Xueren/EMS-Knowledge · Datasets at Hugging Face

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pediatrics.json	knowledge	pediatrics	hpi signs and symptoms	- Time of injury - Mechanism: blunt vs penetrating - Loss of consciousness - Bleeding - Past medical history - Medications - Evidence of multi-system trauma - Pain, swelling, bleeding - Altered mental status, unconsciousness - Respiratory distress, failure - Vomiting - Seizure
pediatrics.json	knowledge	pediatrics	considerations	- Major traumatic mechanism of injury - Skull fracture - Brain injury (concussion, contusion, hemorrhage, or laceration) - Epidural hematoma - Subdural hematoma - Subarachnoid hemorrhage - Spinal injury - Abuse
pediatrics.json	knowledge	pediatrics	procedure	1. Perform general patient management and baseline GCS. 2. Support life-threatening problems associated with airway, breathing, and circulation. Obtain mechanism or injury. 3. Administer oxygen to maintain SpO2 94 - 99%. Consider supporting respirations with a BVM. If signs of hypoventilation are present, ventilate with BVM at an age appropriate rate. 4. Monitor capnography if BVM or intubated/alternative airway. Attempt to maintain between 35 - 45 mm Hg. 5. Consider spinal precautions based on MOI. Avoid excessive compression around the neck by cervical collar. Assess and document PMS in all extremities before and after movement. 6. Place patient on cardiac monitor. 7. Establish an IV of normal saline, if indicated, to maintain an appropriate systolic BP: a. Birth to 1 month – 60 mmHg b. 1 month to 1 year – > 70 mmHg c. Greater than 1 year - 70 + [2 x Age (years)] 8. Obtain a blood glucose sample. 9. If patient is exhibiting signs of shock, refer to Pediatric Shock protocol. 10. Transport per Trauma Triage Scheme and perform ongoing assessment as indicated.
pediatrics.json	knowledge	pediatrics	pearls	1. Hyperventilation is not recommended with head-injury patients. 2. One of the most important indicators of worsening head injury is a change in LOC and/or GCS. 3. Increased ICP may cause hypertension and bradycardia (Cushing’s response). 4. Hypotension usually indicates injury or shock unrelated to the head injury and should be treated aggressively. 5. A decrease of two (2) or more in the patient’s GCS should be considered due to a severe head injury until proven otherwise. 6. Recognize that “normal” blood pressure is not as important as “normal for the patient” when assessing maintenance of adequate cerebral blood flow and adequate cerebral perfusion.
pediatrics.json	knowledge	pediatrics	glasgow coma scale modified for pediatric patients	Eye Opening Response (<1 year) Spontaneous: 4 To shout: 3 To pain: 2 None: 1 Verbal Response (0 to 2 years) Babbles, coos appropriately: 5 Cries but inconsolably: 4 Persistent crying or screaming in pain: 3 Grunts or moans to pain: 2 None: 1 Motor Response (<1 year) Spontaneous: 6 Localizes pain: 5 Withdraws to pain: 4 Abnormal flexion to pain (decerebrate): 3 Abnormal extension to pain (decordicate): 2 None: 1
pediatrics.json	knowledge	pediatrics	document title	Pediatric General Medical Emergencies
pediatrics.json	knowledge	pediatrics	protocol title	Medical – Overdose/Poisoning/Toxic Ingestion
pediatrics.json	knowledge	pediatrics	overview	Ingestion and overdose are among the most common pediatric “accidents.” The substance usually is a medication prescribed for family members or for the child. Other commonly ingested poisons include cleaning chemicals, plants, and anything that fits in a child’s mouth. Primary manifestations may be a depressed mental status and/or respiratory and cardiovascular compromise. Contact Medical Control for patient care orders. Contact Poison Control (804-828-1222 or 800-222-1222) for advice. Do not confuse Poison Control with Medical Control.
pediatrics.json	knowledge	pediatrics	hpi	- Use or suspected use of - a potentially toxic substance - Substance ingested, - route, and quantity used - Time of use - Reason (suicidal, - accidental, criminal) - Available medications in - home
pediatrics.json	knowledge	pediatrics	signs and symptoms	- Mental status changes - Hypotension / - hypertension - Hypothermia / - hyperthermia - Decreased respiratory - rate - Tachycardia, other - dysrhythmias - Seizures
pediatrics.json	knowledge	pediatrics	considerations	- Acetaminophen - (Tylenol) - Depressants - Stimulants - Anticholinergic - Cardiac medications - Solvents, alcohols - Cleaning agents - Insecticides
pediatrics.json	knowledge	pediatrics	procedure	1. Perform general patient management. *** 2. Support life-threatening problems associated with airway, breathing, and circulation. * 3. Administer oxygen to maintain SpO2 94 - 99%. * 4. Establish an IV of normal saline per patient assessment. 5. If child is over 20kg and respiratory effort remains diminished and opiate administration is suspected, give NARCAN INTRANASAL 2mg (one vial). May repeat one time. * 6. a. If respiratory effort remains diminished and opiate administration is suspected, give NARCAN 0.1mg/kg slow IVP/IM max 2mg (ALS only). * 7. Place patient on cardiac monitor and monitor pulse oximetry. 8. Transport and perform ongoing assessment as indicated. ***
pediatrics.json	knowledge	pediatrics	narcan dosage guide	Age Pre-Term Term 3 mos. 6 mos. 1 year 3 years 6 years 8 years Weight (lb / kg) 3.3 lb 1.5 kg 6.6 lb 3 kg 13.2 lb 6 kg 17.6 lb 8 kg 22 lb 10 kg 30.8 lb 14 kg 44 lb 20 kg 55 lb 25 kg Narcan IV 0.1 mg / kg 0.15 mg 0.3 mg 0.6 mg 0.8 mg 1.0 mg 1.4 mg 2.0 mg 2.0 mg
pediatrics.json	knowledge	pediatrics	document title	Pediatric General Medical Emergencies
pediatrics.json	knowledge	pediatrics	protocol title	Medical – Diabetic – Hypoglycemia
pediatrics.json	knowledge	pediatrics	overview	Symptomatic hypoglycemia is defined as a blood glucose level < 60 mg / dL with signs of altered mental status and / or unconsciousness. The many signs and symptoms that are associated with hypoglycemia can be divided into two broad categories: adrenergic and neurologic. The adrenergic stimulation is due to the increased epinephrine levels and the neurologic due to central nervous system dysfunction from the decreased glucose levels.
pediatrics.json	knowledge	pediatrics	hpi	* History of diabetes * Onset of symptoms * Medications * Fever or recent infection * Alcohol consumption * Last meal
pediatrics.json	knowledge	pediatrics	signs and symptoms	* Anxiety, agitation, and / or confusion * Cool, clammy skin * Diaphoresis * Seizure * Decreased visual acuity, blindness * Abnormal/ hostile behavior * Tachycardia * Hypertension * Dizziness, headache, weakness
pediatrics.json	knowledge	pediatrics	considerations	* Hypoxia * Seizure * Stroke * Brain trauma * Alcohol intoxication * Toxin/ substance abuse * Medication effect / overdose
pediatrics.json	knowledge	pediatrics	procedure	1. Perform general patient management. 2. Support life-threatening problems associated with airway, breathing, and circulation. 3. Assess for signs of trauma. Provide spinal immobilization as necessary. 4. Administer oxygen to maintain SPO2 94 - 99%. 5. For altered mental status, perform rapid glucose determination. 6. If glucose < 60 mg / dL or clinical signs and symptoms indicate hypoglycemia: a. If the patient can protect airway, give Oral Glucose 15 grams. Repeat in 15 minutes if necessary. 7. If glucose < 60 mg / dL or clinical signs and symptoms indicate hypoglycemia and oral glucose is contraindicated: Establish an IV of normal saline at KVO. a. If > 30 days, administer DEXTROSE 10% (5 mL / kg, max dose 100mL ) via IV or IO. b. If < 30 days, administer DEXTROSE 10% (2 mL / kg) via IV or IO. c. If DEXTROSE 10% bag unavailable: * If patient is < 30 days old, administer Dextrose 10% (2cc/kg) IV or IO, mixed as below. * If patient is > 30 days old but < 8 years old, administer Dextrose 25% (2cc/kg) IV or IO, mixed as below. * If patient is > 8 years old, administer Dextrose 50% (0.5mg/kg, max 25gm) IV or IO. d. If unable to establish an IV, alternatively administer GLUCAGON: * Under 20 kg: 0.5 mg IM/IN (ALS only) * >20 kg: 1.0 mg IM/IN (EMT and above) (over 20kg only) 8. For signs and symptoms of hypovolemic shock or dehydration, follow the Pediatric Shock protocol. 9. Place on cardiac monitor per patient assessment. 10. Transport and perform ongoing assessment as indicated.
pediatrics.json	knowledge	pediatrics	procedure for making dextrose 25 and 10 percent	Dextrose 25%: In 50 ml syringe, mix 25 ml of Dextrose 50% with 25 ml Normal Saline. Mixture will yield 50 ml of Dextrose 25%. Dextrose 10%: In 50 ml syringe, mix 10 ml of Dextrose 50% with 40 ml Normal Saline. Mixture will yield 50 ml of Dextrose 10%.
pediatrics.json	knowledge	pediatrics	dosage guide by age and weight	For preterm infants (weight not specified), glucagon is not indicated; dextrose 10% (bag or diluted at 2 mL/kg) is given as 4.0 mL, while dextrose 10% at 5 mL/kg and dextrose 25% at 2 mL/kg are not applicable. For term infants (6.6 lb/3 kg), give glucagon 0.5 mg, dextrose 10% (bag or diluted at 2 mL/kg) as 6.0 mL, and no dose of dextrose 10% at 5 mL/kg or dextrose 25% at 2 mL/kg. At 3 months (13.2 lb/6 kg), administer glucagon 0.5 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 30.0 mL; dextrose 25% at 2 mL/kg is 12.0 mL (3 g). At 6 months (17.6 lb/8 kg), administer glucagon 0.5 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 40.0 mL; dextrose 25% at 2 mL/kg is 16.0 mL (4 g). At 1 year (22 lb/10 kg), administer glucagon 0.5 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 50.0 mL; dextrose 25% at 2 mL/kg is 20.0 mL (5 g). At 3 years (30.8 lb/14 kg), administer glucagon 0.5 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 70.0 mL; dextrose 25% at 2 mL/kg is 28.0 mL (7 g). At 6 years (44 lb/20 kg), administer glucagon 1.0 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 100 mL; dextrose 25% at 2 mL/kg is 40.0 mL (10 g). Finally, at 8 years (55 lb/25 kg), administer glucagon 1.0 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 100 mL; dextrose 25% at 2 mL/kg is 50.0 mL (12.5 g).
pediatrics.json	knowledge	pediatrics	pearls	1. Hypoglycemia is the most common metabolic problem in neonates. 2. Use aseptic techniques to draw blood from finger. Allow alcohol to dry completely prior to puncturing finger for blood glucose level. Alcohol may cause inaccurate readings. Do not blow on or fan site to dry faster. 3. Blood glucose levels should be taken from extremity opposite IV and medication administration for most accurate reading. 4. After puncturing finger, use only moderate pressure to obtain blood. Excessive pressure may cause rupture of cells causing inaccurate results. 5. Know your specific agency’s glucometer parameters for a “HI” and “LO” reading. 6. When administering IV fluids, a minimum amount should be delivered as large amounts may lower blood glucose level and impede original goal of administering Dextrose. 7. Patients who are consuming aspirin, acetaminophen, anti-psychotic drugs, beta-blockers, oral diabetic medications, or antibiotics such as sulfa-based, tetracycline, and amoxicillin that experience a hypoglycemic episode are at a greater risk for relapse. These patients should be strongly encouraged to accept transport. 8. An inadequate amount of glucose for heat production, combined with profound diaphoresis, may place a hypoglycemic patient at greater risk for hypothermia. Keep patient warm as needed. 9. Glucagon causes a breakdown of stored glycogen to glucose. Glucagon may not work if glycogen stores are previously depleted due to liver dysfunction, alcoholism, or malnutrition. Effects of Glucagon may take up to 30 minutes. 10. Any patient that has had a hypoglycemic episode without a clear reason should be transported for further evaluation.
pediatrics.json	knowledge	pediatrics	document title	Pediatric General Medical Emergencies
pediatrics.json	knowledge	pediatrics	protocol title	Medical – Hypotension/Shock (Non-trauma)
pediatrics.json	knowledge	pediatrics	overview	Shock is defined as a state of inadequate tissue perfusion. This may result in acidosis, derangements of cellular metabolism, potential end-organ damage, and death. Early in the shock process, patients are able to compensate for decreased perfusion by increased stimulation of the sympathetic nervous system, leading to tachycardia and tachypnea. Later, compensatory mechanisms fail, causing a decreased mental status, hypotension, and death. Early cellular injury may be reversible if definitive therapy is delivered promptly.
pediatrics.json	knowledge	pediatrics	hpi	- Blood loss (vaginal or gastrointestinal) - Fluid loss (vomiting, diarrhea) - Fever - Infection - Medications - Allergic Reaction - Pregnancy, ectopic - Trauma - Coffee -ground emesis - Tarry stools
pediatrics.json	knowledge	pediatrics	signs and symptoms	- Restlessness, confusion - Weakness, dizziness - Weak, rapid pulse - Pale, cool, clammy skin - Delayed capillary refill - Hypotension
pediatrics.json	knowledge	pediatrics	considerations	- Hypovolemic - Cardiogenic - Septic - Neurogenic - Anaphylactic - Ectopic pregnancy - Dysrhythmia - Pulmonary embolus - Tension pneumothorax - Medication effect / overdose - Vaso -vagal - Trauma
pediatrics.json	knowledge	pediatrics	procedure	1. Perform general patient management. 2. Support life -threatening problems associated with airway, breathing, and circulation. 3. Assess for signs of shock including, but not limited to: Restlessness, altered mental status, hypoperfusion (cool, pale, moist skin), tachypnea (rapid breathing), rapid, weak pulse, orthostatic hypotension (blood pressure suddenly drops on standing up), nausea and thirst. 4. Administer oxygen to maintain SpO2 94 - 99%. Support respirations as necessary with a BVM. 5. Transport as soon as possible. 6. Control external bleeding with direct pressure, then tourniquet if direct pressure is inadequate. 7. Establish a large bore IV or IO of Normal Saline. If time permits, establish second access. Do not delay transport to establish vascular access 8. Maintain systolic BP appropriate for patient: - Birth to 1 month - 60 mmHg - 1 month to 1 year - > 70 mmHg - Greater than 1 year - 70 + [2 x Age (years)] 9. Give a 20 mL / kg bolus. If no improvement after first 20 mL / kg bolus, may repeat once. While administering a fluid bolus, frequently reassess perfusion for improvement. If perfusion improves, slow the IV to KVO and monitor closely. If patient develops fluid overload respiratory distress (dyspnea, crackles, rhonchi, decreasing SpO2), slow the IV to KVO. 10. Place the patient on the cardiac monitor. 11. Transport and perform ongoing assessment as indicated.
pediatrics.json	knowledge	pediatrics	classes of shock	Hypovolemic: Caused by hemorrhage, burns, or dehydration. Distributive: Maldistribution of blood, caused by poor vasomotor tone in neurogenic shock, sepsis, anaphylaxis, severe hypoxia, or metabolic shock. Cardiogenic: Caused by necrosis of the myocardial tissue, or by arrhythmias. Obstructive: Caused by impairment of cardiac filling, found in pulmonary embolism, tension pneumothorax, or cardiac Tamponade.
pediatrics.json	knowledge	pediatrics	pearls	1. GI bleeding may be a less obvious cause of hypovolemic shock if it has been gradual. Ask patient about possible melena, hematemesis, and hematochezia. 2. Ectopic pregnancy may be a less obvious cause of hypovolemic shock. Consider this diagnosis in all female patients of child-bearing age if there is a complaint of abdominal or pelvic pain.
pediatrics.json	knowledge	pediatrics	document title	Pediatric General Medical Emergencies
pediatrics.json	knowledge	pediatrics	protocol title	Medical – Altered Mental Status
pediatrics.json	knowledge	pediatrics	overview	Although each of these presentations has unique considerations, prehospital treatment is similar. The unconscious patient is one of the most difficult patient-management problems in pre-hospital care. Causes range from benign problems to potentially life-threatening cardiopulmonary or central nervous system disorders. In the usual clinical approach to a patient, the provider first obtains a history, performs a physical examination, and then administers treatment. However, this sequence must be altered for patients that are unconscious or with an altered level of consciousness. Simple syncope may be the result of a wide variety of medical problems, although the major cause of syncope is a lack of oxygenated blood to the brain. In this situation, it is quickly remedied when the patient collapses, improving circulation to the brain. Altered LOC is such a major variance from normal neurological function that immediate supportive efforts may be required. Efforts should be made to obtain as much of an HPI as possible from family members or bystanders.
pediatrics.json	knowledge	pediatrics	hpi signs symptoms considerations	Cardiac history, stroke, seizures Occult blood loss (GI, ectopic) Females (LMP, vaginal bleeding) Fluid loss (nausea, vomiting, diarrhea) Past medical history Recent trauma Complaint prior to event Loss of consciousness with recovery Lightheadedness, dizziness Palpitations, slow or rapid pulse Pulse irregularity Decreased blood pressure Vaso-vagal Orthostatic hypotension Cardiac syncope / dysrhythmia Micturation Psychiatric Hypoglycemia Seizure Shock GI Bleed Ectopic Pregnancy Toxicological (ETOH) Medication effect (hypertension)
pediatrics.json	knowledge	pediatrics	procedure	1. Perform general patient management. 2. Maintain patient in a supine position and assess for C -spine precautions. 3. Administer oxygen to maintain SPO2 94 - 99%  4. Assess blood glucose level. Refer to Pediatric Hypoglycemia Protocol. 5. If child is over 20kg and respiratory effort remains diminished and opiate administration is suspected, give NARCAN INTRANASAL 2mg (one vial). May repeat one time. 6. Establish IV of Normal Saline. Keep at KVO rate unless hypotensive. If hypotensive, refer to Pediatric Shock protocol. 7. Transport and reassess as needed.
pediatrics.json	knowledge	pediatrics	narcan dosage guide	Age Pre-Term Term 3 6 1 3 6 8 Weight (lb / kg) 3.3 lb1.5 kg 6.6 lb3 kg 13.2 lb6 kg 17.6 lb8 kg 22 lb10 kg 30.8 lb14 kg 44 lb20 kg 55 lb25 kg Narcan IV 0.1 mg/kg 0.15 ml 0.3 ml 0.6 ml 0.8 ml 1.0 ml 1.4 ml 2.0 ml 2.0 ml
pediatrics.json	knowledge	pediatrics	pearls	1. Assess for signs and symptoms of trauma if questionable or suspected fall with syncope. 2. Consider dysrhythmias, GI bleed, ectopic pregnancy, and seizure as possible causes of syncope.
pediatrics.json	knowledge	pediatrics	document title	Pediatric General Medical Emergencies
pediatrics.json	knowledge	pediatrics	protocol title	Medical – Seizure
pediatrics.json	knowledge	pediatrics	overview	A seizure is a period of altered neurologic function caused by abnormal neuronal electrical discharges. Generalized seizures begin with an abrupt loss of consciousness. If motor activity is present, it symmetrically involves all four extremities. Episodes that develop over minutes to hours are less likely to be seizures; most seizures only last 1 - 2 minutes. Patients with seizure disorders tend to have stereotype, or similar, seizures with each episode and are less likely to have inconsistent or highly variable attacks. True seizures are usually not provoked by emotional stress. Most seizures are followed by a postictal state of lethargy and confusion.
pediatrics.json	knowledge	pediatrics	hpi signs symptoms	Reported, witnessed seizure activity description Previous seizure history information Medic alert tag Seizure medications History of trauma History of diabetes mellitus History of pregnancy Decreased mental status Sleepiness Incontinence Observed seizure activity Evidence of trauma
pediatrics.json	knowledge	pediatrics	considerations	CNS (head) trauma Tumor Metabolic, hepatic, renal failure Diabetic Hypoxia Electrolyte abnormality Drugs, medications, non-compliance Infection, fever, meningitis Alcohol withdrawal Hyperthermia
pediatrics.json	knowledge	pediatrics	procedure	1.Perform general patient management. 2.Support life-threatening problems associated with airway, breathing, and circulation. 2a.Suction the oro - and nasopharynx as necessary. 2b.Place a nasopharyngeal airway as necessary (avoid in head trauma). 3.Administer oxygen to maintain SpO2 94 - 99%. Support respirations as necessary with a BVM. 4.Do not restrain the patient. Let the seizure take its course but protect patient from injury. 5.If the seizure persists give MIDAZOLAM 0.2 mg / kg INTRANASAL (max single dose 10 mg) –OR- give MIDAZOLAM 0.1 mg / kg IV / IM (max single dose 10 mg) 5a.Repeat dose in 5 minutes if seizure persists. 5b.If Midazolam is unavailable, administer, DIAZEPAM 0.25 mg / kg up to 5 mg slow IV push, titrated to effect. Diazepam may also be administered Per Rectum (PR) in pediatric patients. 6.Perform rapid glucose determination. If glucose less than 60 mg / dL or clinical signs and symptoms indicate hypoglycemia, refer to the Hypoglycemia protocol 7.Establish an IV of normal saline at KVO. 8.Place patient on cardiac monitor (sometime life-threatening dysrhythmias can cause seizure-like activity). 9.Consider placing the patient in the recovery position during the postictal period. 10. Transport and perform ongoing assessment as indicated.
pediatrics.json	knowledge	pediatrics	generalized seizure types	Absence (Petit -Mal) Atonic (Drop Attack) Myoclonic (Brief bilateral jerking) Tonic-Clonic (Grand - Mal)
pediatrics.json	knowledge	pediatrics	simple partial seizure types	Focal / Local: Localized twitching of hand, arm, leg, face, or eyes. Patient may be conscious or unconscious
pediatrics.json	knowledge	pediatrics	complex partial seizure types	Temporal Lobe Psychomotor
pediatrics.json	knowledge	pediatrics	pediatric dosage information table	Age Pre- Term Term 3 month 6 month 1 year 3 years 6 years 8 years Weight (lb / kg) 3.3 lb 1.5 kg 6.6 lb 3 kg 13.2 lb 6 kg 17.6 lb 8 kg 22 lb 10 kg 30.8 lb 14 kg 44 lb 20 kg 55 lb 25 kg Midazolam IV 0.15 mg 0.3mg 0.6mg 0.8 mg 0.1mg 1.4mg 2mg 2.5mg Midazolam IN 1/2 dose per nostril 0.3 mg 0.6mg 1.2mg 1.6mg 2mg 2.8mg 4mg 5mg Diazepam IV (5.0 mg / ml) 0.3 mg/kg 0.1 ml 0.2 ml 0.4 ml 0.5 ml 0.6 ml 0.84 ml 1.2 ml 1.5 ml Diazepam PR (5.0 mg / ml) 0.5 mg / kg 0.15 ml 0.3 ml 0.6 ml 0.8 ml 1.0 ml 1.4 ml 2.0 ml 2.0 ml
pediatrics.json	knowledge	pediatrics	pearls	1. Respirations during an active seizure should be considered ineffective and airway maintenance should occur per assessment. 2. Status epilepticus is defined as two or more consecutive seizures without a period of consciousness or recovery. This is a true emergency requiring rapid airway support, treatment, and transport. 3. Grand Mal seizures are generalized in nature and associated with loss of consciousness, incontinence, and possibly tongue trauma. 4. Focal seizures affect only a specific part of the body and are not usually associated with loss of consciousness. 5. Jacksonian seizures are seizures, which start as focal in nature and become generalized. 6. Petit Mal seizures may be localized to a single muscle group or may not involve visible seizure activity all. Always examine pupils for nystagmus, which would alert provider to continued seizure activity. 7. Be prepared for airway problems and continued seizures. 8. Investigate possibility of trauma and substance abuse. 9. Be prepared to assist ventilations as dosages of benzodiazepines are increased.
pediatrics.json	knowledge	pediatrics	document title	Pediatric General Medical Emergencies
pediatrics.json	knowledge	pediatrics	protocol title	Medical – Diabetic Hyperglycemia
pediatrics.json	knowledge	pediatrics	overview:	- Diabetes mellitus is the most common endocrine disorder of childhood, affecting approximately 2/1,000 school-age children in the United States. - Symptomatic hyperglycemia is defined as a blood glucose level > 300 mg/dl with signs of severe dehydration, altered mental status, and/ or shock. - Hyperglycemia is usually the result of an inadequate supply of insulin to meet the body's needs. - Most pre -hospital care should be focused around the treatment of severe dehydration and support of vital functions.
pediatrics.json	knowledge	pediatrics	hpi	- History of diabetes - Onset of symptoms - Medications
pediatrics.json	knowledge	pediatrics	signs and symptoms	- Anxiety, agitation, and / or confusion - Dry, red, and / or warm skin - Fruity / acetone smell on breath - Kussmaul respirations - Dry mouth, intensive thirst - Abnormal/ hostile behavior - Tachycardia - Dizziness / headache
pediatrics.json	knowledge	pediatrics	considerations	- Hypoxia - Brain trauma - Alcohol intoxication - Toxin / substance abuse - Medication effect / overdose
pediatrics.json	knowledge	pediatrics	procedure	1. Perform general patient management. 2. Support life -threatening problems associated with airway, breathing, and circulation. 3. Assess for signs of trauma. Provide spinal immobilization as necessary. 4. Administer oxygen to maintain SPO2 94 - 99% 5. For altered mental status, perform rapid glucose determination. 6. If glucose > 300 mg / dL, start an IV of normal saline. 7. For signs and symptoms of hypovolemic shock or dehydration, follow the Pediatric Shock protocol. 8. If glucose level is > 300 mg / dL, and no signs of shock are noted, administer maintenance Normal Saline infusion: - 4.0 ml / kg for first 1 - 10 kg of weight. - Add 2.0 ml / kg for next 11 - 20 kg of weight. - Add 1.0 ml / kg, for every kg of weight, > 20 kg. - Multiply total amount x 2= total hourly hyperglycemic maintenance amount. 9. Place on cardiac monitor and obtain / interpret 12 lead ECG per assessment. 10. Transport and perform ongoing assessment as indicated.
