Pediatrics, 2016) PEDS standard dose for MIDAZOLAM for sedation/anxiety: 0.1 mg/kg slow IVP (0.2 mg/kg IN / IM) (Max single dose 2 mg). May repeat q. 2 min to Max total dose < 6 yrs: 6 mg | 6-12 yrs: 10 mg titrated to size and age-appropriate VS & response 7. Ongoing assessment: Reassess VS, SpO2, ETCO2 (if AMS or sedative given) and pt responses to interventions. Every transported child should have at least 2 sets of VS. Stable: At least q. 15 min & after each drug/CR intervention; take last set shortly before arrival at receiving facility Unstable: More frequent reassessments; continue to reassess all abnormal VS & physical findings 8. Transport all infants and children in an approved child restraint system, per the Illinois Child Passenger Protection Act (P.A. 83-8 eff. Jan 1, 2019) that requires children under age 2 years to be properly secured in a rear-facing child restraint system unless the child weighs ≥ 40 pounds or are ≥ 40 inches tall or per manufacturer’s recommendations in contemporary child restraint devices. Do not allow child to be held in anyone's arms or lap during transport. 9. Selection of receiving facility: Transport children to the closest ED approved for Pediatrics (EDAP) or appropriate pediatric trauma center (if indicated). Stable pts may be transported to an alternate or more distant requested facility per local policy / procedure and/or with prior OLMC authorization. 10. Refusal of service: All peds refusals must have OLMC contact per System policy, even if parent /guardian is present on scene and/or consents to release. PALS 2020 Normal SBP Diastolic Age Ages 0-9 MAP Hypotension Heart rate Resp rate 90 + (2 X age in yrs) BP Neonate 67-84 35-53 45-60 70 + (2 X age in yrs) If bradycardia is due to ↑ vagal tone (ADV Airway attempts), primary AV Block, cholinergic drug toxicity, or persists after epi: ATROPINE 0.02 mg/kg rapid IVP / IO (See dose chart in Appendix) Contraindications: 2˚ Mobitz type II or 3˚ AVB w/ wide QRS; abnormal function of SA node; transplanted heart Single dose range: 0.1 mg to 0.5 mg May repeat X 1 in 5 min to a max total dose of 1 mg Transcutaneous cardiac pacing: If drugs are ineffective or contraindicated | No IV/IO placed and impending hemodynamic collapse, start PACING per procedure while prepping meds (contraindicated in severe hypothermia) 3. Start at age-appropriate HR & lowest mA that achieves electrical + mechanical capture unless contraindicated Pacing is not helpful for peds w/ ↓ HR due to post-arrest hypoxia / ischemic myocardial insult, resp. failure, or asystole Standard sized pace/defib electrodes may be used in children > 10 kg Assess need for sedation and pain management as below *IF SBP ≥ 70 + (2X age) or if ≥ 10 yrs: SBP ≥ 90: Sedation: MIDAZOLAM 0.1 mg/kg slow IVP (0.2 mg/kg IN / IM) (Max single dose 2 mg) | May repeat q. 2 min to Max total dose < 6 yrs: 6 mg | 6-12 yrs: 10 mg titrated to size and age-appropriate VS & response Pain: ≥ 2 yrs and not contraindicated: FENTANYL: Standard dose for pain (Peds IMC, appendix) OR KETAMINE: Standard dose for pain (Peds IMC, appendix) NWC EMSS 2022 SOP 83 Rev. 3-11-24  PEDS NARROW QRS COMPLEX TACHYCARDIA QRS Children > 3 years QRS complex narrow if (≤0.09 sec) and wide if (>0.09 sec). Search for and treat possible contributing factors/underlying cause: Hypoxemia Hyperthermia Tamponade, cardiac Toxins/poisons/drugs Hypovolemia/dehydration Hyper/hypokalemia Tension pneumothorax Infection Pain Hydrogen ion (acidosis) Hypoglycemia Thromboembolism, coronary or pulmonary Probable Sinus Tachycardia Probable supraventricular tachycardia (SVT) History compatible w/ shock (dehydration/hemorrhage) History often vague & nondescriptive P waves present/normal P waves absent/abnormal HR often varies w/ activity; responsive