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PEDIATRIC PROTOCOLS
EMS and Children with Special Healthcare Needs.6-3
AIRWAY / BREATHING PROTOCOLS
Pediatric Airway.6-5 Pediatric Foreign Body Airway Obstruction (FBAO) .6-7 Pediatric Respiratory Distress – Upper Airway .6-9 Pediatric Respiratory Distress – Lower Airway .6-11 ARRYTHMIAS / ACLS

Pediatric Sinus Bradycardia.6-13 Pediatric Narrow Complex Tachycardia (SVT) .6-15 CARDIAC ARREST / ACLS

Pediatric Asystole / Pulseless Electrical Activity (PEA) . 6-17 Pediatric Ventricular Fibrillation (V-FIB) and Pulseless Ventricular Tachycardia . 6-19
MEDICAL PROTOCOLS
Pediatric Altered Level of Consciousness . 6-21 Pediatric Diabetic Emergencies. 6-23 Pediatric Heat Illness. 6-25 Pediatric Hypothermia . 6-27 Pediatric Neonatal Resuscitation. 6-29 APGAR Scoring Chart . 6-30 Pediatric Esophageal Foreign Body . 6-31 Pediatric Seizure . 6-33 Pediatric Shock – Non Trauma. 6-35 Pediatric Toxic Ingestion / Exposure . 6-37 Pediatric Trauma . Head. 6-39 Multiple . 6-41 PEDIATRIC ASSESSMENT CHARTS

Glascow Coma Scale . 6-43 Normal Vital Signs . Pediatric Pharmacology Review . 6-45 EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc THIS PAGE INTENTIONALLY LEFT BLANK EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
EMERGENCIES IN CHILDREN WITH SPECIAL HEALTCHCARE NEEDS

GENERAL CONSIDERATIONS

1. Treat the ABC's first. Treat the child, not the equipment. If the emergency is due to an equipment malfunction, manage the child appropriately using your own equipment. 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. There are multitudes of underlying medical conditions that may categorize children as having special needs. Many are often unstable and may frequently involve the EMS system for evaluation, stabilization, and transport. Special needs children include technology-assisted children such as those with tracheostomy tubes with or without assisted ventilation, children with gastrostomy tubes, and children with indwelling central lines. The most serious complications are related to tracheostomy problems. 3. Children with Special Healthcare Needs (CSHCN) have many allergies. Children with spina bifida are often allergic to latex. Before treating a patient, ask the caregivers if the children are allergic to latex or have any other allergies. Stock latex-free equipment. (Some regularly used equipment that contains latex includes gloves, oxygen masks, IV tubing BVM, blood pressure cuff, IV catheters, etc.) 4. Knowing which children in a given area have special needs and keeping a logbook is encouraged. 5. Parents and caretakers are usually trained in emergency management and can be of assistance to EMS personnel. Listen carefully to the caregiver and follow his/her guidance regarding the child's treatment. 6. Children with chronic illnesses often have different physical development from well children. Therefore, their baseline vital signs may differ from normal standards. The size and developmental level may be different from age-based norms and length based tapes used to calculate drug dosages. Ask the caregiver if the child normally has abnormal vital signs. (i.e. a fast heart rate or a low pulse oximeter reading) 7. Some CSHCN may have sensory deficits (i.e. they may be hearing impaired or blind) yet may have age-appropriate cognitive abilities. Follow the caregivers' lead in talking to and comforting a child during treatment and transport. Do not assume that a CSHCN is developmentally delayed. 8. When moving a special needs child, a slow careful transfer with two or more people is preferable. Do not try to straighten or unnecessarily manipulate contracted extremities as it may cause injury or pain to the child. Certain medical conditions will require special care. Again, consult the child's caregiver. 9. Caregivers of CSHCN often carry "go bags" or diaper bags that contain supplies to use with the child's medical technologies and additional equipment such as extra tracheostomy tubes, adapters for feeding tubes, suction catheters, etc. Before leaving the scene, ask the caregivers if they have a "go bag" and carry it with you. 10. Caregivers may also carry a brief medical information form or card. The child may be enrolled in a medical alert program whereby emergency personnel can get quick access to the child's medical history. Ask the caregivers if they have an emergency information form or some other form of medical information for their child. 11. Caregivers of CSHCN often prefer that their child be transported to the hospital where the child is regularly followed or the "home" hospital. When making the decision as to where to transport a CSHCN, take into account: local protocols, the child's condition, capabilities of the local hospital, caregivers' request, ability to transport to certain locations. EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc THIS PAGE INTENTIONALLY LEFT BLANK EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc AIRWAY / BREATHING
PEDIATRIC
MED CONTROL
Respiratory Rate, Effort, Basic maneuvers first --- Respirations Obstruction Nasal / Oral Airway Positive Gag Reflex See Pediatric Foreign Body Airway Obstruction Direct Laryngoscopy Continue Bag – Valve – Mask Ventilations KEY POINTS
• Capnometry is mandatory with all methods of intubation. Document results of SPO2.
• Limit intubation attempts to 3 per patient.