pediatrics.json	knowledge	pediatrics	pearls:	1. Know your specific agency's glucometer parameters for a "HI" and "LO" reading. 2. It is estimated that 2 - 8% of all hospital admissions are for the treatment of DKA, while mortality for DKA is between 2 - 10%. Published mortality rates for HHS vary, but the trend is that the older the patient and higher the osmolarity, the greater the risk of death.
pediatrics.json	knowledge	pediatrics	document title	Pediatric General Medical Emergencies
pediatrics.json	knowledge	pediatrics	protocol title	Medical – Nausea/Vomiting
pediatrics.json	knowledge	pediatrics	overview	The pre-hospital provider should be very careful to ensure that patients who present with vague complaints such as nausea and vomiting are thoroughly evaluated. The patient’s symptoms and recent history must determine the most appropriate care. Frequently, treatment of an underlying cause and limiting movement may resolve or greatly reduce these complaints. However, persistent nausea and vomiting of unknown etiology may respond well to pharmaceutical therapy. All patients presenting with nausea and vomiting should be screened for potential life-threats initially. Anti-emetic treatment should occur only as a secondary priority.
pediatrics.json	knowledge	pediatrics	hpi	Age Time of last meal Last bowel movement, emesis Improvement, worsening with food or activity Duration of signs and symptoms Other sick contacts Past medical, surgical history Medications Menstrual history (pregnancy) Travel history Recent trauma Pain Character of pain (constant, intermittent, sharp, dull, etc.)
pediatrics.json	knowledge	pediatrics	signs and symptoms	Distention Constipation Diarrhea Anorexia Radiation Associated symptoms (helpful to localize source) Fever, headache, blurred vision, weakness, malaise, myalgias, cough, dysuria, mental status changes, rash
pediatrics.json	knowledge	pediatrics	considerations	CNS (increased pressure, headache, lesions, trauma, hemorrhage, vestibular) Drugs (NSAIDs, antibiotics, narcotics, chemotherapy) GI or renal disorders Gynecological disease (ovarian cyst, PID) Infections (pneumonia, influenza) Electrolyte abnormalities Food or toxin induced Medications, substance abuse Pregnancy Psychologic
pediatrics.json	knowledge	pediatrics	procedure	1. Perform general patient management. 2. Support life-threatening problems associated with airway, breathing, and circulation. 3. Administer oxygen to maintain SPO₂ 94 - 99% 4. Allow the patient to lie in a comfortable position. 5. Establish an IV of normal saline per patient assessment. 6. Assess for signs of shock. If shock is suspected, follow the Pediatric Shock protocol. 7. For severe nausea or vomiting, if available, give ONDANSETRON (ZOFRAN). If only IV formulation is available, administer 0.1 mg / kg IV / IM up to 4 mg over 2 to 5 minutes. 8. In lieu of IV ONDANSETRON, may administer 4 mg PO ONDANSETRON OTD tablet for patients over 44 lbs (20 kg). 9. May repeat Ondansetron PO or IV dosing after 10 minutes, if needed. 10. Perform ongoing assessment as indicated and transport.
pediatrics.json	knowledge	pediatrics	ondansetron dosing table	Ondansetron IV (0.1 mg/kg) is not specified for term infants (6.6 lb/3 kg) or 6-month-olds (17.6 lb/8 kg). For a 1-year-old (22 lb/10 kg), administer 1.0 mg; for a 3-year-old (30.8 lb/14 kg), 1.5 mg; for a 6-year-old (44 lb/20 kg), 2.0 mg; for an 8-year-old (55 lb/25 kg), 2.5 mg; for a 10-year-old (75 lb/34 kg), 3.5 mg; and for both 12-year-olds (88 lb/40 kg) and 14-year-olds (110 lb/50 kg), 4.0 mg.
pediatrics.json	knowledge	pediatrics	pearls	1. Nausea and vomiting has many subtle, sometimes life-threatening causes. Do not minimize its importance as a symptom. 2. Ondansetron may not be as effective for vertigo and labyrinthitis related nausea and vomiting. 3. For nausea and vomiting associated with dehydration, fluid replenishment may be sufficient in improving patient comfort and reduce the need for medication administration. 4. Ensuring that you have reasonably addressed possible causes, will help minimize the potential that you are overlooking a life-threat and/or concern that should receive priority over anti-emetic treatment. 5. In cases of toxic ingestion, including alcohol, poisons, and drug overdoses, vomiting is an internal protective mechanism and should not be prevented with pharmacological therapy in the pre-hospital environment. Care should be given to prevent aspiration. 6. Ondansetron is also safe and effective for nausea and vomiting in trauma patients and can be used in conjunction with pain management. 7. Proper documentation should include the mental status and vital signs before and after medication administration.
pediatrics.json	knowledge	pediatrics	document title	Pediatric General Medical Emergencies
pediatrics.json	knowledge	pediatrics	protocol title	General – Fever
pediatrics.json	knowledge	pediatrics	overview	Fever is a common chief complaint of children encountered in the pre-hospital environment. Patients with fever present in many different ways, depending on the age of the patient, the rate of rise of the temperature, the magnitude of the fever, the etiology of the fever, and the underlying health of the patient. The patient’s skin will be warm to the touch and may be flushed on observation. The patient may also complain of being warm and perspiring. It is important to recognize that fever represents a symptom of an underlying illness, and the actual illness must be determined and treated. Flu-like symptoms may accompany fevers, but it should not be assumed that fevers with these symptoms are minor, as there may be a serious underlying medical condition. Febrile seizures usually are self-limiting and typically occur once from a rapid rise in temperature, usually above 101.8 F / 38.7C. If more than one seizure occurs, causes other than fever should be suspected. The first occurrence of a seizure warrants the most concern because the benign nature of the illness has not been established.
pediatrics.json	knowledge	pediatrics	hpi	- Age - Duration of fever - Severity of fever - Any previous decrease or elevation of fever since onset - Past medical history - Medications - Immunocompromised (transplant, HIV, diabetes, cancer) - Recent illness or socialization with others with illness - Vaccinations - Poor PO intake - Urine production, decrease in diapers - Last acetaminophen dose
pediatrics.json	knowledge	pediatrics	signs and symptoms	- Altered mental status - Unconsciousness - Hot, dry, or flushed skin - Tachycardia - Hypotension, shock - Seizures - Nausea, vomiting - Weakness, dizziness, syncope - Restlessness - Loss of appetite - Decreased urine output - Rapid, shallow respirations - Associated symptoms (helpful in localizing source): myalgias, cough, chest pain, headache, dysuria, abdominal pain, mental status changes, rash
pediatrics.json	knowledge	pediatrics	considerations	- Infection, sepsis - Neoplasms, cancer, tumors, lymphomas - Medication or drug reaction - Connective tissue disease - Vasculitis - Thermoregulatory disorder - Hyperthyroid - Heat stroke - Drug fever
pediatrics.json	knowledge	pediatrics	procedure	1. Perform general patient management. 2. Support life-threatening problems associated with airway, breathing, and circulation. 3. Administer oxygen to maintain SPO2 94 - 99% 4. If the patient is having a seizure, refer to the Pediatric Seizure protocol. 5. If temperature is greater than 106  F / 41C, refer to Hyperthermia Patient Care Protocol. 6. Begin passive cooling by removing excess and constrictive clothing. Avoid overexposure. 7. Obtain blood glucose sample. If glucose is < 60 mg / dL or > 300 mg / dL, refer to Pediatric Hypoglycemia or Hyperglycemia Patient Care Protocol. 8. Establish an IV of normal saline at KVO. Titrate to a systolic pressure appropriate for child: - Birth to 1 month - 60 mmHg - 1 month to 1 year - > 70 mmHg - Greater than 1 year - 70 + [2 x Age (years)] 9. If hypoperfusion is suspected, refer to the Pediatric Shock protocol. 10. Perform ongoing assessment as indicated and transport promptly.
pediatrics.json	knowledge	pediatrics	pearls	1. Fevers with rashes are abnormal and should be considered very serious. 2. Fevers in infants ≤ 3 months old should be considered very serious. 3. Patient may seize if temperature change is rapid, be cautious and prepared to manage both seizure activity and airway at all times. 4. If fever is present with hypotension, it may indicate the patient is in septic shock. 5. Febrile seizures are more likely in children with a history of febrile seizures. 6. It is important to know if an elevation in temperature signals the abrupt onset of a fever or represents the gradual worsening of a long-term fever. 7. Cooling in the pre-hospital environment with water, alcohol, or ice is discouraged. 8. Fevers in children of 104 F / 40C for greater than 24 hours should be considered serious. 9. A common error in the treatment of fever is to wrap the patient in multiple layers of clothing and blankets. This only contributes to the rise in temperature.
pediatrics.json	knowledge	pediatrics	document title	Pediatric General Medical Emergencies
pediatrics.json	knowledge	pediatrics	protocol title	General – Universal Patient Care/Initial Patient Contact
pediatrics.json	knowledge	pediatrics	overview	Few encounters cause greater anxiety for medical providers than a pediatric patient experiencing a life-threatening situation. Although pediatric calls only account for approximately 10% of all EMS calls, they can be among the most stressful. Pre-hospital providers need to be prepared to face these challenges, as prompt recognition and treatment of potentially life-threatening diseases in children in the field may have a significant impact on the outcome of the patient. Of the 10% of EMS calls that involve pediatric patients, fewer than 5% are for life- or limb-threatening situations. When EMS does respond to a pediatric call, treatment such as administering oxygen, starting an IV, or performing endotracheal intubation can be involved in more than 50% of the cases.
pediatrics.json	knowledge	pediatrics	primary assessment	Approach to the pediatric patient varies with the patient's age and the nature of illness or injury. It is critical that EMS providers be cognizant of the emotional and physiological needs of a child throughout the assessment. It is equally important to identify the needs of the child's family members. In this stressful environment, family members will be trying to find the cause of injury or illness in their child and may be unruly when the answers they seek are not available or are contrary to what is expected. The key to pediatric assessment in EMS is to identify and manage immediate life threats. It is often easy to determine whether a child is sick just by looking at him. Sick kids look sick. If a child is active, appropriate and alert, he is not sick. The opposite is true as well. If a child is inactive and non-interactive, assume he is sick until proven otherwise. The most widely accepted approach to forming a general impression in a child is using the Pediatric Assessment Triangle. This tool is especially useful because the assessment criteria are determined during the general impression. This assessment can be performed from across the room, before contact with the patient is ever made.
pediatrics.json	knowledge	pediatrics	airway	The patient’s airway should be assessed to determine whether it is patent, maintainable, or not maintainable. For any patient who may have a traumatic injury, cervical spine precautions should be utilized while the airway is evaluated. Assessment of the patient’s level of consciousness, in conjunction with assessment of the airway, provides an impression of the effectiveness of the patient’s current airway status. If an airway problem is identified, the appropriate intervention should be initiated. The decision to use a particular intervention depends on the nature of the patient’s problem and the potential for complications during transport. Specific equipment, such as a pulse oximetry or capnography, help provide continuous airway evaluation during transport. In addition, it is important to also be able to identify differences between adult and pediatric anatomy and physiology. The anatomical and physiologic variations between adults and children can cause confusion if the EMS provider does not fully understand these differences
pediatrics.json	knowledge	pediatrics	summary of primary airway assessment	Airway: Patent, maintainable, un-maintainable Level of consciousness Skin appearance: Ashen, pale, gray, cyanotic, or mottled Preferred posture to maintain airway Airway clearance Sounds of obstruction
pediatrics.json	knowledge	pediatrics	differences in the pediatric airway	Larger tongue in relation to free space in oropharynx. Trachea is more pliable and smaller in diameter with immature tracheal rings Epiglottis is large and is more u-shaped or oblong Larynx is at the level of the 1st or 2nd vertebrae Main stem bronchi has less angle
pediatrics.json	knowledge	pediatrics	breathing	The assessment of ventilation begins with noting whether the patient is breathing. Patients presenting with apnea or severe respiratory distress, require immediate intervention. If the patient has any difficulty with ventilation, the problem must be identified and the appropriate intervention initiated. Emergent interventions may include manual ventilation of the patient via bag valve mask, endotracheal intubation, and / or needle thoracentesis. Normal respirations in an infant can be irregular and, as a result, respiratory rates should be assessed over a minimum of 30 seconds, but ideally 60 seconds. The variability of respiration in infants may not produce an accurate rate when only observed for 15 seconds. It is important to note that the variable rate of respiration in infants may include cessation in breathing for up to 20 seconds. Anything greater than 20 seconds should be considered abnormal and will require intervention.
pediatrics.json	knowledge	pediatrics	summary of primary breathing assessment	Rate and depth of respirations Cyanosis Work of breathing Use of accessory muscles Flaring of nostrils Presence of bilateral breath sounds Presence of adventitious breath sounds Asymmetric chest movements Oxygen saturation measured with pulse oximetry
pediatrics.json	knowledge	pediatrics	circulation	Palpation of both the peripheral and the central pulse provides information about the patient’s circulatory status. The quality, location, and rate of the patient’s pulses should be noted along with the temperature of the patient’s skin being assessed while obtaining the pulses. Observation of the patient’s level of consciousness may also help evaluate the patient’s perfusion status initially. Although the pediatric and adult hearts share identical anatomy, several important distinctions need to be made between the adult and pediatric cardiovascular systems. First, the adult heart increases its stroke volume by increasing inotropy (strengthening contractions) and chronotropy (increasing heart rate). In contrast, the pediatric heart can only increase chronotropy in an attempt to increase stroke volume. The pediatric heart has low compliance as it relates to volume; therefore, it cannot compensate well by increasing stroke volume. Consequently, heart rate should be seen as a significant clinical marker when monitoring cardiac output in the fetus, neonate and pediatric patient. When the pediatric patient becomes bradycardic, it should be assumed that cardiac output has been drastically reduced. Bradycardia is most commonly caused by hypoxia. Bradycardia may be an early sign of hypoxia in the neonate; however, it is an ominous sign of severe hypoxia in the infant and child. Capillary refill time is typically quite accurate in children and considered to be reliable in most cases. Just as in the adult patient, environmental factors like cold ambient temperatures can influence capillary refill times and should be taken into consideration. For this reason, capillary refill time should be assessed closer to the core in areas like the kneecap or forearm. Normal capillary refill time is less than two to three seconds.
pediatrics.json	knowledge	pediatrics	summary of primary circulation assessment	Pulse rate and quality Skin appearance: Color Peripheral pulses Skin temperature Level of consciousness Urinary output Blood Pressure Cardiac monitor Invasive monitor
pediatrics.json	knowledge	pediatrics	disability	The basic, primary neurological assessment includes assessment of the level of consciousness, the size, shape, and response of the pupils, and motor sensory function. This simple method shows if AVPU should be used to evaluate the patient’s overall level of consciousness. The Glasgow Coma Scale (GCS) provides assessment of the patient’s level of consciousness and motor function and may serve as a predictor of morbidity and mortality after brain injury. If the patient has an altered mental status, it must be determined whether the patient has ingested any toxic substances, such as alcohol or other drugs, or may be hypoxic because of illness or injury. A patient with an altered mental status may pose a safety problem during transport. Use of chemical sedation or physical restraint may be necessary to ensure safe transport of the patient and EMS providers
pediatrics.json	knowledge	pediatrics	summary of primary disability (neurological) assessment	A - Alert, V - Responds to verbal stimuli, P - Responds to painful stimuli, U - Unresponsive
pediatrics.json	knowledge	pediatrics	glasgow coma scale (gcs)	For infants under one year, the Glasgow Coma Scale scores are as follows: Eye Opening—Spontaneous (4), To voice (3), To pain (2), No response (1); Verbal Response—Coos, babbles (5), Irritable cry, consolable (4), Cries persistently to pain (3), Moans to pain (2), No response (1); Motor Response—Spontaneous (6), Withdraws to touch (5), Withdraws to pain (4), Decorticate flexion (3), Decerebrate extension (2), No response (1). For children aged 1–4 years, the scores are: Eye Opening—Spontaneous (4), To voice (3), To pain (2), No response (1); Verbal Response—Speaks and interacts socially (5), Confused speech but consolable (4), Inappropriate and inconsolable (3), Incomprehensible and agitated (2), No response (1); Motor Response—Spontaneous (6), Localizes pain (5), Withdraws to pain (4), Decorticate flexion (3), Decerebrate extension (2), No response (1).
pediatrics.json	knowledge	pediatrics	exposure	As much of the patient’s body as possible should exposed for examination, depending on complaint, with the effects of the environment on the patient kept in mind. Discovery of hidden problems before the patient is loaded for transport may allow time to intervene and avoid disastrous complications. Although exposure for examination is emphasized most frequently in care of the trauma patient, it is equally important in the primary assessment of the patient with a medical illness. The pre-hospital provider should always look under dressings or clothing, which may hide complications or potential problems. Clothing may hide bleeding that occurs as a result of thrombolytic therapy or rashes that may indicate potentially contagious conditions. In inter-facility transport, intravenous access can be wrongly assumed underneath a bulky cover. Once patient assessment has been completed, keep in mind that the patient must be kept warm. Hypothermia can cause cardiac arrhythmias, increased stress response, and hypoxia.
pediatrics.json	knowledge	pediatrics	summary of primary exposure assessment	Identification of injury, active bleeding, or indication of a serious illness. Appropriate tube placement: o Endotracheal tubes, o Chest tubes, feeding tubes, o Naso-gastric or oro-gastric tubes, and urinary catheters. Intravenous access: o Peripheral o Central o Intraosseous
pediatrics.json	knowledge	pediatrics	secondary focused assessment	The secondary assessment is performed after the primary assessment is completed and involves evaluation of the patient from head to toe. Illness specific information is collected by means of inspection, palpation, and auscultation during the secondary assessment. Whether the patient has had an injury or is critically ill, the pre-hospital provider should observe, and listen to the patient. The secondary assessment begins with an evaluation of the patient’s general appearance. The pre-hospital provider should observe the surrounding environment and evaluate its effects on the patient. Is the patient aware of the environment? Is there appropriate interaction between the patient and the environment? Determination of the amount of pain the patient has as a result of illness or injury is also an important component of the patient assessment. Baseline information should be obtained about the pain the patient has so that the effectiveness of interventions can be assessed during transport. Pain relief is one of the most important interventions for prehospital patient care providers.
pediatrics.json	knowledge	pediatrics	document title	Pediatric General Medical Emergencies
pediatrics.json	knowledge	pediatrics	protocol title	Medical – Respiratory Distress/Asthma/COPD/Croup/Reactive Airway RESPIRATORY DISTRESS/ASTHMA
pediatrics.json	knowledge	pediatrics	overview	Respiratory distress is characterized by a clinically recognizable increase in work of breathing while respiratory failure is characterized by ineffective respirations with a decreased level of consciousness. Acute respiratory emergencies in the pediatric patient are common. When not properly treated, respiratory distress can result in significant morbidity and mortality. One of the common causes of respiratory distress is asthma. The treatment of patients in severe asthmaticus must be prompt and efficient. Decisive intervention is mandatory to insure the best outcome. Appearance of the child reflects the adequacy of oxygenation and ventilation. An increased effort to breathe may indicate an airway obstruction or lack of oxygenation. Decreased breathing effort may indicate impending respiratory failure.
pediatrics.json	knowledge	pediatrics	hpi	* Time of onset * Possibility of foreign body * Medical history * Medications * Fever or respiratory infection * Other sick siblings * History of trauma
pediatrics.json	knowledge	pediatrics	signs and symptoms	* Wheezing or stridor * Respiratory retractions * See-saw respirations * Diaphoresis * Tripod position * Increased heart rate * Altered LOC * Anxious appearance
pediatrics.json	knowledge	pediatrics	considerations	* Asthma * Aspiration * Foreign body * Infection * Pneumonia, croup, epiglottitis * Congenital heart disease * Medication or toxin * Trauma
pediatrics.json	knowledge	pediatrics	procedure	1. Perform general patient management. 2. Support life -threatening problems associated with airway, breathing, and circulation. 3. Administer oxygen to maintain SPO2 94 - 99%. Support respirations as necessary with a BVM. 4. Place patient in a position of comfort, typically sitting upright. 5. If stridor present and croup is suspected, refer to Croup & Epiglottitis Protocol 9-11 6. Monitor Capnography , if available. 7. Assist patient with prescribed METERED DOSE INHALER (MDI). If no dosing schedule is prescribed, repeat in 5 to 10 minutes as needed. 8. If in critical respiratory distress, provide BVM ventilation with patient’s spontaneous efforts. If patient becomes unresponsive, perform BVM ventilation with an airway adjunct. If BVM ventilation is inadequate, secure airway with a n alternative airway or endotracheal tube [P only]. For patients in respiratory distress: 9. Give ALBUTEROL via nebulizer : Pt. <10kg : use 2.5 mg Pt > 10kg: use 5.0 mg and IPRATROPIUM 0.5 mg via small volume nebulizer. a. Greater than or equal to 4 years of age – nebulizer with mouthpiece or facemask. b. Repeat ALBUTEROL every 10 minutes up to 4 treatments if respiratory distress persists and no contraindications develop. Note: IPRATROPIUM bromide is only administered with the 1st treatment. 10. Start an IV of normal saline. 11. If greater than 2 years of age and wheezing present, administer DEXAMETHASONE 0.6mg/kg IV/IM/PO to max of 10 mg. 12. Administer CPAP with 5 - 10 cm H20 PEEP for moderate to severe dyspnea. 13. In the asthmatic patient, for severe respiratory distress that is non -responsive to standard medications, consider administration of MAGNESIUM SULFATE 40 mg / kg IV over 20 minutes (max dose of 2 grams). 14. In the asthmatic patient, for severe respiratory distress that is non -responsive to standard medications, consult Medical Control to consider administration of EPINEPHRINE 1:1,000 0.01 mg / kg up to 0.3 mg IM. 15. Place on cardiac monitor and obtain 12 lead ECG per assessment. 16. Transport and perform ongoing assessment as indicated.
pediatrics.json	knowledge	pediatrics	pearls	1. The most important component of respiratory distress is airway control. 2. Any pediatric patient presenting with substernal and intercostal retractions is in immediate need of treatment and transport. Do not delay on scene with treatments that can be completed enroute. 3. Intramuscular epinephrine administration assists with bronchodilation throughout lung tissue. In children < 8 years of age, it should be administered in the lateral thigh for optimal drug delivery. In children > 8 years of age, the deltoid can be used. 4. With repeated nebulized treatments, patients will become tachycardic. Benefits of further treatments should be weighed against the risks of tachycardia. Don’t hesitate to call medical control for concerns or questions. 5. Dexamethasone can be diluted with a small amount of juice (3-5mL) when administered orally.

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hpi signs and symptoms

- Time of injury - Mechanism: blunt vs penetrating - Loss of consciousness - Bleeding - Past medical history - Medications - Evidence of multi-system trauma - Pain, swelling, bleeding - Altered mental status, unconsciousness - Respiratory distress, failure - Vomiting - Seizure

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considerations

- Major traumatic mechanism of injury - Skull fracture - Brain injury (concussion, contusion, hemorrhage, or laceration) - Epidural hematoma - Subdural hematoma - Subarachnoid hemorrhage - Spinal injury - Abuse

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procedure

1. Perform general patient management and baseline GCS. 2. Support life-threatening problems associated with airway, breathing, and circulation. Obtain mechanism or injury. 3. Administer oxygen to maintain SpO2 94 - 99%. Consider supporting respirations with a BVM. If signs of hypoventilation are present, ventilate with BVM at an age appropriate rate. 4. Monitor capnography if BVM or intubated/alternative airway. Attempt to maintain between 35 - 45 mm Hg. 5. Consider spinal precautions based on MOI. Avoid excessive compression around the neck by cervical collar. Assess and document PMS in all extremities before and after movement. 6. Place patient on cardiac monitor. 7. Establish an IV of normal saline, if indicated, to maintain an appropriate systolic BP: a. Birth to 1 month – 60 mmHg b. 1 month to 1 year – > 70 mmHg c. Greater than 1 year - 70 + [2 x Age (years)] 8. Obtain a blood glucose sample. 9. If patient is exhibiting signs of shock, refer to Pediatric Shock protocol. 10. Transport per Trauma Triage Scheme and perform ongoing assessment as indicated.

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pearls

1. Hyperventilation is not recommended with head-injury patients. 2. One of the most important indicators of worsening head injury is a change in LOC and/or GCS. 3. Increased ICP may cause hypertension and bradycardia (Cushing’s response). 4. Hypotension usually indicates injury or shock unrelated to the head injury and should be treated aggressively. 5. A decrease of two (2) or more in the patient’s GCS should be considered due to a severe head injury until proven otherwise. 6. Recognize that “normal” blood pressure is not as important as “normal for the patient” when assessing maintenance of adequate cerebral blood flow and adequate cerebral perfusion.

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glasgow coma scale modified for pediatric patients

Eye Opening Response (<1 year) Spontaneous: 4 To shout: 3 To pain: 2 None: 1 Verbal Response (0 to 2 years) Babbles, coos appropriately: 5 Cries but inconsolably: 4 Persistent crying or screaming in pain: 3 Grunts or moans to pain: 2 None: 1 Motor Response (<1 year) Spontaneous: 6 Localizes pain: 5 Withdraws to pain: 4 Abnormal flexion to pain (decerebrate): 3 Abnormal extension to pain (decordicate): 2 None: 1

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document title

Pediatric General Medical Emergencies

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protocol title

Medical – Overdose/Poisoning/Toxic Ingestion

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overview

Ingestion and overdose are among the most common pediatric “accidents.” The substance usually is a medication prescribed for family members or for the child. Other commonly ingested poisons include cleaning chemicals, plants, and anything that fits in a child’s mouth. Primary manifestations may be a depressed mental status and/or respiratory and cardiovascular compromise. Contact Medical Control for patient care orders. Contact Poison Control (804-828-1222 or 800-222-1222) for advice. Do not confuse Poison Control with Medical Control.

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hpi

- Use or suspected use of - a potentially toxic substance - Substance ingested, - route, and quantity used - Time of use - Reason (suicidal, - accidental, criminal) - Available medications in - home

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signs and symptoms

- Mental status changes - Hypotension / - hypertension - Hypothermia / - hyperthermia - Decreased respiratory - rate - Tachycardia, other - dysrhythmias - Seizures

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considerations

- Acetaminophen - (Tylenol) - Depressants - Stimulants - Anticholinergic - Cardiac medications - Solvents, alcohols - Cleaning agents - Insecticides

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procedure

1. Perform general patient management. ***** 2. Support life-threatening problems associated with airway, breathing, and circulation. ***** 3. Administer oxygen to maintain SpO2 94 - 99%. ***** 4. Establish an IV of normal saline per patient assessment. ** 5. If child is over 20kg and respiratory effort remains diminished and opiate administration is suspected, give NARCAN INTRANASAL 2mg (one vial). May repeat one time. *** 6. a. If respiratory effort remains diminished and opiate administration is suspected, give NARCAN 0.1mg/kg slow IVP/IM max 2mg (ALS only). *** 7. Place patient on cardiac monitor and monitor pulse oximetry. ** 8. Transport and perform ongoing assessment as indicated. *****

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narcan dosage guide

Age Pre-Term Term 3 mos. 6 mos. 1 year 3 years 6 years 8 years Weight (lb / kg) 3.3 lb 1.5 kg 6.6 lb 3 kg 13.2 lb 6 kg 17.6 lb 8 kg 22 lb 10 kg 30.8 lb 14 kg 44 lb 20 kg 55 lb 25 kg Narcan IV 0.1 mg / kg 0.15 mg 0.3 mg 0.6 mg 0.8 mg 1.0 mg 1.4 mg 2.0 mg 2.0 mg

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document title

Pediatric General Medical Emergencies

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protocol title

Medical – Diabetic – Hypoglycemia

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overview

Symptomatic hypoglycemia is defined as a blood glucose level < 60 mg / dL with signs of altered mental status and / or unconsciousness. The many signs and symptoms that are associated with hypoglycemia can be divided into two broad categories: adrenergic and neurologic. The adrenergic stimulation is due to the increased epinephrine levels and the neurologic due to central nervous system dysfunction from the decreased glucose levels.

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hpi

* History of diabetes * Onset of symptoms * Medications * Fever or recent infection * Alcohol consumption * Last meal

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signs and symptoms

* Anxiety, agitation, and / or confusion * Cool, clammy skin * Diaphoresis * Seizure * Decreased visual acuity, blindness * Abnormal/ hostile behavior * Tachycardia * Hypertension * Dizziness, headache, weakness

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considerations

* Hypoxia * Seizure * Stroke * Brain trauma * Alcohol intoxication * Toxin/ substance abuse * Medication effect / overdose

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procedure

1. Perform general patient management. 2. Support life-threatening problems associated with airway, breathing, and circulation. 3. Assess for signs of trauma. Provide spinal immobilization as necessary. 4. Administer oxygen to maintain SPO2 94 - 99%. 5. For altered mental status, perform rapid glucose determination. 6. If glucose < 60 mg / dL or clinical signs and symptoms indicate hypoglycemia: a. If the patient can protect airway, give Oral Glucose 15 grams. Repeat in 15 minutes if necessary. 7. If glucose < 60 mg / dL or clinical signs and symptoms indicate hypoglycemia and oral glucose is contraindicated: Establish an IV of normal saline at KVO. a. If > 30 days, administer DEXTROSE 10% (5 mL / kg, max dose 100mL ) via IV or IO. b. If < 30 days, administer DEXTROSE 10% (2 mL / kg) via IV or IO. c. If DEXTROSE 10% bag unavailable: * If patient is < 30 days old, administer Dextrose 10% (2cc/kg) IV or IO, mixed as below. * If patient is > 30 days old but < 8 years old, administer Dextrose 25% (2cc/kg) IV or IO, mixed as below. * If patient is > 8 years old, administer Dextrose 50% (0.5mg/kg, max 25gm) IV or IO. d. If unable to establish an IV, alternatively administer GLUCAGON: * Under 20 kg: 0.5 mg IM/IN (ALS only) * >20 kg: 1.0 mg IM/IN (EMT and above) (over 20kg only) 8. For signs and symptoms of hypovolemic shock or dehydration, follow the Pediatric Shock protocol. 9. Place on cardiac monitor per patient assessment. 10. Transport and perform ongoing assessment as indicated.

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procedure for making dextrose 25 and 10 percent

Dextrose 25%: In 50 ml syringe, mix 25 ml of Dextrose 50% with 25 ml Normal Saline. Mixture will yield 50 ml of Dextrose 25%. Dextrose 10%: In 50 ml syringe, mix 10 ml of Dextrose 50% with 40 ml Normal Saline. Mixture will yield 50 ml of Dextrose 10%.

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dosage guide by age and weight

For preterm infants (weight not specified), glucagon is not indicated; dextrose 10% (bag or diluted at 2 mL/kg) is given as 4.0 mL, while dextrose 10% at 5 mL/kg and dextrose 25% at 2 mL/kg are not applicable. For term infants (6.6 lb/3 kg), give glucagon 0.5 mg, dextrose 10% (bag or diluted at 2 mL/kg) as 6.0 mL, and no dose of dextrose 10% at 5 mL/kg or dextrose 25% at 2 mL/kg. At 3 months (13.2 lb/6 kg), administer glucagon 0.5 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 30.0 mL; dextrose 25% at 2 mL/kg is 12.0 mL (3 g). At 6 months (17.6 lb/8 kg), administer glucagon 0.5 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 40.0 mL; dextrose 25% at 2 mL/kg is 16.0 mL (4 g). At 1 year (22 lb/10 kg), administer glucagon 0.5 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 50.0 mL; dextrose 25% at 2 mL/kg is 20.0 mL (5 g). At 3 years (30.8 lb/14 kg), administer glucagon 0.5 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 70.0 mL; dextrose 25% at 2 mL/kg is 28.0 mL (7 g). At 6 years (44 lb/20 kg), administer glucagon 1.0 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 100 mL; dextrose 25% at 2 mL/kg is 40.0 mL (10 g). Finally, at 8 years (55 lb/25 kg), administer glucagon 1.0 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 100 mL; dextrose 25% at 2 mL/kg is 50.0 mL (12.5 g).

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pearls

1. Hypoglycemia is the most common metabolic problem in neonates. 2. Use aseptic techniques to draw blood from finger. Allow alcohol to dry completely prior to puncturing finger for blood glucose level. Alcohol may cause inaccurate readings. Do not blow on or fan site to dry faster. 3. Blood glucose levels should be taken from extremity opposite IV and medication administration for most accurate reading. 4. After puncturing finger, use only moderate pressure to obtain blood. Excessive pressure may cause rupture of cells causing inaccurate results. 5. Know your specific agency’s glucometer parameters for a “HI” and “LO” reading. 6. When administering IV fluids, a minimum amount should be delivered as large amounts may lower blood glucose level and impede original goal of administering Dextrose. 7. Patients who are consuming aspirin, acetaminophen, anti-psychotic drugs, beta-blockers, oral diabetic medications, or antibiotics such as sulfa-based, tetracycline, and amoxicillin that experience a hypoglycemic episode are at a greater risk for relapse. These patients should be strongly encouraged to accept transport. 8. An inadequate amount of glucose for heat production, combined with profound diaphoresis, may place a hypoglycemic patient at greater risk for hypothermia. Keep patient warm as needed. 9. Glucagon causes a breakdown of stored glycogen to glucose. Glucagon may not work if glycogen stores are previously depleted due to liver dysfunction, alcoholism, or malnutrition. Effects of Glucagon may take up to 30 minutes. 10. Any patient that has had a hypoglycemic episode without a clear reason should be transported for further evaluation.

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document title

Pediatric General Medical Emergencies

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protocol title

Medical – Hypotension/Shock (Non-trauma)

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overview

Shock is defined as a state of inadequate tissue perfusion. This may result in acidosis, derangements of cellular metabolism, potential end-organ damage, and death. Early in the shock process, patients are able to compensate for decreased perfusion by increased stimulation of the sympathetic nervous system, leading to tachycardia and tachypnea. Later, compensatory mechanisms fail, causing a decreased mental status, hypotension, and death. Early cellular injury may be reversible if definitive therapy is delivered promptly.

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hpi

- Blood loss (vaginal or gastrointestinal) - Fluid loss (vomiting, diarrhea) - Fever - Infection - Medications - Allergic Reaction - Pregnancy, ectopic - Trauma - Coffee -ground emesis - Tarry stools

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signs and symptoms

- Restlessness, confusion - Weakness, dizziness - Weak, rapid pulse - Pale, cool, clammy skin - Delayed capillary refill - Hypotension

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considerations

- Hypovolemic - Cardiogenic - Septic - Neurogenic - Anaphylactic - Ectopic pregnancy - Dysrhythmia - Pulmonary embolus - Tension pneumothorax - Medication effect / overdose - Vaso -vagal - Trauma

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procedure

1. Perform general patient management. 2. Support life -threatening problems associated with airway, breathing, and circulation. 3. Assess for signs of shock including, but not limited to: Restlessness, altered mental status, hypoperfusion (cool, pale, moist skin), tachypnea (rapid breathing), rapid, weak pulse, orthostatic hypotension (blood pressure suddenly drops on standing up), nausea and thirst. 4. Administer oxygen to maintain SpO2 94 - 99%. Support respirations as necessary with a BVM. 5. Transport as soon as possible. 6. Control external bleeding with direct pressure, then tourniquet if direct pressure is inadequate. 7. Establish a large bore IV or IO of Normal Saline. If time permits, establish second access. Do not delay transport to establish vascular access 8. Maintain systolic BP appropriate for patient: - Birth to 1 month - 60 mmHg - 1 month to 1 year - > 70 mmHg - Greater than 1 year - 70 + [2 x Age (years)] 9. Give a 20 mL / kg bolus. If no improvement after first 20 mL / kg bolus, may repeat once. While administering a fluid bolus, frequently reassess perfusion for improvement. If perfusion improves, slow the IV to KVO and monitor closely. If patient develops fluid overload respiratory distress (dyspnea, crackles, rhonchi, decreasing SpO2), slow the IV to KVO. 10. Place the patient on the cardiac monitor. 11. Transport and perform ongoing assessment as indicated.

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classes of shock

Hypovolemic: Caused by hemorrhage, burns, or dehydration. Distributive: Maldistribution of blood, caused by poor vasomotor tone in neurogenic shock, sepsis, anaphylaxis, severe hypoxia, or metabolic shock. Cardiogenic: Caused by necrosis of the myocardial tissue, or by arrhythmias. Obstructive: Caused by impairment of cardiac filling, found in pulmonary embolism, tension pneumothorax, or cardiac Tamponade.

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pearls

1. GI bleeding may be a less obvious cause of hypovolemic shock if it has been gradual. Ask patient about possible melena, hematemesis, and hematochezia. 2. Ectopic pregnancy may be a less obvious cause of hypovolemic shock. Consider this diagnosis in all female patients of child-bearing age if there is a complaint of abdominal or pelvic pain.

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document title

Pediatric General Medical Emergencies

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protocol title

Medical – Altered Mental Status

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overview

Although each of these presentations has unique considerations, prehospital treatment is similar. The unconscious patient is one of the most difficult patient-management problems in pre-hospital care. Causes range from benign problems to potentially life-threatening cardiopulmonary or central nervous system disorders. In the usual clinical approach to a patient, the provider first obtains a history, performs a physical examination, and then administers treatment. However, this sequence must be altered for patients that are unconscious or with an altered level of consciousness. Simple syncope may be the result of a wide variety of medical problems, although the major cause of syncope is a lack of oxygenated blood to the brain. In this situation, it is quickly remedied when the patient collapses, improving circulation to the brain. Altered LOC is such a major variance from normal neurological function that immediate supportive efforts may be required. Efforts should be made to obtain as much of an HPI as possible from family members or bystanders.

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hpi signs symptoms considerations

Cardiac history, stroke, seizures Occult blood loss (GI, ectopic) Females (LMP, vaginal bleeding) Fluid loss (nausea, vomiting, diarrhea) Past medical history Recent trauma Complaint prior to event Loss of consciousness with recovery Lightheadedness, dizziness Palpitations, slow or rapid pulse Pulse irregularity Decreased blood pressure Vaso-vagal Orthostatic hypotension Cardiac syncope / dysrhythmia Micturation Psychiatric Hypoglycemia Seizure Shock GI Bleed Ectopic Pregnancy Toxicological (ETOH) Medication effect (hypertension)

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procedure

1. Perform general patient management. 2. Maintain patient in a supine position and assess for C -spine precautions. 3. Administer oxygen to maintain SPO2 94 - 99%  4. Assess blood glucose level. Refer to Pediatric Hypoglycemia Protocol. 5. If child is over 20kg and respiratory effort remains diminished and opiate administration is suspected, give NARCAN INTRANASAL 2mg (one vial). May repeat one time. 6. Establish IV of Normal Saline. Keep at KVO rate unless hypotensive. If hypotensive, refer to Pediatric Shock protocol. 7. Transport and reassess as needed.

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narcan dosage guide

Age Pre-Term Term 3 6 1 3 6 8 Weight (lb / kg) 3.3 lb1.5 kg 6.6 lb3 kg 13.2 lb6 kg 17.6 lb8 kg 22 lb10 kg 30.8 lb14 kg 44 lb20 kg 55 lb25 kg Narcan IV 0.1 mg/kg 0.15 ml 0.3 ml 0.6 ml 0.8 ml 1.0 ml 1.4 ml 2.0 ml 2.0 ml

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pearls

1. Assess for signs and symptoms of trauma if questionable or suspected fall with syncope. 2. Consider dysrhythmias, GI bleed, ectopic pregnancy, and seizure as possible causes of syncope.

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document title

Pediatric General Medical Emergencies

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protocol title

Medical – Seizure

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overview

A seizure is a period of altered neurologic function caused by abnormal neuronal electrical discharges. Generalized seizures begin with an abrupt loss of consciousness. If motor activity is present, it symmetrically involves all four extremities. Episodes that develop over minutes to hours are less likely to be seizures; most seizures only last 1 - 2 minutes. Patients with seizure disorders tend to have stereotype, or similar, seizures with each episode and are less likely to have inconsistent or highly variable attacks. True seizures are usually not provoked by emotional stress. Most seizures are followed by a postictal state of lethargy and confusion.

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hpi signs symptoms

Reported, witnessed seizure activity description Previous seizure history information Medic alert tag Seizure medications History of trauma History of diabetes mellitus History of pregnancy Decreased mental status Sleepiness Incontinence Observed seizure activity Evidence of trauma

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considerations

CNS (head) trauma Tumor Metabolic, hepatic, renal failure Diabetic Hypoxia Electrolyte abnormality Drugs, medications, non-compliance Infection, fever, meningitis Alcohol withdrawal Hyperthermia

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procedure

1.Perform general patient management. 2.Support life-threatening problems associated with airway, breathing, and circulation. 2a.Suction the oro - and nasopharynx as necessary. 2b.Place a nasopharyngeal airway as necessary (avoid in head trauma). 3.Administer oxygen to maintain SpO2 94 - 99%. Support respirations as necessary with a BVM. 4.Do not restrain the patient. Let the seizure take its course but protect patient from injury. 5.If the seizure persists give MIDAZOLAM 0.2 mg / kg INTRANASAL (max single dose 10 mg) –OR- give MIDAZOLAM 0.1 mg / kg IV / IM (max single dose 10 mg) 5a.Repeat dose in 5 minutes if seizure persists. 5b.If Midazolam is unavailable, administer, DIAZEPAM 0.25 mg / kg up to 5 mg slow IV push, titrated to effect. Diazepam may also be administered Per Rectum (PR) in pediatric patients. 6.Perform rapid glucose determination. If glucose less than 60 mg / dL or clinical signs and symptoms indicate hypoglycemia, refer to the Hypoglycemia protocol 7.Establish an IV of normal saline at KVO. 8.Place patient on cardiac monitor (sometime life-threatening dysrhythmias can cause seizure-like activity). 9.Consider placing the patient in the recovery position during the postictal period. 10. Transport and perform ongoing assessment as indicated.

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generalized seizure types

Absence (Petit -Mal) Atonic (Drop Attack) Myoclonic (Brief bilateral jerking) Tonic-Clonic (Grand - Mal)

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simple partial seizure types

Focal / Local: Localized twitching of hand, arm, leg, face, or eyes. Patient may be conscious or unconscious

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complex partial seizure types

Temporal Lobe Psychomotor

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pediatric dosage information table

Age Pre- Term Term 3 month 6 month 1 year 3 years 6 years 8 years Weight (lb / kg) 3.3 lb 1.5 kg 6.6 lb 3 kg 13.2 lb 6 kg 17.6 lb 8 kg 22 lb 10 kg 30.8 lb 14 kg 44 lb 20 kg 55 lb 25 kg Midazolam IV 0.15 mg 0.3mg 0.6mg 0.8 mg 0.1mg 1.4mg 2mg 2.5mg Midazolam IN *1/2 dose per nostril* 0.3 mg 0.6mg 1.2mg 1.6mg 2mg 2.8mg 4mg 5mg Diazepam IV (5.0 mg / ml) 0.3 mg/kg 0.1 ml 0.2 ml 0.4 ml 0.5 ml 0.6 ml 0.84 ml 1.2 ml 1.5 ml Diazepam PR (5.0 mg / ml) 0.5 mg / kg 0.15 ml 0.3 ml 0.6 ml 0.8 ml 1.0 ml 1.4 ml 2.0 ml 2.0 ml

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pearls

1. Respirations during an active seizure should be considered ineffective and airway maintenance should occur per assessment. 2. Status epilepticus is defined as two or more consecutive seizures without a period of consciousness or recovery. This is a true emergency requiring rapid airway support, treatment, and transport. 3. Grand Mal seizures are generalized in nature and associated with loss of consciousness, incontinence, and possibly tongue trauma. 4. Focal seizures affect only a specific part of the body and are not usually associated with loss of consciousness. 5. Jacksonian seizures are seizures, which start as focal in nature and become generalized. 6. Petit Mal seizures may be localized to a single muscle group or may not involve visible seizure activity all. Always examine pupils for nystagmus, which would alert provider to continued seizure activity. 7. Be prepared for airway problems and continued seizures. 8. Investigate possibility of trauma and substance abuse. 9. Be prepared to assist ventilations as dosages of benzodiazepines are increased.

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document title

Pediatric General Medical Emergencies

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protocol title

Medical – Diabetic Hyperglycemia

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overview:

- Diabetes mellitus is the most common endocrine disorder of childhood, affecting approximately 2/1,000 school-age children in the United States. - Symptomatic hyperglycemia is defined as a blood glucose level > 300 mg/dl with signs of severe dehydration, altered mental status, and/ or shock. - Hyperglycemia is usually the result of an inadequate supply of insulin to meet the body's needs. - Most pre -hospital care should be focused around the treatment of severe dehydration and support of vital functions.

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hpi

- History of diabetes - Onset of symptoms - Medications

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signs and symptoms

- Anxiety, agitation, and / or confusion - Dry, red, and / or warm skin - Fruity / acetone smell on breath - Kussmaul respirations - Dry mouth, intensive thirst - Abnormal/ hostile behavior - Tachycardia - Dizziness / headache

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considerations

- Hypoxia - Brain trauma - Alcohol intoxication - Toxin / substance abuse - Medication effect / overdose

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procedure

1. Perform general patient management. 2. Support life -threatening problems associated with airway, breathing, and circulation. 3. Assess for signs of trauma. Provide spinal immobilization as necessary. 4. Administer oxygen to maintain SPO2 94 - 99% 5. For altered mental status, perform rapid glucose determination. 6. If glucose > 300 mg / dL, start an IV of normal saline. 7. For signs and symptoms of hypovolemic shock or dehydration, follow the Pediatric Shock protocol. 8. If glucose level is > 300 mg / dL, and no signs of shock are noted, administer maintenance Normal Saline infusion: - 4.0 ml / kg for first 1 - 10 kg of weight. - Add 2.0 ml / kg for next 11 - 20 kg of weight. - Add 1.0 ml / kg, for every kg of weight, > 20 kg. - Multiply total amount x 2= total hourly hyperglycemic maintenance amount. 9. Place on cardiac monitor and obtain / interpret 12 lead ECG per assessment. 10. Transport and perform ongoing assessment as indicated.

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pearls:

1. Know your specific agency's glucometer parameters for a "HI" and "LO" reading. 2. It is estimated that 2 - 8% of all hospital admissions are for the treatment of DKA, while mortality for DKA is between 2 - 10%. Published mortality rates for HHS vary, but the trend is that the older the patient and higher the osmolarity, the greater the risk of death.

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document title

Pediatric General Medical Emergencies

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protocol title

Medical – Nausea/Vomiting

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overview

The pre-hospital provider should be very careful to ensure that patients who present with vague complaints such as nausea and vomiting are thoroughly evaluated. The patient’s symptoms and recent history must determine the most appropriate care. Frequently, treatment of an underlying cause and limiting movement may resolve or greatly reduce these complaints. However, persistent nausea and vomiting of unknown etiology may respond well to pharmaceutical therapy. All patients presenting with nausea and vomiting should be screened for potential life-threats initially. Anti-emetic treatment should occur only as a secondary priority.

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hpi

Age Time of last meal Last bowel movement, emesis Improvement, worsening with food or activity Duration of signs and symptoms Other sick contacts Past medical, surgical history Medications Menstrual history (pregnancy) Travel history Recent trauma Pain Character of pain (constant, intermittent, sharp, dull, etc.)

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signs and symptoms

Distention Constipation Diarrhea Anorexia Radiation Associated symptoms (helpful to localize source) Fever, headache, blurred vision, weakness, malaise, myalgias, cough, dysuria, mental status changes, rash

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considerations

CNS (increased pressure, headache, lesions, trauma, hemorrhage, vestibular) Drugs (NSAIDs, antibiotics, narcotics, chemotherapy) GI or renal disorders Gynecological disease (ovarian cyst, PID) Infections (pneumonia, influenza) Electrolyte abnormalities Food or toxin induced Medications, substance abuse Pregnancy Psychologic

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procedure

1. Perform general patient management. 2. Support life-threatening problems associated with airway, breathing, and circulation. 3. Administer oxygen to maintain SPO₂ 94 - 99% 4. Allow the patient to lie in a comfortable position. 5. Establish an IV of normal saline per patient assessment. 6. Assess for signs of shock. If shock is suspected, follow the Pediatric Shock protocol. 7. For severe nausea or vomiting, if available, give ONDANSETRON (ZOFRAN). *If only IV formulation is available, administer 0.1 mg / kg IV / IM up to 4 mg over 2 to 5 minutes.* 8. In lieu of IV ONDANSETRON, may administer 4 mg PO ONDANSETRON OTD tablet for patients over 44 lbs (20 kg). 9. May repeat Ondansetron PO or IV dosing after 10 minutes, if needed. 10. Perform ongoing assessment as indicated and transport.

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ondansetron dosing table

Ondansetron IV (0.1 mg/kg) is not specified for term infants (6.6 lb/3 kg) or 6-month-olds (17.6 lb/8 kg). For a 1-year-old (22 lb/10 kg), administer 1.0 mg; for a 3-year-old (30.8 lb/14 kg), 1.5 mg; for a 6-year-old (44 lb/20 kg), 2.0 mg; for an 8-year-old (55 lb/25 kg), 2.5 mg; for a 10-year-old (75 lb/34 kg), 3.5 mg; and for both 12-year-olds (88 lb/40 kg) and 14-year-olds (110 lb/50 kg), 4.0 mg.

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pearls

1. Nausea and vomiting has many subtle, sometimes life-threatening causes. Do not minimize its importance as a symptom. 2. Ondansetron may not be as effective for vertigo and labyrinthitis related nausea and vomiting. 3. For nausea and vomiting associated with dehydration, fluid replenishment may be sufficient in improving patient comfort and reduce the need for medication administration. 4. Ensuring that you have reasonably addressed possible causes, will help minimize the potential that you are overlooking a life-threat and/or concern that should receive priority over anti-emetic treatment. 5. In cases of toxic ingestion, including alcohol, poisons, and drug overdoses, vomiting is an internal protective mechanism and should not be prevented with pharmacological therapy in the pre-hospital environment. Care should be given to prevent aspiration. 6. Ondansetron is also safe and effective for nausea and vomiting in trauma patients and can be used in conjunction with pain management. 7. Proper documentation should include the mental status and vital signs before and after medication administration.

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document title

Pediatric General Medical Emergencies

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protocol title

General – Fever

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overview

Fever is a common chief complaint of children encountered in the pre-hospital environment. Patients with fever present in many different ways, depending on the age of the patient, the rate of rise of the temperature, the magnitude of the fever, the etiology of the fever, and the underlying health of the patient. The patient’s skin will be warm to the touch and may be flushed on observation. The patient may also complain of being warm and perspiring. It is important to recognize that fever represents a symptom of an underlying illness, and the actual illness must be determined and treated. Flu-like symptoms may accompany fevers, but it should not be assumed that fevers with these symptoms are minor, as there may be a serious underlying medical condition. Febrile seizures usually are self-limiting and typically occur once from a rapid rise in temperature, usually above 101.8 F / 38.7C. If more than one seizure occurs, causes other than fever should be suspected. The first occurrence of a seizure warrants the most concern because the benign nature of the illness has not been established.

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hpi

- Age - Duration of fever - Severity of fever - Any previous decrease or elevation of fever since onset - Past medical history - Medications - Immunocompromised (transplant, HIV, diabetes, cancer) - Recent illness or socialization with others with illness - Vaccinations - Poor PO intake - Urine production, decrease in diapers - Last acetaminophen dose

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signs and symptoms

- Altered mental status - Unconsciousness - Hot, dry, or flushed skin - Tachycardia - Hypotension, shock - Seizures - Nausea, vomiting - Weakness, dizziness, syncope - Restlessness - Loss of appetite - Decreased urine output - Rapid, shallow respirations - Associated symptoms (helpful in localizing source): myalgias, cough, chest pain, headache, dysuria, abdominal pain, mental status changes, rash

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considerations

- Infection, sepsis - Neoplasms, cancer, tumors, lymphomas - Medication or drug reaction - Connective tissue disease - Vasculitis - Thermoregulatory disorder - Hyperthyroid - Heat stroke - Drug fever

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procedure

1. Perform general patient management. 2. Support life-threatening problems associated with airway, breathing, and circulation. 3. Administer oxygen to maintain SPO2 94 - 99% 4. If the patient is having a seizure, refer to the Pediatric Seizure protocol. 5. If temperature is greater than 106  F / 41C, refer to Hyperthermia Patient Care Protocol. 6. Begin passive cooling by removing excess and constrictive clothing. Avoid overexposure. 7. Obtain blood glucose sample. If glucose is < 60 mg / dL or > 300 mg / dL, refer to Pediatric Hypoglycemia or Hyperglycemia Patient Care Protocol. 8. Establish an IV of normal saline at KVO. Titrate to a systolic pressure appropriate for child: - Birth to 1 month - 60 mmHg - 1 month to 1 year - > 70 mmHg - Greater than 1 year - 70 + [2 x Age (years)] 9. If hypoperfusion is suspected, refer to the Pediatric Shock protocol. 10. Perform ongoing assessment as indicated and transport promptly.

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pearls

1. Fevers with rashes are abnormal and should be considered very serious. 2. Fevers in infants ≤ 3 months old should be considered very serious. 3. Patient may seize if temperature change is rapid, be cautious and prepared to manage both seizure activity and airway at all times. 4. If fever is present with hypotension, it may indicate the patient is in septic shock. 5. Febrile seizures are more likely in children with a history of febrile seizures. 6. It is important to know if an elevation in temperature signals the abrupt onset of a fever or represents the gradual worsening of a long-term fever. 7. Cooling in the pre-hospital environment with water, alcohol, or ice is discouraged. 8. Fevers in children of 104 F / 40C for greater than 24 hours should be considered serious. 9. A common error in the treatment of fever is to wrap the patient in multiple layers of clothing and blankets. This only contributes to the rise in temperature.

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document title

Pediatric General Medical Emergencies

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protocol title

General – Universal Patient Care/Initial Patient Contact

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overview

Few encounters cause greater anxiety for medical providers than a pediatric patient experiencing a life-threatening situation. Although pediatric calls only account for approximately 10% of all EMS calls, they can be among the most stressful. Pre-hospital providers need to be prepared to face these challenges, as prompt recognition and treatment of potentially life-threatening diseases in children in the field may have a significant impact on the outcome of the patient. Of the 10% of EMS calls that involve pediatric patients, fewer than 5% are for life- or limb-threatening situations. When EMS does respond to a pediatric call, treatment such as administering oxygen, starting an IV, or performing endotracheal intubation can be involved in more than 50% of the cases.

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primary assessment

Approach to the pediatric patient varies with the patient's age and the nature of illness or injury. It is critical that EMS providers be cognizant of the emotional and physiological needs of a child throughout the assessment. It is equally important to identify the needs of the child's family members. In this stressful environment, family members will be trying to find the cause of injury or illness in their child and may be unruly when the answers they seek are not available or are contrary to what is expected. The key to pediatric assessment in EMS is to identify and manage immediate life threats. It is often easy to determine whether a child is sick just by looking at him. Sick kids look sick. If a child is active, appropriate and alert, he is not sick. The opposite is true as well. If a child is inactive and non-interactive, assume he is sick until proven otherwise. The most widely accepted approach to forming a general impression in a child is using the Pediatric Assessment Triangle. This tool is especially useful because the assessment criteria are determined during the general impression. This assessment can be performed from across the room, before contact with the patient is ever made.

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airway

The patient’s airway should be assessed to determine whether it is patent, maintainable, or not maintainable. For any patient who may have a traumatic injury, cervical spine precautions should be utilized while the airway is evaluated. Assessment of the patient’s level of consciousness, in conjunction with assessment of the airway, provides an impression of the effectiveness of the patient’s current airway status. If an airway problem is identified, the appropriate intervention should be initiated. The decision to use a particular intervention depends on the nature of the patient’s problem and the potential for complications during transport. Specific equipment, such as a pulse oximetry or capnography, help provide continuous airway evaluation during transport. In addition, it is important to also be able to identify differences between adult and pediatric anatomy and physiology. The anatomical and physiologic variations between adults and children can cause confusion if the EMS provider does not fully understand these differences

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summary of primary airway assessment

Airway: Patent, maintainable, un-maintainable Level of consciousness Skin appearance: Ashen, pale, gray, cyanotic, or mottled Preferred posture to maintain airway Airway clearance Sounds of obstruction

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differences in the pediatric airway

Larger tongue in relation to free space in oropharynx. Trachea is more pliable and smaller in diameter with immature tracheal rings Epiglottis is large and is more u-shaped or oblong Larynx is at the level of the 1st or 2nd vertebrae Main stem bronchi has less angle

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breathing

The assessment of ventilation begins with noting whether the patient is breathing. Patients presenting with apnea or severe respiratory distress, require immediate intervention. If the patient has any difficulty with ventilation, the problem must be identified and the appropriate intervention initiated. Emergent interventions may include manual ventilation of the patient via bag valve mask, endotracheal intubation, and / or needle thoracentesis. Normal respirations in an infant can be irregular and, as a result, respiratory rates should be assessed over a minimum of 30 seconds, but ideally 60 seconds. The variability of respiration in infants may not produce an accurate rate when only observed for 15 seconds. It is important to note that the variable rate of respiration in infants may include cessation in breathing for up to 20 seconds. Anything greater than 20 seconds should be considered abnormal and will require intervention.

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summary of primary breathing assessment

Rate and depth of respirations Cyanosis Work of breathing Use of accessory muscles Flaring of nostrils Presence of bilateral breath sounds Presence of adventitious breath sounds Asymmetric chest movements Oxygen saturation measured with pulse oximetry

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circulation

Palpation of both the peripheral and the central pulse provides information about the patient’s circulatory status. The quality, location, and rate of the patient’s pulses should be noted along with the temperature of the patient’s skin being assessed while obtaining the pulses. Observation of the patient’s level of consciousness may also help evaluate the patient’s perfusion status initially. Although the pediatric and adult hearts share identical anatomy, several important distinctions need to be made between the adult and pediatric cardiovascular systems. First, the adult heart increases its stroke volume by increasing inotropy (strengthening contractions) and chronotropy (increasing heart rate). In contrast, the pediatric heart can only increase chronotropy in an attempt to increase stroke volume. The pediatric heart has low compliance as it relates to volume; therefore, it cannot compensate well by increasing stroke volume. Consequently, heart rate should be seen as a significant clinical marker when monitoring cardiac output in the fetus, neonate and pediatric patient. When the pediatric patient becomes bradycardic, it should be assumed that cardiac output has been drastically reduced. Bradycardia is most commonly caused by hypoxia. Bradycardia may be an early sign of hypoxia in the neonate; however, it is an ominous sign of severe hypoxia in the infant and child. Capillary refill time is typically quite accurate in children and considered to be reliable in most cases. Just as in the adult patient, environmental factors like cold ambient temperatures can influence capillary refill times and should be taken into consideration. For this reason, capillary refill time should be assessed closer to the core in areas like the kneecap or forearm. Normal capillary refill time is less than two to three seconds.

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summary of primary circulation assessment

Pulse rate and quality Skin appearance: Color Peripheral pulses Skin temperature Level of consciousness Urinary output Blood Pressure Cardiac monitor Invasive monitor

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disability

The basic, primary neurological assessment includes assessment of the level of consciousness, the size, shape, and response of the pupils, and motor sensory function. This simple method shows if AVPU should be used to evaluate the patient’s overall level of consciousness. The Glasgow Coma Scale (GCS) provides assessment of the patient’s level of consciousness and motor function and may serve as a predictor of morbidity and mortality after brain injury. If the patient has an altered mental status, it must be determined whether the patient has ingested any toxic substances, such as alcohol or other drugs, or may be hypoxic because of illness or injury. A patient with an altered mental status may pose a safety problem during transport. Use of chemical sedation or physical restraint may be necessary to ensure safe transport of the patient and EMS providers

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summary of primary disability (neurological) assessment

A - Alert, V - Responds to verbal stimuli, P - Responds to painful stimuli, U - Unresponsive

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glasgow coma scale (gcs)

For infants under one year, the Glasgow Coma Scale scores are as follows: Eye Opening—Spontaneous (4), To voice (3), To pain (2), No response (1); Verbal Response—Coos, babbles (5), Irritable cry, consolable (4), Cries persistently to pain (3), Moans to pain (2), No response (1); Motor Response—Spontaneous (6), Withdraws to touch (5), Withdraws to pain (4), Decorticate flexion (3), Decerebrate extension (2), No response (1). For children aged 1–4 years, the scores are: Eye Opening—Spontaneous (4), To voice (3), To pain (2), No response (1); Verbal Response—Speaks and interacts socially (5), Confused speech but consolable (4), Inappropriate and inconsolable (3), Incomprehensible and agitated (2), No response (1); Motor Response—Spontaneous (6), Localizes pain (5), Withdraws to pain (4), Decorticate flexion (3), Decerebrate extension (2), No response (1).

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exposure

As much of the patient’s body as possible should exposed for examination, depending on complaint, with the effects of the environment on the patient kept in mind. Discovery of hidden problems before the patient is loaded for transport may allow time to intervene and avoid disastrous complications. Although exposure for examination is emphasized most frequently in care of the trauma patient, it is equally important in the primary assessment of the patient with a medical illness. The pre-hospital provider should always look under dressings or clothing, which may hide complications or potential problems. Clothing may hide bleeding that occurs as a result of thrombolytic therapy or rashes that may indicate potentially contagious conditions. In inter-facility transport, intravenous access can be wrongly assumed underneath a bulky cover. Once patient assessment has been completed, keep in mind that the patient must be kept warm. Hypothermia can cause cardiac arrhythmias, increased stress response, and hypoxia.

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summary of primary exposure assessment

Identification of injury, active bleeding, or indication of a serious illness. Appropriate tube placement: o Endotracheal tubes, o Chest tubes, feeding tubes, o Naso-gastric or oro-gastric tubes, and urinary catheters. Intravenous access: o Peripheral o Central o Intraosseous

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secondary focused assessment

The secondary assessment is performed after the primary assessment is completed and involves evaluation of the patient from head to toe. Illness specific information is collected by means of inspection, palpation, and auscultation during the secondary assessment. Whether the patient has had an injury or is critically ill, the pre-hospital provider should observe, and listen to the patient. The secondary assessment begins with an evaluation of the patient’s general appearance. The pre-hospital provider should observe the surrounding environment and evaluate its effects on the patient. Is the patient aware of the environment? Is there appropriate interaction between the patient and the environment? Determination of the amount of pain the patient has as a result of illness or injury is also an important component of the patient assessment. Baseline information should be obtained about the pain the patient has so that the effectiveness of interventions can be assessed during transport. Pain relief is one of the most important interventions for prehospital patient care providers.

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document title

Pediatric General Medical Emergencies

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protocol title

Medical – Respiratory Distress/Asthma/COPD/Croup/Reactive Airway RESPIRATORY DISTRESS/ASTHMA

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pediatrics

overview

Respiratory distress is characterized by a clinically recognizable increase in work of breathing while respiratory failure is characterized by ineffective respirations with a decreased level of consciousness. Acute respiratory emergencies in the pediatric patient are common. When not properly treated, respiratory distress can result in significant morbidity and mortality. One of the common causes of respiratory distress is asthma. The treatment of patients in severe asthmaticus must be prompt and efficient. Decisive intervention is mandatory to insure the best outcome. Appearance of the child reflects the adequacy of oxygenation and ventilation. An increased effort to breathe may indicate an airway obstruction or lack of oxygenation. Decreased breathing effort may indicate impending respiratory failure.

pediatrics.json

knowledge

pediatrics

hpi

* Time of onset * Possibility of foreign body * Medical history * Medications * Fever or respiratory infection * Other sick siblings * History of trauma

pediatrics.json

knowledge

pediatrics

signs and symptoms

* Wheezing or stridor * Respiratory retractions * See-saw respirations * Diaphoresis * Tripod position * Increased heart rate * Altered LOC * Anxious appearance

pediatrics.json

knowledge

pediatrics

considerations

* Asthma * Aspiration * Foreign body * Infection * Pneumonia, croup, epiglottitis * Congenital heart disease * Medication or toxin * Trauma

pediatrics.json

knowledge

pediatrics

procedure

1. Perform general patient management. 2. Support life -threatening problems associated with airway, breathing, and circulation. 3. Administer oxygen to maintain SPO2 94 - 99%. Support respirations as necessary with a BVM. 4. Place patient in a position of comfort, typically sitting upright. 5. If stridor present and croup is suspected, refer to Croup & Epiglottitis Protocol 9-11 6. Monitor Capnography , if available. 7. Assist patient with prescribed METERED DOSE INHALER (MDI). If no dosing schedule is prescribed, repeat in 5 to 10 minutes as needed. 8. If in critical respiratory distress, provide BVM ventilation with patient’s spontaneous efforts. If patient becomes unresponsive, perform BVM ventilation with an airway adjunct. If BVM ventilation is inadequate, secure airway with a n alternative airway or endotracheal tube [P only]. For patients in respiratory distress: 9. Give ALBUTEROL via nebulizer : Pt. <10kg : use 2.5 mg Pt > 10kg: use 5.0 mg and IPRATROPIUM 0.5 mg via small volume nebulizer. a. Greater than or equal to 4 years of age – nebulizer with mouthpiece or facemask. b. Repeat ALBUTEROL every 10 minutes up to 4 treatments if respiratory distress persists and no contraindications develop. Note: IPRATROPIUM bromide is only administered with the 1st treatment. 10. Start an IV of normal saline. 11. If greater than 2 years of age and wheezing present, administer DEXAMETHASONE 0.6mg/kg IV/IM/PO to max of 10 mg. 12. Administer CPAP with 5 - 10 cm H20 PEEP for moderate to severe dyspnea. 13. In the asthmatic patient, for severe respiratory distress that is non -responsive to standard medications, consider administration of MAGNESIUM SULFATE 40 mg / kg IV over 20 minutes (max dose of 2 grams). 14. In the asthmatic patient, for severe respiratory distress that is non -responsive to standard medications, consult Medical Control to consider administration of EPINEPHRINE 1:1,000 0.01 mg / kg up to 0.3 mg IM. 15. Place on cardiac monitor and obtain 12 lead ECG per assessment. 16. Transport and perform ongoing assessment as indicated.

pediatrics.json

knowledge

pediatrics

pearls

1. The most important component of respiratory distress is airway control. 2. Any pediatric patient presenting with substernal and intercostal retractions is in immediate need of treatment and transport. Do not delay on scene with treatments that can be completed enroute. 3. Intramuscular epinephrine administration assists with bronchodilation throughout lung tissue. In children < 8 years of age, it should be administered in the lateral thigh for optimal drug delivery. In children > 8 years of age, the deltoid can be used. 4. With repeated nebulized treatments, patients will become tachycardic. Benefits of further treatments should be weighed against the risks of tachycardia. Don’t hesitate to call medical control for concerns or questions. 5. Dexamethasone can be diluted with a small amount of juice (3-5mL) when administered orally.