to stimulation HR not variable w/ activity Variable RR w/ constant PR Abrupt rate changes w/ termination Infants: HR usually < 220 BPM Infants: HR usually > 220 BPM Children: HR usually < 180 BPM Children: HR usually > 180 BPM Clinical presentations: Cardiorespiratory (CR) stability is affected by child's age, duration of SVT, prior ventricular function, and HR Older children C/O lightheadedness, dizziness, shortness of breath, chest discomfort, or note fast HR Infants: Fussiness, poor feeding, lethargy; may be undetected for long periods until low cardiac output and shock develop 1. IMC special considerations: NO CR compromise: Assess and support ABCs; O2 if SpO2 < 95% or SOB ECG monitor; 12-L ECG if available and condition permits (do not delay emergent Rx) IV or IO access: Defer vascular access until after cardioversion if unconscious If hypovolemic: NS fluid bolus 20 mL/kg IVP followed by reassessment Lower Acuity to EMERGENT: Mild to Moderate CR or perfusion compromise Alert, HR > 150, SBP ≥ 70 + (2X age) or if 10-12 yrs: ≥ 90; normal perfusion and level of consciousness 2. If probable SVT: Assess need for VAGAL maneuvers per procedure (Monitor ECG) 3. ADENOSINE 0.1 mg/kg (Max 6 mg) rapid IVP | follow w/ 5 mL NS flush 2nd dose: 0.2 mg/kg (Max 12 mg) rapid IVP | follow w/ 5 mL NS flush 4. If rhythm improves but continued hypoperfusion: Refer to shock SOP If no rhythm improvement: Proceed to severe CR compromise CRITICAL: SEVERE cardiorespiratory compromise: Time Instability related to HR often > 200-230 beats per minute; may present with one or more of the following: HF w/ ↓ sensitive peripheral perfusion, ↑ work of breathing, altered LOC, or hypotension pt 2. IMC special considerations in conscious patient: If IV/IO placed: May give brief trial of meds while preparing for cardioversion | See above If responsive: MIDAZOLAM 0.1 mg/kg slow IVP (0.2 mg/kg IN/IM) (Max single dose 2 mg) | May repeat q. 2 min to max total dose < 6 yrs: 6 mg | 6-12 yrs: 10 mg titrated to size and age-appropriate VS & response OR KETAMINE sedation dose | If condition is deteriorating, omit sedation 3. Synchronized CARDIOVERSION at 0.5 - 1 J/kg up to adult max joules (See chart p. 108) If delays in synchronization and condition critical, go immediately to unsynchronized shocks 4. Cardioversion successful: Support ABCs; observe Cardioversion unsuccessful: Synchronize cardioversion at 2 J/kg up to adult max joules: QRS regular: 50-100 J; QRS irregular: 120-200 J Re-evaluate rhythm & possible causes (metabolic or toxic) | Rx possible causes NWC EMSS 2022 SOP 84 Rev. 3-11-24  PEDS WIDE COMPLEX TACHYCARDIA with Pulse Rate > 120 - (QRS 0.10 sec or longer) – VT; SVT with aberrancy, WPW; Torsades de pointes Search for and treat possible contributing factors: Hypoxemia Hypoglycemia Tamponade, cardiac Pain Hypovolemia/dehydration Tension pneumothorax Congenital heart disease Hypothermia Hydrogen ion (acidosis) Toxins/poisons/drugs Cardiomyopathy, myocarditis Hyper/hypokalemia Thrombosis/thromboembolism Prolonged QT syndrome. 1. Uncommon: Assess for hypoperfusion, CR compromise, & acidosis | May be difficult to diagnose in small children due to narrower QRS complex | May go unrecognized until child acutely decompensates 2. IMC: Support ABCs as needed; determine need for ADV airway management Obtain, review and transmit 12 lead ECG; determine rhythm & stability ASAP If unconscious, defer IV until after cardioversion Apply appropriate size defib pads if available or prepare peds defib paddles Assess ECG rhythm in more than one lead | Assess for S&S of HF HR varies from near normal to > 300 | Confirm wide QRS (> 0.08 s in infants; > 0.09 s children > 3 years) EMERGENT: None to Moderate cardiorespiratory compromise Alert, HR > 150, SBP ≥ 70 + (2X