Post on 11-Jan-2016
Taking Control of the Pediatric EMS CallTaking Control of the Pediatric EMS Call
Never let them Never let them see you sweatsee you sweat
Lou Romig MD, FAAP, FACEP
It’s hardly ever good when the rescuer’s pulse or respiratory rate
is greater than that of their pediatric patient.
Romig’s Rule of Vital Sign ComparisonsRomig’s Rule of Vital Sign Comparisons
Romig’s Rules
GoalsGoals
Tell you the secrets of how many good “pedi people” control tough kid calls (even though
they might not realize they’re doing it).
To turn “How do they do that?” into
“I can do that!”using the PREP approach
The 3 P’s of ControlThe 3 P’s of Control
Preparation
Practice
Perception
The 3 P’s of ControlThe 3 P’s of Control
Preparation
Practice
Perception
PP
RR
EE
PP
Physiology
Responses
Equipment
Protocols
Using PREP, Using PREP, half of your half of your scene control scene control can be done can be done before you before you even arrive. even arrive.
How’d you like to be caught unprepared for this?
PREP before arrival: PREP before arrival: PPhysiologyhysiology
Given the available dispatch information on a pediatric
call, what should you anticipate?
PREP before arrival: PREP before arrival: PPhysiologyhysiology
What is the anticipated age of the child? How does their age influence:
Physiology
Physiologic weaknesses and strengths
Yes, EMTs can do this too!
PREP before arrival: PREP before arrival: PPhysiologyhysiologyWhat is the reported mechanism of injury (MOI) or chief complaint?
What are the most likely injuries based on the age/size and MOI?
What are the most common illnesses that present with this complaint?
What interventions are the child most likely to need on scene/in transit?
PREP before arrival: PREP before arrival: Rescuer Rescuer RResponsesesponses
Given the age and MOI/chief complaint:
What kind of emotional reactions can you expect within yourself before, during and after the call?
How about in your crewmates?
PREP before arrival: PREP before arrival: Rescuer Rescuer RResponsesesponses
Identify crew strengths and weaknesses
Who among the crew is most confident with children?
Should usual task assignments be modified for this call?
High stress/critical calls are not the time to practice weak skills
PREP before arrival: PREP before arrival: Rescuer Rescuer RResponsesesponses
The Huddle:
Reinforce need for personal control if call is likely to be emotionally-charged.
Reinforce ability to relax if call is not emergent.
Reinforce the need to be able to change gears if the unexpected occurs.
PREP before arrival:PREP before arrival:Non-rescuer Non-rescuer RResponsesesponses
The Patient
Assuming normal brain development for age, how is the patient likely to react to you and the situation?
“I would worry if …”
PREP before arrival:PREP before arrival:Non-rescuer Non-rescuer RResponsesesponses
Family/caregivers
Child with chronic illness?
Set-up for guilt reactions?
Set-up for aggression?
What may be the expectations of the caregivers?
PREP before arrival:PREP before arrival:Non-rescuer Non-rescuer RResponsesesponses
Designate a crew member with good communications skills to be the liaison with
the family/caregivers.
PREP before arrival:PREP before arrival:Non-rescuer Non-rescuer RResponsesesponses
Bystanders
Will the emotional environment of the scene be stable and safe?
Are the bystanders likely to become a distraction?
What may be the expectations of the bystanders? How might they react if you don’t do what they expect?
PREP before arrival: PREP before arrival: EEquipmentquipment
Based upon your analysis of the expected physiology:
What kinds of gear are you most likely to need?
What sizes?
Where is the equipment?
What goes with you to the patient’s side?
PREP before arrival: PREP before arrival: EEquipmentquipment
Use your memory aids!!!!
PREP before arrival: PREP before arrival: PProtocolsrotocols
Based upon your analysis of the expected physiology:
What protocols/drugs are you most likely to use?
Where are your drugs? Do they need special preparation?
Based on your protocols, what are your alternatives for patient disposition? Might there be consent issues?
PREPPREPare for the worst.are for the worst.Hope for the best.Hope for the best.
Do practice runs as drills!
PREPPREParation: After Arrival aration: After Arrival
Your first clue upon arrival:Your first clue upon arrival:The WaverThe Waver
PREP after arrivalPREP after arrival
Scene size-up:
Safety
Mechanism of injury or illness
“OBTWs” (Oh-by-the-ways)Completely different complaintAdditional patientsEmotional atmosphereNeed to change the game plan?
PREP after arrival: PREP after arrival: PPhysiologyhysiology
Should guide most actions during the rest of the call
Rapidly determine:
How sick is the child?
How quickly do you need to intervene?