• If unable to intubate, continue BVM ventilations, transport rapidly, and notify receiving hospital early
• Maintain C-spine immobilization for patients with suspected spinal injury. • Do not assume hyperventilation is psychogenic -- use oxygen, not a paper bag. • Sellick's maneuver should be used to assist with difficult intubations. • Continuous pulse oximetry should be utilized in all patients with an inadequate respiratory function. • Consider c-collar to help maintain ETT placement for all intubated patients . EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc THIS PAGE INTENTIONALLY LEFT BLANK EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc AIRWAY / BREATHING
PEDIATRIC
FOREIGN BODY AIRWAY OBSTRUCTION (FBAO)
Infant (0 – 12 months) Head Tilt / Chin Lift/ Jaw Thrust / Airway Maneuvers MED CONTROL
Complete Obstruction Complete Obstruction Encourage patient to cough 5 Back Blows / 5 Chest thrusts (Only if visualized / attainable) 10 – 15 L Pediatric Mask, Laryngoscope/ Magill Forceps Open airway / ventilate (May reposition repeat) 5 Back Blows / 5 Chest thrusts If unable to ventilate, repeat / continue sequence Child (1 – 8 years) Head Tilt / Chin Lift/ Jaw Thrust / Airway Maneuvers Complete Obstruction Complete Obstruction Encourage patient to cough (Only if visualized / attainable) 10 – 15 L Pediatric Mask, Laryngoscope/ Magill Forceps Open airway / ventilate (May reposition repeat) 5 Abdominal Thrusts If unable to ventilate, CONTACT MEDICAL CONTROL repeat / continue sequence EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc AIRWAY / BREATHING
PEDIATRIC
FOREIGN BODY AIRWAY OBSTRUCTION (FBAO)
SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS
• Sudden Episode of Choking • Inablity to speak • Audible Stridor • Unresponsive • Change in Skin Color • Increased / Decreased Respiratory Rate • Unproductive KEY POINTS
• Infants 0-12 months DO NOT receive abdominal thrusts. Use chest thrusts. • NEVER perform blind finger sweeps in infants or children. • Attempt to clear the airway should only be made if foreign body aspiration is witnessed or very strongly suspected and there is complete airway obstruction. • Even with a complete airway obstruction, positive-pressure ventilation is often successful. EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc AIRWAY / BREATHING
PEDIATRIC
Respiratory Distress Upper Airway – CROUP
UNIVERSAL PATIENT CARE PROTOCOL MED CONTROL
Sit Patient on Parent's Lap Position Patient Sitting Upright Do not Lay Patient Down Do Not Perform Digital Airway Exam Check Pulse Oximetry Mild – Moderate Distress Severe Distress Evaluate Level of Distress / Pulse Oximetry Cool Mist with Sterile Water SPO2 = 97% with retraction Accessory Muscle Use With Severe Respiratory Distress RACEPHINEPHRINE INHALATION 0.5 mL Diluted to 3mL Sterile NS Nebulized @ 6 L O2 over 15 minutes x1 treatment DO NOT USE RACEPHINEPHRINE INHALATION If color is pink or darker than slightly yellow/ temperature > 68 degrees Fahrenheit EPINEPHRINE 1:1000 (Undiluted Dose) (Pediatric < 10 kg = 3 mL , Nebulized @ 6 L Oxygen) (Pediatric > 10 kg = 5 mL, Nebulized @ 6 L Oxygen) CONTACT MEDICAL CONTROL EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc PEDIATRIC
Respiratory Distress Upper Airway - CROUP
SIGNS AND SYMPTOMS
• Time of onset • Possibility of foreign body • Fever or respiratory • Inability to Swallow • Congenital heart disease • History of trauma • Medication or Toxin KEY POINTS
• Exam: Mental Status, HEENT, Skin, Neck, Heart, Lungs, Abdomen, Extremities, Neuro
• Do not force a child into a position. They will protect their airway by their body position. • The most important component of respiratory distress is airway control. • Croup typically affects children < 2 years of age. It is viral, possible fever, gradual onset, no drooling is • Epiglottitis typically affects children > 2 years of age. It is bacterial, with fever, rapid onset, possible stridor, patient wants to sit up to keep airway open, and drooling is common. Airway manipulation may worsen the condition. • DO NOT attempt an invasive airway procedures unless the patient is in respiratory arrest. • Stridor, gagging or choking in the breathing patient with respiratory distress may indicate upper airway • 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. • If the patient has signs of respiratory failure, begin to assist ventilations with BVM, even when they are • Epiglottis should be considered if the patient has drooling, stridor, and is unable to speak or cry. DO NOT attempt invasive procedures on the conscious patient who is suspected to have epiglottis. EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc PEDIATRIC
RESPIRATORY DISTRESS LOWER AIRWAY
UNIVERSAL PATIENT CARE PROTOCOL MED CONTROL
Respiratory Insufficiency Pediatric Airway Protocol Position to Patient Attempt if severe CONTACT MEDICAL CONTROL EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
RESPIRATORY DISTRESS - LOWER AIRWAY
SIGNS AND SYMPTOMS
• Time of onset • Possibility of foreign body • Increased heart rate • Fever or respiratory • Epiglottitis • History of trauma • Congenital heart disease • Medication or Toxin KEY POINTS
• Exam: Mental Status, HEENT, Skin, Neck, Heart, Lungs, Abdomen, Extremities, Neuro
• Do not force a child into a position. They will protect their airway by their body position. • The most important component of respiratory distress is airway control. • DO NOT attempt an invasive airway procedures unless the patient is in respiratory arrest. • For some patients in severe respiratory distress, wheezing may not be heard. Consider Albuterol for the known asthmatic in severe respiratory distress. • Stridor, gagging or choking in the breathing patient with respiratory distress may indicate upper airway • 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. • If the patient has signs of respiratory failure, begin to assist ventilations with BVM, even when they are • Contact Medical Direction for patients with a cardiac history. EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc ARRYTHMIAS / ACLS
PEDIATRIC
SINUS BRADYCARDIA
MED CONTROL
UNIVERSAL PATIENT Pediatric Airway Protocol Respiratory Insufficiency Heart Rate < 60 Monitor and Reassess 0.01 mg/kg IV/IO 1:10000 Solution Repeat every 3- 5 minutes 0.02 mg/kg IV/IO repeat every 3-5 minutes Consider External Pulseless Arrest Protocol EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc ARRYTHMIAS / ACLS
PEDIATRIC
SINUS BRADYCARDIA
SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS
• Foreign body exposure • Decreased heart rate • Delayed capillary refill or • Foreign body / secretions • Croup / Epigolotitis • Possible toxic or poison • Hypotension or arrest • Infection / Sepsis • Medication or Toxin • Medication (maternal or • Hypoglycemia • Short of Breath KEY POINTS
• Exam: Mental Status, HEENT, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro • Heart Rate < 100 (Neonates) • Heart Rate < 80 (Infants) • Heart Rate <60 (Children > 2 years) • Infant = < 1 year of age • Most maternal medications pass through breast milk to the infant. • The majority of pediatric arrests are due to airway problems. • Hypoglycemia, severe dehydration and narcotic effects may produce bradycardia. • Pediatric patients requiring external transcutaneous pacing require the use of pads appropriate for pediatric patients per the manufacturers guidelines. • Identify and treat possible causes for pediatric bradycardia: 1. Hypoxia 2. Hypothermia 3. Head ingestion/exposure • Refer to Broselow Pediatric Tape when unsure about patient weight, age and/or drug dosage. • The minimum dose of Atropine that should be administered to a pediatric patient is 0.1 mg/kg. • If the rhythm changes, follow the appropriate protocol. EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc ARRYTHMIAS / ACLS
PEDIATRIC
NARROW – COMPLEX TACHYCARDIA
UNIVERSAL PATIENT CARE PROTOCOL MED CONTROL
Continuous Cardiac Monitor Attempt to Identify Cause Heart Rate > 240 infant Heart Rate >180 child May attempt Vagal Maneuvers May go directly to Cardioversion 0.1 mg/kg IV, flush 0.2 mg/kg slow IV/IO 2 mg. IV or Atomizer 0.2 mg/kg IV, flush Repeat SYNCHRONIZED (1.0 – 2.0 J/kg) Repeat SYNCHRONIZED (1.0 – 2.0 J/kg) CONTACT MEDICAL CONTROL EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc ARRYTHMIAS / ACLS
PEDIATRIC
NARROW – COMPLEX TACHYCARDIA
SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS
• HR: Child > 180/bpm • Heart disease (Congenital) • Medications or Toxic Infant > 240/bpm • Hypo / Hyperthermia Ingestion (Aminophylline, • Pale or Cyanosis • Hypovolemia or Anemia Diet pills, Thyroid • Anxiety / Pain / Emotional Decongestants, Digoxin) • Fever / Infection / Sepsis • Congenital Heart Disease • Hypoglycemia • Syncope or Near Syncope • Medication / Toxin / Drugs KEY POINTS
• Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro
• Carefully evaluate the rhythm to distinguish Sinus Tachycardia, Supraventricular Tachycardia, and Ventricular Tachycardia • Separating the child from the caregiver may worsen the child's clinical condition. • Pediatric paddles should be used in children < 10 kg or Broselow Tape color Purple • Monitor for respiratory depression and hypotension associated if Diazepam is used. • Continuous pulse oximetry is required for all SVT Patients if available. • Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic • Possible causes of tachycardia; hypoxia, hypovolemia, fear, and pain. • A complete medical history must be obtained. • Do not delay cardioversion to gain vascular access for the unstable patient. • If you are unable to get the monitor to select low enough joules, then rapid transport to the nearest appropriate facility is indicated. • If the patient is stable, do not cardiovert. • Record 3-Lead EKG strips during adenosine administration. • Perform a 12-Lead EKG prior to and after Adenosine conversion or cardioversion of SVT. • If the rhythm changes, follow the appropriate protocol. EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc CARDIAC ARREST / ACLS
PEDIATRIC
ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY (PEA)
MED CONTROL
UNIVERSAL PATIENT CARE PROTOCOL See Pediatric Airway Protocol Apply Cardiac Monitor Identify Possible Confirm Asystole Confirm Asystole / PEA IV PROTOCOL / IO Procedure 0.01 mg/kg IV/IO 1:10000 Solution Repeat every 3- 5 minutes NORMAL SALINE IV, BOLUS Repeat as needed Blood Glucose Analysis CONTACT MEDICAL CONTROL EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc CARDIAC ARREST / ACLS
PEDIATRIC
ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY (PEA)
SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS
• Time of arrest • Ventricular Fibrillation
• Apneic or Agonal • Pulseless Ventricular
Tachycardia
• Possibility of foreign body CONSIDER TREATABLE CAUSES
• Cardiac Tamponade • Tension Pnuemothorax • Pulmonary Embolism • Tricyclic Overdose • Drug Overdose • Hypoglycemia • Hyperkalemia KEY POINTS
• Exam: Mental Status
• Always confirm asystole in more than one lead. • Cardiac arrest in children is primarily due to lack of an adequate airway, resulting in hypoxia • If the patient converts to another rhythm or has a return of circulation, refer to the appropriate protocol and treat accordingly. • When assessing for a pulse palpate the brachial or femoral arteries for infants and the carotid or femoral artery for children. • Continue BLS procedures throughout the resuscitation. • If the patient is intubated, be sure to routinely reassess tube placement. • If the patient has an IO, routinely reassess for patency. • When there is an established ETT, DO NOT delay administration of medications for IV/IO attempts. Administer the appropriate medications down the tube. EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc CARDIAC ARREST / ACLS
PEDIATRIC
VENTRICULAR FIBRILLATION (V-FIB)
PULSELESS VENTRICULAR TACHYCARDIA
UNIVERSAL PATIENT CARE PROTOCOL MED CONTROL
CPR X 5 cycles / 2 minutes Apply Cardiac Monitor / AED Pulseless V-Tach Defibrillate 2 J/kg See Pediatric Airway Protocol CPR X 5 cycles / 2 minutes 0.01 mg/kg IV/IO 1:10000 Solution Repeat every 3- 5 minutes CPR X 5 cycles / 2 minutes Defibrillate 4 J/kg Give Antiarrhythmic during CPR 25 – 50 mg/kg IV CPR X 5 cycles / 2 minutes Defibrillate 4 J/kg CONTACT MEDICAL CONTROL EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc PEDIATRIC
VENTRICULAR FIBRILLATION (V-FIB)
PULSELESS VENTRICULAR TACHYCARDIA
SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS
• Time of arrest • Unresponsive • Possibility of foreign body • Congenital heart disease • Toxin or medication • Hypoglycemia KEY POINTS
• Exam: Mental Status
• Monophasic and Biphasic waveform defibrillators should use the same energy levels noted. • In order to be successful in pediatric arrests, a cause must be identified and corrected. • Airway is the most important intervention. This should be accomplished immediately. Patient survival is often dependent on airway management success. • If the patient converts to another rhythm, follow the appropriate protocol and treat accordingly. • If the patient converts back to ventricular fibrillation or pulseless ventricular tachycardia, defibrillate at the previously used setting. • Defibrillation is the definitive therapy for ventricular fibrillation and pulseless ventricular tachycardia. • Defibrillate 30-60 seconds after each medication administration. • The proper administration sequence is shock, drug, shock, and drug. EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
ALTERED LEVEL OF CONSCIOUSNESS
MED CONTROL
UNIVERSAL PATIENT CARE PROTOCOL See Pediatric Airway Protocol Spinal Immobilization Protocol Blood Glucose Analysis Glucose < 60 (Signs of Dehydration) Check for Hypotension, (If Alert with no IV Access Tachcardia, Poor Cap Refill and no airway compromise) NORMAL SALINE IV, (If no IV Access) Maximum 1 mg
CONTACT MEDICAL CONTROL Monitor and Reassess EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
ALTERED LEVEL OF CONSCIOUSNESS
SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS
• Known diabetic, medic • Unresponsive • Drugs, drug paraphernalia • Inadequate Respirations seizure, infection) • Report of illicit drug use or toxic ingestion • Shock (septic, metabolic, • Decreased mental status • Change in baseline mental • Diabetes (hyper / • History of trauma • Hypoglycemia diaphoretic skin) • Acidosis / Alkalosis • Environmental KEY POINTS
• Protect the patient airway and support ABCs. • Document the patient's initial Glasgow Coma Score. • Naloxone (Narcan) administration may cause acute opiate withdraw, which includes vomiting, agitation, or combative behavior. Be prepared for the possibility of combative behavior to ensure crew safety. • Naloxone (Narcan) may wear off in as little as 20 minutes causing the patient to become more sedate and possibly hypoventilate. All patients receiving Naloxone (Narcan) MUST be transported. ONLY A FEW CAUSES CAN BE TREATED IN THE FIELD. CARE SHOULD FOCUS ON
MAINTAINING AIRWAY AND RAPID TRANSPORT
EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
DIABETIC EMERGENCIES
MED CONTROL
UNIVERSAL PATIENT CARE PROTOCOL Blood Sugar Analysis Check for Hypotension, Tachcardia, Poor Cap Refill (If Alert with no IV Access and no airway compromise) NORMAL SALINE IV, (If no IV Access) Maximum 1 mg per dose Recheck Blood Glucose CONTACT MEDICAL CONTROL EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
DIABETIC EMERGENCIES
SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS
• Known diabetic, medic • Irritability • Pre-existing SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS
• Known diabetic, medic Consciousness / Coma • Nausea / Vomiting • Frequent Thirst and • Hyperventilation • Deep / Rapid Respirations KEY POINTS
• Diabetic Ketoacidosis(DKA) is a complication of diabetes mellitus. It can occur when insulin levels become inadequate to meet the metabolic demands of the body for a prolonged amount of time (onset can be within 12-24 hours). Without enough insulin the blood glucose increases and cellular glucose depletes. The body removes excess blood glucose by dumping it into the urine. Pediatric patients in DKA should be treated as hyperglycemic under the Pediatric Diabetic Emergency Protocol. • Patients can have Hyperglycemia without having DKA. • Always suspect Hypoglycemia in patients with an altered mental status. • If a blood glucose analysis is not available, a patient with altered mental status and signs and symptoms consistent with hypoglycemia should receive Dextrose or Glucagon. Dextrose is used to elevate BGL but it will not maintain it. The patient will need to follow up with a meal, if not transported to a hospital. • If the patient is alert and has the ability to swallow; consider administering oral glucose, have patient drink orange juice with sugar or a sugar – containing beverage, or have the patient eat a candy bar or meal. • Check the patient's BGL after the administration of Dextrose, Glucagon, or after any attempt to raise the • If IV access is successful after Glucagon IM and the patient is still symptomatic, Dextrose 25% 2 ml/kg IV/IO can be administered. EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
HEAT ILLNESS
MED CONTROL
UNIVERSAL PATIENT CARE PROTOCOL Document Patient Temperature Remove Patient from Heat Source Remove Patient Clothing Apply Room Temperature Water to Patient Skin and Increase Air Flow Around Patient Fever – 20 cc kg, NS Bolus Heat Exhaustion: IV NS Wide Open Heat Stroke: IV NS TKO Monitor and Reassess Appropriate Protocol Based on Patient CONTACT MEDICAL CONTROL EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
HEAT ILLNESS
SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS
• Altered mental status or • Exposure to increased temperatures and humidity • Hot, dry or sweaty skin • Hypotension or shock • Hyperthyroidism history/medications • Delirium tremens (DT's) • Time and length of • Poor PO intake • CNS lesions or tumors • Fatigue and/or muscle Heat Exhaustion: Dehydration
Heat Stroke: Cerebral Edema
• Muscular/abdominal • Skin hot, dry, febrile • BP normal or orthostatic KEY POINTS
• Exam: Mental Status, Skin, HEENT, Heart, Lungs, Neuro
• Extremes of age are more prone to heat emergencies (i.e. young and old). • Predisposed by use of: tricyclic antidepressants, phenothiazines, anticholineergic medications, and • Cocaine, Amphetamines, and Salicylates may elevate body temperatures. • Sweating generally disappears as body temperature rises above 104EF (40EC). • Intensive shivering may occur as patient is cooled. • Heat Cramps consists of benign muscle cramping 2E to dehydration and is not associated with an elevated temperature. • Heat Exhaustion consists of dehydration, salt depletion, dizziness, fever, mental status changes, headache, cramping, nausea and vomiting. Vital signs usually consist of tachycardia, hypotension, and an elevated temperature. • Heat Stroke consists of dehydration, tachycardia, hypotension, temperature >104EF (40EC), and altered • Patients at risk for heat emergencies include neonates, infants, geriatric patients, and patients with mental illness. Other contributory factors may include heart medications, diuretics, cold medications and/or psychiatric medications. • Heat exposure can occur either due to increased environmental temperatures or prolonged exercise or a combination of both. Environments with temperature >90EF and humidity >60% present the most risk. • Heat stroke occurs when the cooling mechanism of the body (sweating) ceases due to temperature overload and/or electrolyte imbalances. Be alert for cardiac dysrhythmias for the patient with heat stroke. EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL EMERGENCIES
PEDIATRIC
HYPOTHERMIA / FROSTBITE
MEDCONTROL
UNIVERSAL PATIENT CARE PROTOCOL Remove wet clothing Evidence or decreased core temperature? Handle patient gently Apply hot packs indirectly to skin and/or blankets and turn up vehicle heat Appropriate Protocol Based on patient Signs and Symptoms CONTACT MEDICAL CONTROL EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS
• Environmental • Exposure to environment even • Mental status changes • Hypoglycemia in normal temperatures • Extremity pain or • Exposure to extreme cold • Drug use: Alcohol, barbituates • Spinal cord injury • Infections / Sepsis • Hypotension or shock • Length of exposure / Wetness KEY POINTS
• Exam: Mental Status, Heart, Lungs, Abdomen, Extremities, Neuro • Hypothermic/drowning/near drowning patients that appear cold and dead are NOT dead until they are warm and dead, or have other signs of obvious death (putrification, traumatic injury unsustainable to life). • Defined as core temperature < 35° C (95° F). • Extremes of age are more susceptible (i.e. young and old). • Patients with low core temperatures will not respond to ALS drug interventions. Maintain warming procedure and supportive care. Warming procedures includes removing wet clothing, limiting exposure, and covering the patient with warm blankets if available. • Do not allow patients with frozen extremities to ambulate. • Superficial frostbite can be treated by using the patient's own body heat. • Do not attempt to rewarm deep frostbite unless there is an extreme delay in transport, and there is a no risk that the affected body part will be refrozen. Contact Medical Command prior to rewarming a deep frostbite injury. • With temperature less than 31° C (88° F) ventricular fibrillation is common cause of death. Handling patients gently may prevent this. (rarely responds to defibrillation). • If the temperature is unable to be measured, treat the patient based on the suspected temperature. • Hypothermia may produce severe bradycardia. • Shivering stops below 32° C (90° F). • Hot packs can be activated and placed in the armpit and groin area if available. • Care should be taken not to place the packs directly against the patient's skin. • Consider withholding CPR if patient has organized rhythm. Discuss with medical control. • All hypothermic patients should have resuscitation performed until care is transferred, or if there are other signs of obvious death (putrification, traumatic injury unsustainable to life). • Patients with low core temperatures will not respond to ALS drug interventions. Maintain warming procedure and supportive care. Warming procedures includes removing wet clothing, limiting exposure, and covering the patient with warm blankets if available. • The most common mechanism of death in hypothermia is ventricular fibrillation. If the hypothermia victim is in ventricular fibrillation, CPR should be initiated. If V fib is not present, then all treatment and transport decisions should be tempered by the fact that V fib can be caused by rough handling, noxious stimuli or even minor mechanical disturbances, this means that respiratory support with 100% oxygen should be done gently, including intubation, avoiding hyperventilation. • The heart is most likely to fibrillate between 85-88 degrees F. (29-31 degrees C.) Defibrillate VF / VT at 360 J with affective CPR intervals. May give a total of 3 shocks. • Do not allow patients with frozen extremities to ambulate. • Superficial frostbite can be treated by using the patient's own body heat. • Do not attempt to rewarm deep frostbite unless there is an extreme delay in transport, and there is a no risk that the affected body part will be refrozen. Contact Medical Command prior to rewarming a deep frostbite injury. EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
NEONATAL RESUSCITATION
UNIVERSAL PATIENT CARE MED CONTROL
Meconium in Amniotic Fluid? Dry Infant and Keep Warm. Bulb syringe suction mouth and Stimulate infant and note Respirations Present? Reassess Heart Rate and BVM 30 seconds at 40 – 60 Breaths per minute with 100% See Pediatric Airway Protocol Monitor and Reassess See Pediatric Airway Appropriate Dysrhythmia NORMAL SALINE BOLUS EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
NEONATAL RESUSCITATION
SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS
• Due date and gestational • Multiple gestation (twins mottling (normal) • Maternal medication effect • Hypoglycemia • Congenital heart disease substance abuse smoking KEY POINTS
• Exam: Mental Status, Skin, HEENT, Neck, Chest, Heart, Abdomen, Extremities, Neuro
• Maternal sedation or narcotics will sedate infant (Naloxone effective). • Consider hypoglycemia in infant. • Document 1 and 5 minute APGAR scores (see Appendix) • If the patient is in distress, consider causes such as; hypovolemia. Administer a 10 ml/kg fluid bolus of • If the BGL less than 40 mg/dl go to the Pediatric Diabetic Protocol. • Hypothermia is a common complication of home and field deliveries. Keep the baby warm and dry. • If there is a history of recent maternal narcotic use, consider Naloxone (Narcan) 0.1 mg/kg every 2-5 minutes until patient responds. • Meconium may need to be suctioned several times to clear airway. 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 his suctioning is done, the infant will have to be
reintubated with a new tube. This lower airway suction is only done when the infant is NOT vigorous.
• If drying and suction has not provided enough stimulation, try rubbing the infant's back or flicking their feet. If the infant still has poor respiratory effort, poor tone, or central cyanosis, consider them to be distressed, Most distressed infants will respond quickly to BVM. • Use caution not to allow newborns to slip from grasp. APGAR SCORING
HEART RATE
(Response to
Stimulation)
MUSCLE TONE
Flexion of Extremities Active Motion RESPIRATORY
Slow and Regular EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOL
PEDIATRIC
ESOPHAGEAL FOREIGN BODY OBSTRUCTION
UNIVERSAL PATIENT CARE PROTOCOL MEDCONTROL
Airway Obstruction Esophageal Obstruction Difficulty Breathing Unable to Swallow Difficulty/Unable to Talk To Airway Protocol Patient is in Distress Evaluate Level of HIGH (Neck Down) Protected Airway <16 years give ½ mg well mixed Glucagon IV PROBLEM RESOLVED?
CONTACT MEDICAL CONTROL To Consider 0.4 mg S/L NTG EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
ESOPHAGEAL FOREIGN BODY OBSTRUCTION
SIGNS AND SYMPTOMS
• Onset during eating or • Airway obstruction – swallowing pills, etc. • Unable to swallow coughing, unable to speak, difficulty breathing • Able to breathe but may KEY POINTS
• Rule out airway obstruction first. • Patient may be helpful in identifying location of bolus obstruction as they can feel it, point to it. • If bolus is located in neck area, glucagon will not work, just monitor and transport. • If bolus located from neck down, proceed with glucagon treatment. • Treat patients <16 years with ½ mg dose of glucagon. • Discuss use of NTG with Medical Control. EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
MED CONTROL
UNIVERSAL PATIENT CARE PROTOCOL Position on side to prevent aspiration Cooling Measures Blood Glucose Analysis e of Shock or Trauma? (If Alert with no IV Access) no airway compromise (If no IV Access) (See Chart in Protocol) (If no IV Access) 0.2 mg/kg slow IV/IO 0.02 mg/kg slow IV OR Via Atomizer Nasally CONTACT MEDICAL CONTROL EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
SIGNS AND SYMPTOMS
• Prior history of seizures • Altered mental status • Hot, dry skin or elevated body temperature • Medication or Toxin • History of recent head • Hypoglycemia • Metabolic abnormality / Categories of Seizures
Unconscious
Partial,
Localized
Conscious
Generalized
Generalized
Generalized
KEY POINTS
• Exam: Mental Status, HEENT, Heart, Lungs, Extremities, Neuro
• Status Epilepticus is defined as two or more successive seizures without a period of consciousness or
recovery. This is a true emergency requiring rapid airway control, treatment, and transport. • Grand mal seizures (generalized) are associated with loss of consciousness, incontinence, and tongue
• Focal seizures (petit mal) effect only a part of the body and are not usually associated with a loss of
• Jacksonian seizures are seizures, which start as a focal seizure and become generalized.
• Be prepared to assist ventilations especially if a benzodiazipine is used. • If evidence or suspicion of trauma, spine should be immobilized. • If febrile, remove clothing and sponge with room temperature water. • In an infant, a seizure may be the only evidence of a closed head injury.
EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
SHOCK (NON – TRAUMATIC)
MED CONTROL
UNIVERSAL PATIENT CARE PROTOCOL Pediatric Trauma Evidence or history of trauma Hypovolemic / Septic/ Neurogenic PERSONAL EPI PEN Allergic Reaction Monitor and Reassess Blood Glucose Analysis Glucose < 60 (If Alert with no IV Access) If no airway compromise Impending Full Arrest & Hypotensive (If no IV Access) 0.01 mg/kg IV/IO 1:10000 Solution CONTACT MEDICAL CONTROL EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
SHOCK (NON – TRAUMATIC)
SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS
• Restlessness, • Increased HR, rapid pulse Pale, cool, clammy skin • Delayed capillary refill • Congenital heart disease • Medication or Toxin
ALLERGIC REACTION / ANAPHYLAXIS
SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS
• Onset and location • Warm Burning Feeling • Urticaria (rash only) • Insect sting or bite • Food allergy / exposure • Medication allergy / • Shock (vascular effect) • New clothing, soap, • Aspiration / Airway • Past history of reactions • Altered LOC / Coma • Pulmonary Edema • Facial / Airway Edema • Urticaria / Hives KEY POINTS
• Exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Extremities, Back, Neuro
• Consider all possible causes of shock and treat per appropriate protocol. • Decreasing heart rate is a sign of impending collapse. • Most maternal medications pass through breast milk to the infant. Examples: Narcotics, Benzodiazepines. • Be sure to use the appropriate sized BP cuff. • Findings in the primary assessment should alert you that the patient is in shock. Pay particular attention to the patient's mental status, tachycardia, skin color, and capillary refill. • 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 and malnutrition. • Do not use only the patient's blood pressure in evaluating shock; also look for lower body temperature, poor capillary refill, decreased LOC, increased heart rate and/or poor skin color or turgor • Routinely reassess the patient and provide supportive care. • Use caution when using Epinephrine for patients with a cardiac history. • Use caution when using Epinephrine for patients with a heart rate greater than 120 bpm. EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
TOXIC INGESTION / EXPOSURE / OVERDOSE
MED CONTROL
UNIVERSAL PATIENT CARE PROTOCOL See Pediatric Airway Protocol Blood Glucose Analysis Tricyclic Ingestion? SODIUM BICARBONATE Diluted in 1:1 NS
Respiratory Depression
Organophosphates 0.02 mg/kg IV/IO repeat every 3-5 minutes CONTACT MEDICAL CONTROL EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc MEDICAL PROTOCOLS
PEDIATRIC
TOXIC INGESTION / EXPOSURE / OVERDOSE
SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS
• Ingestion or suspected • Mental status changes ingestion of a potentially • Hypo / Hypertension • Decreased respiratory rate • Acetaminophen • Tachycardia, • Time of ingestion • Anticholinergic accidental, criminal) • Available medications in • Insecticides (organophosphates) Organophosphates
COMMON TRICYCLICS
Brand
Tofranil Imipramine Norpramin Vivactil Protriptyline Ludimomil KEY POINTS
• Routinely assess and document the patient's cardiopulmonary status. • Determine what the patient was exposed to, how much, and when. If it is safe to do so, bring a sample with you to the hospital. • Be sure to find out what interventions were administered prior to EMS arrival and document. • If the patient ingested bleach, monitor the airway and remove contaminated clothing. • Medical Direction may order antidotes for specific ingestions. • DO NOT use syrup of ipecac.
• Reference: Greater Cleveland Poison Control Center 1-800-222-1222. EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 10 – 2006 0406-074.doc TRAUMA PROTOCOLS
PEDIATRIC
HEAD TRAUMA
UNIVERSAL PATIENT CARE MED CONTROL
Isolated Head Trauma? Spinal Immobilization Protocol Does patient respond to verbal? No None or Extension Response to Pain? Localizes, Flexes, or Withdraws Pupils Equal and Reactive? Pediatric Seizure Blood Glucose Analysis (If no IV Access) Monitor and Reassess CONTACT MEDICAL CONTROL EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 6 – 2006 0406-074.doc TRAUMA PROTOCOLS
PEDIATRIC
HEAD TRAUMA
SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS
• Time of injury • Pain, swelling, bleeding • Mechanism (blunt vs. • Altered mental status • Brain injury (Concussion, Contusion, Hemorrhage or • Loss of consciousness • Respiratory distress / • Subarachnoid • Evidence for multi-trauma mechanism of injury KEY POINTS
• Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Back, Neuro
• If GCS < 12 consider air / rapid transport and if GCS < 8 intubation should be anticipated. • Hyperventilate the patient only if evidence of herniation (blown pupil, decorticate / decerebrate posturing, • If hyperventilation is needed (35/minute for infants <1 year and 25/minute for children >1 year) • Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing's Response). • Hypotension usually indicates injury or shock unrelated to the head injury. • The most important item to monitor and document is a change in the level of consciousness. • Concussions are periods of confusion or LOC associated with trauma, which may have resolved by the time EMS arrives. A physician ASAP should evaluate any prolonged confusion or mental status abnormality, which does not return to normal within 15 minutes or any documented loss of consciousness. EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 6 – 2006 0406-074.doc TRAUMA PROTOCOLS
PEDIATRIC
MULTIPLE TRAUMA
MED CONTROL
UNIVERSAL PATIENT CARE PROTOCOL Rapid trauma assessment See Pediatric Airway Protocol Spinal Immobilization Protocol If Indicated Rapid Transport to Determine Load and Go Situation Consider rapid / Most Appropriate Vital Signs / Perfusion? NORMAL SALINE IV Ongoing Assessment Appropriate Protocol Repeat as needed Reassess Airway Protocol Check tube placement / hyperventilate CONTACT MEDICAL CONTROL EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 6 – 2006 0406-074.doc TRAUMA PROTOCOLS
PEDIATRIC
MULTIPLE TRAUMA
SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS
Time and mechanism of Life Threatening:
Deformity, lesions, bleeding Damage to structure or Location in structure or Hypotension or shock Others injured or dead • Intra-abdominal Speed and details of MVC Pelvis / Femur fracture Restraints / Protective Spine fracture / Cord injury Head injury (see Head Extremity fracture / HEENT (Airway obstruction) Past medical history
A Pediatric Trauma Victim is a person < 16 years of age exhibiting one or more of the following
physiologic or anatomic conditions:

Physiologic conditions
Anatomic conditions
Glasgow Coma Scale < 13; Penetrating trauma to the head, neck, or torso; Loss of consciousness > 5 minutes; Significant, penetrating trauma to extremities proximal to the Deterioration in level of consciousness at the scene or knee or elbow with evidence of neurovascular compromise; during transport; Injuries to the head, neck, or torso where the following physical Failure to localize to pain; findings are present; Evidence of poor perfusion, or evidence of respiratory distress or failure. Abdominal tenderness, distention, or seatbelt sign; Injuries to the extremities where the following physical findings are present: Amputations proximal to the wrist or ankle; Fractures of two or more proximal long bones; Evidence of neurovascular compromise. Signs or symptoms of spinal cord injury; 2nd or 3rd Degree burns > 10% total BSA, or other significant burns involving the face, feet, hands, genitalia, or airway. KEY POINTS
Exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Extremities, Back, Neuro Mechanism is the most reliable indicator of serious injury. Examine all restraints / protective equipment for damage. In prolonged extrications or serious trauma consider air transportation for transport times and the ability to give blood. Do not overlook the possibility for child abuse. A trauma victim is considered to be a pediatric patient if they are 15 years old or younger. Major Trauma patients are to be transported to the closest Pediatric Trauma Center. Contact the receiving hospital for all major trauma or critical patients. The Proper size equipment is very important to resuscitation care. Refer to length based drug treatment guide (e.g. BROSELOW PEDIATRIC EMERGENCY TAPE OR SIMILAR GUIDE) when unsure about patient weight, age and/or drug dosage and when choosing equipment size. Cover open wounds, burns, eviscerations. With the exception of airway control, initiate ALS enroute when transporting major trauma patients. If unable to access patient airway and ventilate, then transport to the closest facility for airway stabilization. The on scene time for major trauma patients should not exceed 10 minutes without documented, acceptable reason for the delay. When initiating an IV and drawing blood, collect a red top blood tube to assist the receiving hospital with determining the patient's blood type. All major trauma patients should receive oxygen administration, an IV(s), and cardiac monitoring. Provide a documented reason if an intervention could not be performed. Pediatric Trauma Centers include MetroHealth Medical Center and Rainbow, Babies, and Children's Hospital. EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 6 – 2006 0406-074.doc PEDIATRIC ASSESSMENT CHARTS
PEDIATRIC
GLASCOW COMA SCALE
EYE OPENING
Spontaneous Spontaneous VERBAL RESPONSE
Irritable cry, inconsolable MOTOR RESPONSE
Normal movements Withdraws to touch Withdraws to pain Withdraws to pain Extension Extension * NOTE: MOTOR RESPONSE IS MOST INDICATIVE OF LEVEL OF INJURY
PEDIATRIC ASSESSMENT CHARTS
PEDIATRIC
NORMAL VITAL SIGNS
HEART RATE
SYSTOLIC BLOOD PRESSURE
Newborn 126-160 30-60 Blood pressure is a late and unreliable indicator of shock in children EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 6 – 2006 0406-074.doc THIS PAGE INTENTIONALLY LEFT BLANK EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 6 – 2006 0406-074.doc PEDIATRIC
PHARMACOLOGY REVIEW
MEDICATION
• Acetaminophen (Tylenol)
Useful for musculoskeletal pain and fever control • Activated charcoal
Do not give to child with altered level of consciousness • Adenosine
Indicated for SVT. First dose 6mg, second dose 6mg. Max dose 12mg • Albuterol
Indicated for wheezing as per protocol • Amiodarone
Over 20-60 minutes, maximum 15 mg/kg per day. For shock-refractory pulseless VT/VF: 5 mg/kg rapid IV/IO • Atropine
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 • Dextrose 25%
Try to obtain bedside glucose level before administering ----administer if blood glucose < 60; dilute 50% 1:1 with sterile water; consult Medical Control if infant < 1 month as solution may need to be further diluted. • Diazepam (Valium
Indicated for uncontrolled seizure mg/kg activity; anticipate respiratory depression. Max. dose 10 mg. • Diazepam (Valium)
Indicated for uncontrolled seizure activity; anticipate respiratory depression. Max. dose 10 mg. • Diphenhydramine
Useful in allergic reactions and anaphylaxis. Max dose 50 mg (Benadryl)

• Epinephrine
Commonly used in cardiac arrest rhythms as first dose. (1:10,000)
Increase second dose 10 X (may use 1:1,000 solution). • Epinephrine
Commonly used in cardiac arrest rhythms. (1:1,000)
Use for all ET doses, and second and subsequent IV/IO doses. *The ET route has limited absorption, use IV/IO route whenever possible Used for anaphylaxis. Max dose is 0.3ml • Lidocaine
Can repeat once. If successful start continuous infusion at 20-50 mg/kg/min. Also useful before intubating for cerebral protection and decreases airway reactivity. • Morphine
Useful for moderate pain, may cause respiratory depression. Hypotension and reflex bradycardia may develop from histamine release • Midazolam (Versed)
Indicated for uncontrolled seizure activity; anticipate respiratory depression Useful to facilitate advanced airway management in combative patients • Naloxone (Narcan)
Useful for unknown unconscious, known narcotic overdoses • Procainamide
Over 30-60 minutes. Alternative treatment for recurrent or refractory VT, SVT. EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 6 – 2006 0406-074.doc

EUCLID, HILLCREST, HURON, AND SOUTH POINTE HOSPITALS EMS PROTOCOLSAND PROCEDURES - PEDIATRIC PROTOCOLS REVISED 6 – 2006 0406-074.doc

Source: http://www.cchseast.org/Portals/23/ems/EMSProtocols/6_0%20Pediatric.pdf