age) or if 10-12 yrs: ≥ 90; normal perfusion and level of consciousness Regular Monomorphic VT; polymorphic VT w/ normal QT interval; WPW; Irregular Polymorphic VT w/ Irregular wide complex tachycardia; AF w/ aberrancy; AF Prolonged QT / Torsades de Pointes w/ WPW (short PR, delta wave) Contact OLMC first 3. MAGNESIUM (50%) 25 mg/kg (max 2 g) in NS to total 3. AMIODARONE 5 mg/kg (max 150 mg) in NS to total 20 mL in syringe (slow IVP) or in 50 mL NS (IVPB) | Give volume of 20 mL (slow IVP) or in 50 mL NS (IVPB) over 10 min - Max 1 g / 5 min. | Cover IV site with cold over 20 min | Complete dose even if rhythm converts moist gauze or cold pack to relieve burning CRITICAL: SEVERE cardiorespiratory compromise: Time S&S compromised tissue perfusion, shock, hypotension, and/or impaired level of consciousness sensitive pt 3. IMC special considerations If IV/IO placed: May give brief trial of meds while preparing for cardioversion | See above If responsive: MIDAZOLAM 0.1 mg/kg slow IVP (0.2 mg/kg IN/IM) (Max single dose 2 mg) | May repeat q. 2 min to max total dose < 6 yrs: 6 mg | 6-12 yrs: 10 mg titrated to size and age-appropriate VS & response OR KETAMINE sedation dose | If condition is deteriorating, omit sedation 4. Monomorphic VT: Synchronized CARDIOVERSION at 0.5 – 1 J / kg (See chart p. 108) All polymorphic VT / Torsades de pointes: DEFIBRILLATE at 0.5 - 1 J / kg If delays in synchronization and condition critical, go immediately to unsynchronized shocks up to adult max joules HR generally > 220 before cardioversion necessary in children Assess ECG and pulse after each shock delivery | Treat post-cardioversion dysrhythmias per appropriate SOP 5. If cardioversion successful: Complete ALS IMC: Support ABCs; observe; keep warm; transport If VT returns after successful cardioversion, start protocol at last intervention 6. If VT persists: Complete ALS IMC; re-evaluate rhythm & possible causes (metabolic or toxic) AMIODARONE 5 mg/kg (max 150 mg) mixed with NS to total volume of 20 mL in syringe or in 50 mL (IVPB) Give slow IVP or IVPB over 20 min. Synchronized cardioversion at 2 J / kg after ½ of the amiodarone dose Complete amiodarone even if patient converts after shock delivery if BP is normal for age NWC EMSS 2022 SOP 85 Rev. 3-11-24  PEDS ALTERED MENTAL STATUS AMS: Consider possible etiologies; use appropriate SOPs H Head injury Syncope differential E Epilepsy A: Alcohol and ingested drugs/toxins; ACS/HF, arrhythmias, anticoagulation; A Aneurysm acid-base imbalances (acidosis/hypercarbia) D Drugs/psychiatric causes E: Endocrine/exocrine (thyroid/liver/pancreas/adrenals); F&E imbalances; H Hypoxia or heart disease ECG abnormalities/dysrhythmias: prolonged QT; Brugada syndrome E Embolism (incomplete RBBB pattern in V1/V2 w/ ST segment elevation) A Arrhythmia I: Insulin disorders: hypoglycemia; DKA/HHNS R Respiratory (hyperventilation or breath-holding) O: O2 deficit (hypoxia), opioids, OD, occult blood loss (GI/GU) T Thoracic outlet syndrome U: Uremia; other renal causes including hypertensive problems V Vasovagal T: (recent) Trauma, temperature changes E Ectopic (pregnancy-related hypotension) S Situational, sepsis I: Infections (neurologic and systemic); infarction S Sinus sensitivity P: Psychological; (massive) pulmonary embolism E Electrolytes S: Space occupying pathology (epi or subdural, subarachnoid hemorrhage, L Lung (pulmonary embolism) tumors); stroke, sepsis, shock, seizures, SUD S Subclavian steal syndrome Scene size up: Inspect environment for bottles, meds/drugs, letters/notes, sources of toxins suggesting cause Ask bystanders/patient about symptoms immediately prior to change in mentation; S&S during event; duration of event, resolution of event (spontaneous, after interventions) Secondary assessment: Special considerations Level of consciousness using Peds GCS Affect | Behavior: consolable or non-consolable agitation | Cognitive function (recognition of familiar objects; ability to answer simple questions); hallucinations/delusions | Insight Memory deficits; speech patterns Inspect for Medic alert jewelry, tags, body art Consider vulnerability factors: functional impairment, malnutrition, substance use disorder General appearance; odors on breath; evidence of alcohol/drug use; trauma VS: Abnormal respiratory patterns; ↑ or ↓ T; orthostatic changes Skin: Lesions that may be diagnostic of the etiology Neuro exam: Pupils/EOMs; visual deficits; motor/sensory exam; for nuchal rigidity; EMS stroke screen Pain: Facial expression, body movements, muscle tension, vocalization; FLACC for Peds 1. IMC special considerations: Suction cautiously prn; seizure/vomiting/aspiration precautions GCS ≤ 8: Rx per Peds Airway Adjuncts SOP If SpO2 < 95%: O2 and PPV per Peds IMC If SBP < 70 + (2 X Age): IV NS 20 mL/kg IVP | May repeat X 2 if indicated Position patient on side unless contraindicated | Suspicion of spine trauma: SMR If supine: Maintain head and neck in neutral alignment; do not flex the neck Monitor ECG continually enroute; consider need for 12 L ECG (long QT syndromes); Rx dysrhythmias per SOP Monitor for S&S of ↑ ICP: reduce environmental stimuli Document changes in Peds GCS, VS, oximetry, ECG, and neuro exam 2. Obtain and record glucose level If < 70: Rx per Peds Glucose Emergencies SOP | Observe/record response; recheck bG level If ≥ 70: Observe and continue to assess patient 3. If possible opioid toxicity w/ AMS and slow RR for age / respiratory arrest | May not have small pupils: NALOXONE 0.1 mg/kg (max single dose 1 mg) IVP/IO [ALS] | IN/IM [EMR / BLS] w/ repeat doses q. 2 min until breathing adequate up to 4 mg per EMS). Additional doses: OLMC. See Drug Appendix for dosing chart. Presyncope: Prodromal symptoms of syncope: last for seconds to minutes; “nearly blacking out” or “nearly fainting” Syncope: Loss of consciousness and loss of postural tone | Abrupt in onset, resolves quickly Risk factors for adverse outcomes: Older age, structural heart disease, history of CAD Syncope vs. seizure: Assess for PMH of seizure disorder | Look for incontinence with seizures; rare with syncope NWC EMSS 2022 SOP 86 Rev. 3-11-24  Case by case PEDS DRUG OVERDOSE | POISONING determination if time sensitive GENERAL APPROACH 1. History: PMH of SUD? Determine route: ingestion, injected, absorbed, or inhaled; pts often unreliable historians. 2. IMC special considerations: Uncooperative behavior may be due to intoxication/poisoning; assess for underlying pathology Anticipate hypoxia, hypercarbia, respiratory and/or cardiac arrest, hyper or hypotension, dysrhythmias, vomiting, seizures, AMS, coma | Monitor ECG, SpO2 and EtCO2 in all pts with AMS or given sedatives Assess need for Adv. airway if GCS ≤ 8; aspiration risk, airway compromised. See Peds Airway Adjuncts SOP Support ventilations w/ 15L O2/Peds BVM if respiratory depression, hypercarbic ventilatory failure NS IV/IO titrated to adequate perfusion (SBP ≥70 + 2X age; 10-12 yrs SBP ≥ 90 ) Monitor ECG if AMS, tachycardic, bradycardic, hypotensive; or HR irregular Impaired pts should be treated and transported. Call OLMC if parent/guardian wishes to refuse transport 3. If AMS, seizure activity, or focal neurologic deficit: glucose level | If < 70: Rx per Peds Glucose Emergencies SOP STANDARD DOSING GUIDELINES: See dosing charts in Appendix If additional doses appear needed: Contact OLMC Possible opioid toxicity w/ AMS + resp. depression/arrest: NALOXONE 0.1 mg/kg (max single dose 1 mg) IVP/IO [ALS] IN/IM [EMR/BLS]. May repeat q. 2 min until breathing adequate (max total dose 4 mg