PPhysiology determines hysiology determines RResponseesponse
Intense goal-oriented rapid action focusing on the patient, with tight
emotional control by crew
OR
More relaxed family-centered approach with increased interaction between crew,
patient and others on scene
PPhysiology determines hysiology determines EEquipment and quipment and PProtocolsrotocols
What equipment is needed now? What might be needed later?
What kinds of treatment are indicated? Where should treatment take place?
Balance speed and efficiency
Determine patient disposition. Initiate additional notifications and responses if needed.
How sick? How quick?
The Pediatric Assessment Triangle The Pediatric Assessment Triangle (PAT)(PAT)
From the AAP’s Pediatric Education for Prehospital Professionals (PEPP) course. www.PEPPsite.com
The PATThe PAT
Can be considered a “patient size-up”
Is a pre-primary survey
Can be done in seconds
Often best done before getting close to the pediatric patient
Results in assignment of the patient into a “physiologic cubbyhole”
Can be done whenever you’re in the weeds!
The PATThe PAT
General Appearance
Work of Breathing
Circulation to the Skin
General AppearanceGeneral Appearance
Assesses higher brain function by looking mostly at interaction with the environment
Higher brain function depends on good oxygenation, ventilation and perfusion to the brain
Don’t be fooled by chronic features or dramatic physical findings that don’t affect function
General AppearanceGeneral Appearance
T Tone
I Interactiveness
C Consolability
L Look/gaze
S Speech/cry
Good general appearanceGood general appearance
Normal to well-compensated Normal to well-compensated physiologyphysiology
“Not sick”“Not sick”“Not quick”“Not quick”
Poor general appearancePoor general appearance
Inadequate physiologic Inadequate physiologic compensationcompensation
““Sick!Sick!””““Quick!Quick!””
Work of BreathingWork of Breathing
More informative in children than absolute respiratory rate
Reflects resistance in small air passages, dependence on diaphragm and weakness of chest wall muscles
Increased WOB (including tachypnea) is a compensatory mechanism
Decreased WOB (poor effort/slow breathing) means decompensation
Circulation to the SkinCirculation to the Skin
Decreased circulation to the skin is an early sign of compensation for a circulatory problem in kids (not always true in adults)
Cap refill is a good measure in kids, especially when done in serial fashion in a normothermic environment
Putting the PAT togetherPutting the PAT together
A B C PhysiologicCubbyhole
Sick?
Good Respiratory Distress
Poor Respiratory Failure
RespiratoryRespiratory
A B C PhysiologicCubbyhole
Sick?
GoodNonspecific Peripheral
Vasoconstriction
Poor Shock
CirculatoryCirculatory
A B C PhysiologicCubbyhole
Sick?
Poor Good GoodCNS
Dysfunction
Central Nervous SystemCentral Nervous System
Seizure/Postictal Head injuryIntoxication/Drug effect Meningitis/EncephalitisMetabolic Chronic disability
A B C PhysiologicCubbyhole
Sick?
Cardiopulmonary Failure!
The Last ChanceThe Last Chance
PREP after Arrival: PREP after Arrival: PPhysiologyhysiology
PAT = How sick? How quick?
Primary Survey (Initial Assessment) = More detailed assessment of physiologic disruption
Secondary Survey (Focused Assessment = More detailed assessment of anatomic disruption
PREP after Arrival: PREP after Arrival: RResponsesesponses
PAT = Quick/patient focused or Relaxed/Family focused
Use the PAT to show the family that the patient is doing well
PREP after Arrival: PREP after Arrival: EEquipment/quipment/PProtocolsrotocols
Major or “minor” but “sick” trauma patients
Minimal stabilization on sceneRapid disposition decisions
PREP after Arrival: PREP after Arrival: EEquipment/quipment/PProtocolsrotocols
Medical patients who are “not sick”
Initial assessment and management on scene (unless unsafe)
No rush to separate child and family
PREP after Arrival: PREP after Arrival: EEquipment/quipment/PProtocolsrotocols
“Sick” medical patients
Consider what is the most favorable environment in which to provide
initial assessment and intervention.Rapid disposition decision.
Emergency Departments rarely have anything
more to offer a sick child in the first minutes than
a well-equipped and well-trained ALS EMS
crew!And sometimes they have less…
Applying Applying the PREP the PREP ApproachApproach
PREP
A mislabeled prescription has caused a A mislabeled prescription has caused a mother to give her 4 month old daughter mother to give her 4 month old daughter
five times the normal dose of a cold five times the normal dose of a cold medicine – three times! The mother tells medicine – three times! The mother tells the dispatcher that the baby’s heart feels the dispatcher that the baby’s heart feels
like it’s racing and the child is acting like it’s racing and the child is acting “nervous”.“nervous”.
Before ArrivalBefore Arrival
Physiology:
Cold meds usually stimulate the sympathetic system
Kids tolerate sympathetic stimulation well
Seizures can occur with marked toxicity
Has mom called Poison Control yet?
Before ArrivalBefore Arrival
Responses:
Mom’s liable to be frantic and feeling very guilty.
Crew members who are not comfortable with infants will not be very comfortable with this patient.
Before ArrivalBefore Arrival
Equipment:
Be ready to monitor basic vital signs.
Take in suction. Mom may have been instructed to make child vomit.
Seizures are a possibility so anticipate them.
Before ArrivalBefore Arrival
Protocols
Contact Poison Control?
Administer charcoal?
Seizure management
Upon ArrivalUpon Arrival
Mom is anxious but controlled
Rx was mislabeled. Mom gave three doses of an antihistamine/decongestant over 18 hrs, each one 5 times the usual dose.
Child has been “hyperactive” and unable to sleep.
This is what you see …This is what you see …
PREP on scenePREP on scenePhysiology
Good general appearance
No increased WOB
Good skin circulation
PAT says NOT SICK
HR 170’s, RR 30’s, BP 114/73
Exam normal except the baby is a little cranky on and off and moves around a lot
PREP on scenePREP on scene
Responses
Crew can relax and take their time
Try to reassure mom
Keep child with mom as much as possible.
PREP on scenePREP on scene
Equipment
Basic monitoring during transport
Remain prepared for seizure
PREP on scenePREP on sceneProtocols
Consider calling Poison Control on scene
Consider charcoal
IV probably not needed
Calculate anticonvulsant dose in case it’s needed. Be prepared to give rectally
Transport to pediatric-capable facility with mother (ALS)
You respond to a 6 month old with vomiting and diarrhea for a week. The child doesn’t want to drink.
Mom states “He looks at me but he doesn’t seem to see me!”
You respond to a 6 month old with vomiting and diarrhea for a week. The child doesn’t want to drink.
Mom states “He looks at me but he doesn’t seem to see me!”
Before ArrivalBefore Arrival
Physiology:
Child’s been sick for a while
Dehydration most likely cause of any serious problems. Worst case is shock.
Consider low blood glucose.
“Not seeing me” doesn’t sound good.
Before ArrivalBefore Arrival
Responses:
Mom’s liable to be alarmed or hysterical as well as exhausted.
This may be a really sick kid who needs vascular access and fluids badly.
Before ArrivalBefore Arrival
Equipment:
Be ready to monitor vital signs manually or electronically.
Be prepared to keep infant warm.
IV equipment (including IO), glucometer, oxygen, pulse ox
Stretcher
Before ArrivalBefore Arrival
Protocols
Vascular access
Shock
Hypoglycemia
May need critical care facility
Where to start interventions?
This is what you see and This is what you see and hear…hear…
PREP on scenePREP on scene
Physiology
POOR general appearance
Retracting but good effort, RR 60
HR 200, CR 4 sec, skin pale and cool in distal extremities
PAT says this child is SICK and you need to move QUICKLY! This is early cardiopulmonary failure.
PREP on scenePREP on scene
Physiology
Further exam confirms clinical impression of shock. BP 78/58.
Oxygen saturation not obtainable on fingers/toes
Rapid blood sugar is 83
PREP on scenePREP on scene
Responses
This is the time to focus energies and defer emotions.
Most capable team member goes for IV access. Don’t let the rest of the call get lost in the search for an IV.
Stay calm to keep mom calm.
PREP on scenePREP on scene
Equipment
You need all the stuff you thought you might need and
were prepared with.
PREP on scenePREP on scene
Protocols
Shock. Probably will need rapid, repeated boluses. Monitor HR, skin signs and general appearance as indicators of improvement.
Sugar is OK for now
PREP on scenePREP on scene
Protocols
The house may be the best place to secure vascular access and begin fluid replacement.
If BLS, need fastest possible access to ALS by call-in, intercept or transport to closest pediatric capable facility.
Needs pediatric critical care facility.
The 3 P’s of ControlThe 3 P’s of Control
Preparation
Practice
Perception
PP
RR
EE
PP
Physiology
Responses
Equipment
Protocols
SummarySummary
Use dispatch information to PREPare before you make patient contact.
Use the PREP approach to analyze and control the scene once you get there.
SummarySummary
The PAT is the anchor tool for the PREP approach
The Boy Scouts have it right…
“Always be PREPared!”
Questions or Comments?Questions or Comments?
Lou Romig
Louromig@bellsouth.net
JEMS, May 2001
www.jumpstarttriage.com
Thank you!