Pediatrics in EMS
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Approximately 10% of all EMS treatment is for children younger than 14 years of age
#1
#2
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The mnemonic nightmare…
Difficulties in Assessment
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PEPP: Pediatric Education for Prehospital Providers
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PAT: Pediatric Assessment Triangle (appearance, work of breathing, circulation)
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PALS: Pediatric Advanced Life Support•
ABCDE: Airway, Breathing, Circulation, Disability, Exposure
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AVPU: Alert, Responsive to Verbal/Painful stimuli, Unresponsive
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SAMPLE: Signs/Symptoms, Allergies, Medications, Past medical hx, Last meal, Events leading up to illness/injury
Difficulties in Assessment
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Vital Signs–
Respiratory Rate and Quality
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Pulse Rate and Quality–
Blood Pressure
–
Capillary Refill–
Pulse Oximetry
–
WEIGHT
General Pediatric Assessment
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Depends on…–
Age
–
Size–
Development
–
Chronic conditions
What is NORMAL?
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USE THE PARENTS!!•
Ask about:–
medical problems
–
normal assessment findings–
medical devices
–
Emergency Health Information Form•
If unavailable, base assessment on normal VS for age
What is NORMAL?
What is NORMAL?
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Most pediatric arrests are of respiratory origin•
Once respiratory arrest progresses to pulseless cardiac arrest, outcome is
poor
Airway/Breathing
80%
10%
10%
RespShockCardiac
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Occiput•
Airway size
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Nose•
Tongue
•
Larynx•
Vocal Cords
•
Epiglottis•
Physiology
Anatomic and Physiologic Differences…and the
Consequences
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The infant has a large occiput•
“sniffing position”
ineffective in
patients < 2yo
Anatomy: Occiput size
•
Manipulation and visualization•
Peripheral airway contribution to total resistance:–
Adults: 20%
–
Children: 50%
Anatomy: Airway Size
Anatomy: Airway Size
••
PoiseuillePoiseuille’’ss
Law: if the radius is Law: if the radius is halvedhalved, resistance increases , resistance increases 1616--
fold fold (with laminar flow)(with laminar flow)
R =R =8 n l8 n l
ΠΠ
rr44
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The nose is responsible for 50% of airway resistance at all ages
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In the infant, blockage of the nose = respiratory distress
Anatomy: Nose
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The infant’s tongue is larger
relative to the oropharynx
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Loss of tone with sleep, sedation, CNS dysfunction
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Frequent cause of upper airway obstruction
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May be difficult to control with the laryngoscope blade
Anatomy: Tongue
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More acute angle between the base of the tongue and glottic
opening
•
Straight blade more useful to create a direct visual
plane•
Positioning
Anatomy: Larynx
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Narrowest portion of the airway:–
Adults: glottic
inlet
–
Children <10yo: cricoid
cartilage•
Funnel vs
cylinder shape
Anatomy: Larynx
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Endotracheal tube size selection
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Through the cords ≠
home-free•
Cuffed vs
uncuffed
Anatomy: Larynx
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Vocal cords slanted anteriorly vs
perpendicular to trachea
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Affects visualization•
Can make passage of ETT more difficult
Anatomy: Vocal Cords
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Short, narrow, and angled away from the long axis of the trachea
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Floppy (little cartilage)•
Straight laryngoscope
blades
Anatomy: Epiglottis
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High metabolic rate and oxygen demand
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O2
consumption:–
infants 6-8 mL/kg/min
–
adults 3-4 mL/kg/min•
Hypoxemia develops more rapidly in presence of apnea or inadequate alveolar ventilation
Breathing
•
Weak intercostal muscles, cartilage
•
Tidal volume dependent
on movement of diaphragm
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Little reserve if movement of
diaphragm is impeded
Breathing
•
General Principles•
Positioning
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Bag-Valve-Mask ventilation•
Airway Adjuncts
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Endotracheal intubation
Assisting Ventilation
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Anticipate and Recognize•
Prepare
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Oxygen and Humidification•
Position of comfort
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Lessen anxiety•
Be aggressive with secretions
•
Start simple…unobstruct
the airway
General Principles
Signs of Respiratory Distress
RetractionsRetractionsAccessory muscle useAccessory muscle useWheezingWheezingSweatingSweatingProlonged expirationProlonged expirationPulsusPulsus
paradoxusparadoxus
CyanosisCyanosis
TachypneaTachycardiaGrunting StridorHead bobbingFlaringInability to lie downAgitation
Signs of Respiratory Failure
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Reduced air entry•
Severe work
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Cyanosis despite O2
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Irregular breathing / apnea•
Altered Consciousness
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Diaphoresis
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Mask: bridge of nose to cleft of chin, as small as possible
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Infants and toddlers: jaw supported with base of the middle or ring finger
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Older children: fingertips of 3rd, 4th, and 5th
fingers
on ramus
of mandible
Bag-Valve-Mask Ventilation
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May need two providers to get a good seal
Bag-Valve-Mask Ventilation
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Don’t forget the Sellick
maneuver!
Bag-Valve-Mask Ventilation
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Oropharyngeal
airway–
holds tongue and soft hypopharyngeal
structures away from posterior pharyngeal wall
–
unconscious patients only–
4-10cm length
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Estimate length: corner of mouth to angle of jaw
Airway Adjuncts
Airway Adjuncts
Airway Adjuncts
Airway Adjuncts
Insertion technique:
Airway Adjuncts
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Nasopharyngeal Airway:•
12F (3mm ETT) to 36F
•
Suction•
Contraindications
Tip of nose to tragus
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Isolates airway•
Reduces potential for aspiration
•
Allows control of inspiratory time and peak inspiratory pressures
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Allows delivery of PEEP
Endotracheal Intubation
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Inadequate CNS control of ventilation•
Functional or anatomic airway obstruction
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Excessive work of breathing•
Need for high peak inspiratory pressures or PEEP to maintain effective alveolar gas exchange
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Need for mechanical ventilatory
support•
Inability to protect airway
Endotracheal Intubation: Indications
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SOAP ME•
Suction
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Oxygen•
Airway equipment (check it!)
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Pharmacologic agents•
Monitor, Mechanical
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Equipment
Endotracheal Intubation: Preparation
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ETT:–
Uncuffed in children <8yo
–
Cuffed in children >8yo–
Size: Use your CODE CARD!
Endotracheal Intubation: Equipment
ETT size =Age (yrs) + 16
4
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ETT:–
Have other sizes available!
–
Rigid stylet–
Depth of insertion: 3 x internal diameter
(5.0 ETT inserted 15cm)
Endotracheal Intubation: Equipment
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Laryngoscope–
Miller for infants and toddlers
–
Miller or Macintosh for older children
Endotracheal Intubation: Equipment
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Confirm tube placement–
Auscultation
–
CO2
detection–
Ability to ventilate
Endotracheal Intubation
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Cardiac monitor•
Pediatric electrodes for infants and young children.
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Adult electrodes may be used for larger children and adolescents.
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Make sure pediatric paddles are available for defibrillation if necessary.
Circulation
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Tachycardia:•
Hypovolemia
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Hypoxia•
Anxiety
•
Fever•
Pain
•
Cardiac impairment
•
Bradycardia
Circulation
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Pulses–
Newborns: Umbilical
artery–
Infants: brachial artery
–
Children: carotid artery
Circulation
•
Pulse quality–
Rate
–
Strength–
Central vs
Peripheral
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Capillary refill time (CRT)•
Skin color and temperature:–
Warm, cool, pale, or cyanotic?
Circulation
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Blood Pressure (5th
percentile)–
Infants SBP 60
–
1 year SBP 70–
>1 year SBP (70 + 2 x age)
Circulation
•
Intraosseous
(IO) access–
No age restrictions
–
30-90 seconds or 3 attempts–
Can infuse ANYTHING
–
New options: EZ-IO©
Circulation
You cannot remember normal weights, respiratory rates,
blood pressures, heart rates, and calculate drug doses in your head….so don’t try….
Pediatric Pearls