per EMS) Anxiety/serotonin syndrome: IF SBP ≥ 70 + (2X age) or if ≥10 yrs: SBP ≥ 90: MIDAZOLAM 0.1 mg/kg slow IVP (0.2 mg/kg IN/IM) (max single dose 2 mg) | May repeat q. 2 min to a max total dose < 6 yrs: 6 mg | 6-12 yrs: 10 mg titrated to size and age-appropriate VS and response Tonic-clonic seizures: MIDAZOLAM 0.1 mg/kg IVP/IO (0.2 mg/kg IN/IM) (max single dose 2 mg) | May repeat q. 30-60 sec up to a max total dose < 6 yrs: 6 mg | 6-12 yrs: 10 mg based on size and titrated to stop seizure Violent/combative/undifferentiated delirium w/severe agitation: Carefully estimate weight KETAMINE SEDATION DOSE: 2 mg/kg slow IVP/IO (over 1 min) or 4 mg/kg IN/IM (not to exceed 300 mg by SOP) Recommended approach: Combination of doses/routes to achieve desired sedation within max dose by weight Up to 50 mg (1 mL) each nostril IN (unless contraindicated) may repeat within 90 seconds AND/OR Up to 150 mg (3 mL) IM (may use both anterolateral thighs through clothing prn) Use caution in pts with active psychosis | Frequently monitor/document mental status, VS, SpO2, EtCO2, ECG BETA BLOCKER “LOLs” - See list on Pulmonary Edema/Cardiogenic shock SOP. 4. If ↓ BP: Limit fluid boluses to 5-10 mL/kg; reassess after each bolus due to high freq. of heart dysfunction 5. If P < 60 + SBP < 70 & unresponsive to drugs & pacing per Peds Bradycardia w/ Pulse SOP: GLUCAGON IV/IO [ALS] IN/IM [BLS] < 20 kg (44 lbs):0.5 mg ≥ 20 kg (45 lbs):1 mg CYCLIC ANTIDEPRESSANTS: (Block Na channels and alpha receptors): Adapin, Amitriptyline, Amoxapine, Anafranil, Ascendin, Desipramine, Desyrel, Doxepin, Elavil, Endep, Imipramine, Limbitrol, Ludiomil, Norpramin, Pamelor, Sinequan, Triavil, Tofranil, Vivactil. These DO NOT include serotonin reuptake inhibitors (SSRIs) like Paxil, Prozac, Luvox, Zoloft 4. IF ↓ BP: IV NS fluid challenge 10 mL/kg IVP/IO(to offset alpha blockade). May repeat until BP stable. 5. SODIUM BICARB 1 mEq/kg IVP (max 50 mEq). Repeat X1 if ↓ BP, AMS, wide QRS persists, or dysrhythmias DEPRESSANTS: DEPRESSANTS: Barbiturates: Phenobarbital, Seconal (secobarbital) l Benzodiazepines: diazepam (Valium), midazolam (Versed), lorazepam (Ativan), Librium, flunitrazepam (Rohypnol) - Relatively non-toxic except when combined with other CNS depressants (ETOH). GHB: Cherry meth, Easy lay, G-riffic, Grievous body harm, liquid ecstasy, liquid X, liquid E, organic quaalude, salty water, scoop, soap, and somatomax; SSRIs 4. Observe for CNS depression, respiratory depression, apnea, nystagmus, ↓ P, ↓ BP, seizures. Supportive care. Dextromethorphan (DXM): Active ingredient in over-the-counter cough-suppressants. Liquid & capsule/tablet forms. Abuse referred to as "Robotripping" referring to Robitussin®, and using "Skittles" or "Triple C's" due to red pill forms in Coricidin Cough & Cold® products. Acts as a dissociative anesthetic with increasing effects depending on amount consumed. Clinical effects may mimic ketamine (including nystagmus). 4. Supportive care: Check for salicylate or acetaminophen intoxication, as preparations are often coformulated. If coformulated with diphenhydramine, look for S&S of tricyclic antidepressant-like sodium channel blockade (wide QRS and/or abnormal R wave in aVR). 5. Treat sodium channel blockade toxicity with SODIUM BICARBONATE (See cyclic antidepressants) NWC EMSS 2022 SOP 87 Rev. 3-11-24  Case by case PEDS DRUG OVERDOSE | POISONING cont. determination if time sensitive HALLUCINOGENS: Lysergic acid diethylamide (LSD), phencyclidine (PCP, Angel dust, TIC); cannabis, ketamine, methoxetamine (MXE) -analog of ketamine, both have structural similarity to PCP. Synthetic cannabinoids come as white or off-white powders, or may be combined with various plant products and sold as Spice, K2, Chill Zone, Sensation, Chaos, Aztec Thunder, Red Merkury, and Zen.. May be ingested or insufflated (if powdered chemicals) or smoked when mixed with other plant products. Liquid forms increasingly popular for use in electronic cigarette devices. Belong to varied classes of designer drugs and do not resemble THC in chemical structure. S&S: Variable (mild to significant paranoia and agitation resulting in self-harm); nystagmus, AMS (out-of-body experiences), significant analgesia 4. Supportive care, quiet environment devoid of stimulation (lights, noise and touch) INHALANTS: Caustic agents in form of gasses, vapors, fumes or aerosols. Ex: Gases - CO, NH4 (ammonia), chlorine, freon, carbon tetrachloride, methyl chloride, tear gas, mustard gas, nitrous oxide; spray paint (particularly metallics); household chemicals like cooking spray, furniture polish, correction fluid, propane, mineral spirits, nail polish remover, aerosol propellants, glue, oven cleaners, lighter fluid, gasoline and solvents. Mechanisms of abuse: Sniffing, huffing, bagging. S&S: alcohol-like effects - slurred speech, ataxic movements, euphoria, dizziness and hallucinations; may also include bad headache, N/V, syncope, mood changes, short-term memory loss, diminished hearing, muscle spasms, brain damage, non-cardiogenic pulmonary edema, and dysrhythmias. Sniffing volatile solvents can affect the nervous system, liver, kidneys, blood, bone marrow and severely damage brain. Can suffer from "sudden sniffing death" from a single session of inhalant use. 4. Look for discoloration, spots or sores around the mouth, nausea, anorexia, chemical breath odor and drunken appearance. Supportive care. OPIOIDS: Codeine, fentanyl (carfentanil, Duragesic, Sublimaze, Actiq); heroin, hydrocodone (Vicodin, Norco, Lortab, Lorcet); hydromorphone (Dilaudid, Exalgo, Opana ER); meperidine (Demerol); methadone (Dolophine, Methadone, Diskets); morphine (MS Contin, Kadian, Roxanol; Morphine Sulfate ER); oxycodone (Oxycontin, Percodan, Percocet); propoxyphene (Darvon, Darvocet); diphenoxylate/atropine (Lomotil); Roxanol, Talwin, tramadol (Ultram); Tylox, Wygesic 4. If AMS + RR slow for age (pupils may or may not be small): NALOXONE standard dose (top previous page) 5. Assess need for restraints; monitor for HTN after opioid is reversed if speedballs are used ORGANOPHOSPHATES (cholinergic poisoning): Insecticides: Malathion, parathion, diazinon, fenthion, dichlorvos, chlorpyrifos, ethion | Antihelmintics: Trichlorfon Nerve gases: Soman, sarin, tabun, VX | Ophthalmic agents: Echothiophate, isofluorphate | Herbicides: Tribufos (DEF), merphos S&S: "SLUDGEM" reaction (salivation, lacrimation, urination, defecation, GI distress, emesis, miosis (pinpoint pupils) + Killer Bs: Bronchorrhea, Bronchospasm, Bradycardia (muscarinic). Tachycardia may occur with nicotinic toxicity. 4. Remove from the contaminated area; decontaminate as much as possible before moving to the ambulance 5. ATROPINE 0.02 mg/kg (minimum 0.1 mg) rapid IVP/IM: Repeat q. 3 min until improvement (reduction in secretions) The usual dose limit does not apply Cholinergic poisonings cause an accumulation of acetylcholine. Atropine blocks acetylcholine receptors, thus inhibiting parasympathetic stimulation. Also see Chemical Agents SOP. STIMULANTS: Amphetamines: Benzedrine, Dexedrine, Ritalin, Methamphetamine (crystal, ice); ECSTASY: “Molly” - MDMA (methylene-dioxy-methamphetamine), designer drug used at "rave" parties with stimulant and hallucinogenic properties. Produces feelings of increased energy and euphoria and distorts users' sense and perception of time. May have S&S of serotonin syndrome (hyperthermia, HTN, tachycardia, AMS, ophthalmic clonus, hyper-reflexia, clonus, muscle rigidity, and bruxism (teeth grinding-users known to use pacifiers). Suspect if pt is holding a Vicks vapor rub inhaler; anticipate seizures). COCAINE ("Coke", "Crack", "Blow", "Rock"), ephedrine, PCP; BATH SALTS produce clinical effects like amphetamines or other stimulants. Sympathomimetic effects (↑ HR, BP & Temp; diaphoresis; agitation; hallucinations and psychotic S&S 4. Supportive care for sympathomimetic effects and AMS; prepare to secure pt safety with restraint if necessary Treat tachycardia, dysrhythmias, cardiac ischemia, and hyperthermia per appropriate SOP. 5. If anxiety, seizures, serotonin syndrome &/or HTN crisis. MIDAZOLAM standard dose If violent, combative, uncooperative, delirium w/severe agitation KETAMINE standard sedation dose 6. If hallucinations: quiet environment devoid of stimulation (lights, noise and touch) ILLINOIS POISON CENTER #: 1-800-222-1222 www.illinoispoisoncenter.org NWC EMSS 2022 SOP 88 Rev. 3-11-24  PEDS GLUCOSE | DIABETIC EMERGENCIES Note: Peds patients have high glucose requirements and low glycogen stores During periods of ↑ energy requirements, such as shock, they may become hypoglycemic 1. IMC special considerations: Obtain PMH; ask about history of diabetes (type 1 or 2) | Type 2 incidence is rising in children Assess for presence of automated insulin delivery (AID) systems; glucose monitoring devices Determine general compliance, time and last dose of medication prescribed for diabetes mgt, and last oral intake Vomiting and seizure precautions: prepare suction Obtain/record blood glucose (bG) level (heel stick ≤12 mos) if S&S hypo or hyperglycemia Reference ranges: Neonates > 3 days to adults: Fasting: 70-99 mg/dL Non-fasting: 70-139 mg/dL S&S Hypoglycemia Pallor; diaphoresis; shakiness; weakness, fatigue; hunger, anxiety, nervousness, irritability, difficulty Mild: concentrating; HA; dizziness; numbness, tingling around mouth and lips; nausea, rapid HR, palpitations Moderate Irritability, agitation, confusion; ataxia; weakness/hypotonia; difficulty speaking or slurred speech Severe Lethargy, confusion to coma; seizures; inability to swallow; cold limbs/hypothermia Blood Glucose ≤ 70 or S & S of hypoglycemia Hypoglycemic pts with AMS are considered nondecisional. When hypoglycemia is corrected and confirmed by a repeat bG reading, they can be re-assessed for parent/guardian’s ability to refuse further care/transport. 2. [BLS] If GCS is 14-15 and able to swallow safely (+ gag reflex): 0.3 g/kg (up to 15 g) of a rapidly-absorbed oral carbohydrate if available. May repeat in 15 minutes. Options include (not limited to) any one of the following: Glucose tablets (5 g per tablet) | Glucose gel (15 g per tube) Sweetened fruit juice: 12 g carbs / 4 oz (120 mL) | Regular soda (not diet): 18 g carbs / per 6 oz (180 mL) Honey: 17 g carbs / 1 T (15 mL) | Granulated sugar: 12.5 g sugar / 1 T 3. [ALS] If AMS & cannot swallow safely | Infants and Children (up to 50 kg or 110 lbs) DEXTROSE 10% (25 g/250 mL) 0.5 g/kg up to 25 g (5 mL/kg). See dosing chart in appendix. For smaller children, draw up desired volume into a syringe and administer slow IVP If S&S of hypoglycemia fully reverse and pt becomes decisional after a partial dose, reassess bG If >70; close clamp to D10% and open NS TKO If bG is borderline 60-70 and symptomatic: Give ½ of the dose as listed above Approved alternative if D10% unavailable: D25%:(0.25 g/mL) 2 mL/kg up to 25 g 4. Assess patient response 5 min after dextrose administration: Mental status (GCS) and bG level If ≥70: Ongoing assessment If 70 + (2X Age) Retake BP every 2 min until desired BP is reached (don’t overshoot), then every 5 min Maintenance: Titrate drip downward just to maintain target BP (MAP) | Option: Alternate approved inopressor Keep fingers on pulse & watch SpO2 pleth on monitor for 5 min to detect PEA At risk populations: