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Flashcards in 2019 Protocols (Pediatric) Deck (41)
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1

S-160 Pediatric Airway Obstruction BLS

For a CONSCIOUS patient:
-Reassure, encourage coughing
-O2 prn

For inadequate air exchange:
(airway maneuvers AHA)
-Abdominal thrusts
-Use chest thrusts in the obese or pregnant patient
Note: for infants <1 year
-5 back blows and chest thrusts
-MR prn

If patient becomes UNCONSCIOUS or is found UNCONSCIOUS:
-Begin CPR

Once obstruction is removed:
-O2 saturation prn
-High flow O2 ventilate prn
Note: if suspected epiglottits:
-Place patient in sitting position
-Do not visualize the oropharynx
-STAT transport
-Treat as per Respirator Distress Protocol S-167

2

S-160 Pediatric Airway Obstruction ALS+Note

If patient becomes unconscious or has a decreasing LOC:
-Direct laryngoscopy and Magill forceps SO
MR prn SO
-
Once obstruction is removed:
-Monitor EKG
-IV/IO SO adjust prn

Note:
If unable to secure airway, transport STAT while continuing CPR (unconscious patient).

3

S-161 Pediatric Altered Neurologic Function (Nontraumatic) BLS

-Ensure patent airway, O2 and/or ventilate prn
-O2 saturation prn
-Spinal stabilization when indicated
-Secretion problems; position on affected side
-Do not allow patient to walk
-Restrain prn
-Monitor blood glucose prn

Hypoglycemia (suspected) or patient's glucometer results, if available, read <60 (Neonate <45):
-If patient is awake and has gag reflex, give oral glucose paste or 3 tablet (15g). Patient may eat or drink if able.
-If patient is unconscious, NPO

Seizures:
-Protect airway, and protect from injury
-Treat associate injuries
-If febrile, remove excess clothing/covering

Behavioral Emergencies:
-Restrain only if necessary to prevent injury
-Avoid unnecessary sirens
-Consider law enforcement support

4

S-161 Pediatric Altered Neurologic Function (Nontraumatic) ALS

-IV/IO SO adjust prn
-Monitor EKG/blood glucose prn
-Capnography SO prn

Symptomatic ?opioid (excluding opioid dependent pain management patients):
-Naloxone per drug chart IN/IV/IM SO. MR SO

Symptomatic ?opioids OD is opioid dependent pain management patients:
-Naloxone titrate per drug chart IV (dilute IV dose per drug chart) or IN/IM per drug chart SO. MR BHO

Hypoglycemia: Symptomatic patient unresponsive to oral glucose agents:
-D10 per drug chart IV SO if BS <60 (Neonate <45)
-If patient remains symptomatic and BS remains <60 (Neonate <45) MR SO
-If no IV: Glucagon per drug chart IM SO if BS <60 (Neonate <45)

Seizures:
FOR:
-Ongoing generalized seizure lasting >5 minutes (including seizure time prior to arrival of prehospital provider) SO
-Partial seizure with respiratory compromise SO
-Recurrent tonic-clonic seizures without lucid interval SO
GIVE:
-Versed per drug chart slow IV, (d/c if seizure stops) SO
MR x1 in 10" SO
-If no IV: Versed per drug chart IN/IM SO
MR x1 in 10" SO

5

S-162 Pediatric Allergic Reaction/Anaphylaxis BLS

-Ensure patent airway
-O2 saturation prn
-O2 and/or ventilate prn
-Remove sting/injection mechanism
-May assist patient to self-medicate own prescribed epinephrine auto injector or MDI ONE TIME ONLY. Base hospital contact required prior to any repeat dose
-Epinephrine auto-injector 0.15mg IM x1

6

S-162 Pediatric Allergic Reaction/Anaphylaxis ALS

-Monitor EKG
-IV/IO SO adjust prn

Hives (Urticaria):
-Diphenhydramine per drug chart IV/IM SO

Anaphylaxis:
-Epinephrine 1:1,000 per drug chart IM SO
MR x2 q5" SO
**THEN**
-Fluid bolus IV/IO per drug chart SO
to maintain adequate perfusion MR SO
-Diphenhydramine per drug chart IV/IM SO
-Albuterol per drug chart via nebulizer SO for respiratory involvement MR SO
-Atrovent per drug chart via nebulizer added to first dose of Albuterol SO for respiratory involvement
-Epinephrine 1:10,000 per drug chart IV/IO BHO
MR x2 q3-5" BHO

7

S-162 Pediatric Allergic Reaction/Anaphylaxis (Anaphylaxis Critera+Angioedema+Note)

Anaphylaxis critera (may include any):
-Unknown exposure: Skin AND respiratory AND/OR cardiovascular
-Likely allergen exposure (e.g. bee sting, peanut): 2/4 systems involved (skin, GI, respiratory, cardiovascular)
-Known allergen exposure

Angioedema: lip/tongue/face swelling/difficulty swallowing, throat tightness, hoarse voice

Note: In pediatric anaphylaxis, the maximum Epinephrine dose is 0.1mg IV/IO (should not exceed adult dose).

8

S-163 Pediatric Dysrythmias BLS+Unstable Dysrhythmia

-Assess level of consciousness
-O2 saturation prn
-Determine peripheral pulses
-Ensure patent airway, O2 and/or ventilate prn

Unstable Dysrhythmia:
Includes heart rates listed and any of the following:
-Poor perfusion (cyanosis, delayed capillary refill, mottling)
**OR**
-Altered LOC, Dyspnea
**OR**
-BP 200/min.

-Pulseless and unconscious, use AED if available. If pediatric pads not available may use adult pads but ensure they do not touch each other when applied.
-When heart rate indicates patient is unstable ventilate per BVM for 30 seconds, reassess HR and begin compression if indicated:
Heart rate:
<9 yrs HR <60
9-14 yrs HR <40

9

S-163 Pediatric Dysrythmias ALS (Unstable Bradycardia/ Unstable/Stable Supraventricular Tachycardia)

-Monitor EKG
-IV/IO SO
-Fluid bolus IV/IO per drug chart with clear lungs SO
MR to maintain systolic adequate perfusion SO

Unstable Bradycardia:
Heart rate:
Infant/Child (<9 yrs) <60
Child (9-14 yrs) <40
-Ventilate per BVM for 30 seconds, then reassess HR prior to compressions and drug therapy
-Epinephrine 1:10,000 per drug chart IV/IO SO
MR x2 q3-5" SO. MR q3-5" BHO
After 3rd dose of Epinephrine:
-Atropine per drug chart IV/IO SO. MR x1 in 5" SO

Unstable Supraventricular Tachycardia:
Heart rate:
<4 yrs >220
>4 yrs >180
-VSM per SO. MR SO
-Adenosine per drug chart rapid IV BHPO
follow with NS 20ml rapid IV
-Adenosine per drug chart rapid IV BHPO
follow with NS 20ml rapid IV
-If no sustained rhythm change, MR x1 BHPO

prn precardioversion
-Versed per drug chart IV BHPO
-Synchronized cardioversion per drug chart* BHPO
MR per drug chart BHPO
*or according to defibrillators manufacturer's recommendations

Stable Supraventricular Tachycardia:
-Continue to monitor

10

S-163 Pediatric Dysrythmias BLS (Ventricular Tachycardia/VF/Pulseless VT)

-O2 and/or ventilate prn
-CPR: Being compressions. After first 30 compressions give first ventilation
-Use AED if, pulseless and unconscious, and AED available. If pediatric pads not available may use adult pads but ensure they do not touch each other when applied.

11

S-163 Pediatric Dysrhythmias ALS (Ventricular Tachycardia/VF/Pulseless VT)

Ventricular Tachycardia:
-12-lead to confirm
-Contact BHPO for direction

VF/Pulseless VT:
-Begin CPR
If arrest witnessed by medical personnel
-Perform CPR until ready to defibrillate
If unwitnessed arrest
-Perform CPR x2 min.

-Defibrillate per drug chart** SO
-Resume CPR for 2 min immediately after shock
-Perform no more than 5 second rhythm/pulse check if rhythm is organized
-Defibrillate per drug chart** for persistent VF/Pulseless VT prn SO
-Continue CPR for persistent VF/Pulseless VT. Repeat 2 min cycle followed by rhythm/pulse check, followed by defibrillation/medication, if indicated
-IV/IO SO Do not interrupt CPR to establish IV/IO

Once IV/IO is established, if no pulse after pulse/rhythm check:
-Epinephrine 1:10,000 per drug chart SO
MR x2 q3-5" SO. MR q3-5" BHO

After first shock if still refractory:
-Amiodorone per drug chart IV/IO MR x1 in 3-5" SO
**OR**
-Lidocaine per drug chart IV/IO MR x1 in 3-5" SO

-BVM
-Avoid interruption of CPR
-Capnography monitoring SO
-NG/OG prn SO

** = see notes

12

S-163 Pediatric Dysrhythmias Notes (Ventricular Tachycardia/VF/Pulseless VT)

-For patients with a Capnography reading of less than 10mmHg or patients in nonperfusing rhythms after resuscitative effort, consider early Base Hospital contact for disposition/pronouncement at scene
-Medication should be administered as soon as possible after rhythm checks. The timing of drug delivery is less important than is the need to minimize interruptions in chest compressions
-Flush IV line with Normal Saline after medication administration
-CPR should be performed during charging of defibrillator

**or according to defibrillator manufacturer's recommendations

13

S-163 Pediatric Dysrhythmias BLS (Pulseless Electrical Activity[PEA]/Asystole)

-O2 and/or ventilate prn
-CPR: begin compressions. After first 30 compressions give first ventilations

14

S-163 Pediatric Dysrhythmias ALS (Pulseless Electrical Activity[PEA]/Asystole)

-Perform CPR x2 min
-Perform no more than 5 second rhythm/pulse check if rhythm is organized
-CPR for 2 min
-IV/IO SO Do not interrupt CPR to establish IV/IO

Once IV/IO established, if no pulse after rhythm/pulse check:
-Epinephrine 1:10,000 per drug chart IV/IO SO
MR x2 in q3-5" SO. MR q3-5" BHO
-Fluid per drug chart IV/IO. may repeat x1

-BVM
-Capnography monitoring SO
-NG/OG prn SO
-Pronouncement at scene BHPO

15

S-164 Pediatric Envenemation Injuries BLS

-O2 and/or ventilate prn

Jellyfish sting:
-Liberally rinse with salt water for at least 30 sec
-Scrape to remove stinger(s)
-Heat as tolerated (not to exceed 110 deg)

Stingray or Sculpin injury:
-Heat as tolerated (not to exceed 110 deg)

Snakebites:
-Mark proximal extent of swelling and/or tenderness
-Keep involved extremity at heart level & immobile
-Remove pre-existing constrictive device

16

S-164 Pediatric Envenemation Injuries ALS

-IV/IO SO adjust prn
-Treat pain as per Pain Management Protocol (S-173)

17

S-165 Pediatric Poisoning/Overdose BLS

-Ensure patent airway
-O2 saturation prn
-O2 and/or ventilate prn
-Carboxyhemoglobin monitor prn, if available

Ingestions:
-Identify substance

Skin:
-Remove clothes
-Brush off dry chemicals
-Flush with copious water

Inhalation of Smoke/Gas/Toxic substance:
-Move patient to safe environment
-100% O2 via mask
-Consider transport to facility with hyperbaric chamber for suspected carbon monoxide poisoning in the unconscious or pregnant patient

Symptomatic suspected opioid OD:
-May assist family or friend to medicate with patients own prescribed Naloxone

18

S-165 Pediatric Poisoning/Overdose ALS

-Monitor EKG
-IV/IO SO adjust prn

Ingestions:
-Charcoal per drug chart PO if ingestion within 60 minutes and recommended by Poison Center SO
-Assure child has gag reflex and is cooperative
-In oral hypoglycemic agent ingestion, any change in mentation requires blood glucose check or recheck SO

Symptomatic suspected opioid OD (excluding opioid dependent pain management patients):
-Naloxone per drug chart IN/IV/IM SO. MR SO

Symptomatic suspected opioid OD in opioid dependent pain management patients:
-Naloxone titrate per drug chart IV (dilute per drug chart) or IN/IM SO. MR BHO

Symptomatic organophosphate poisoning:
-Atropine per drug chart IV/IM/IO SO. MR x2 q3-5" SO. MR q3-5" prn BHO

Extrapyramidal reactions:
-Benadryl per drug chart slow IV/IM SO

Suspected Tricyclic OD with cardiac effects (hypotension, heart block, widened QRS):
-NaHCO3 per drug chart IV x1 BHO

19

S-165 Pediatric Poisoning/Overdose Notes

-For scene safety, consider HAZMAT activation as needed.
-In symptomatic suspected opioid OD (excluding opioid dependent pain management patients) administer Narcan IN/IM prior to IV.

20

S-166 Newborn Deliveries BLS+Low Heart Rate Births

-Ensure patent airway
-Suction baby's airway if excessive secretions causing increased work of breathing, first mouth, then nose, suction after fully delivered
-O2 saturation prn

Low Heart Rate Births:
-Ventilate via BVM room air if HR <100 bpm
-If HR <60 after 90 sec of ventilation, increase to BVM 100% O2:
-CPR
-Clamp and cut cord between clamps following delivery (wait 60 seconds after delivery prior to clamping and cutting cord)
-Keep warm & dry (wrap in warm, dry blanket). Keep head warm
-APGAR at 1 minute and 5 minutes
-Document name of person cutting cord, time cut & address of delivery
-Place identification bands on mother and infant
-Bring mother and infant to same hospital
-Complete "Out of Hospital Birth Form" (S-166A) and provide to parent

21

S-166 Newborn Deliveries BLS (Premature and/or Low Birth Weight Infants+Cord Wrapped Around Neck)

Premature and/or Low Birth Weight Infants:
-If amniotic sac intact, remove infant from sac after delivery
-STAT transport
-When HR <100bpm, ventilate room air
-If HR <60bpm after 90 seconds of ventilation, increase to BVM 100% O2 and start CPR
-CPR need NOT be initiated if there are no signs of life AND gestational age is <24 weeks

Cord Wrapped Around Neck:
-Slip the cord over the head and off the neck. Clamp and cut the cord if wrapped too tightly

22

S-166 Newborn Deliveries BLS (Prolapsed Cord+Breech Birth)

Prolapsed Cord:
-Place the mother with her hips elevated on pillows
Insert a gloved hand into the vagina and gently push the presenting part off the cord
-Transport STAT while retaining this position. Do not remove hand until relieved by hospital personnel

Breech Birth:
-Allow infant to deliver to the waist without active assistance (support only)
-When legs and buttocks are delivered, the head can be assisted out. If head does not deliver within 1-2 min, insert a gloved hand into the vagina and create an airway for the infant
-Transport STAT if head undelivered

23

S-166 Newborn Deliveries ALS

-Monitor EKG
-NG prn SO

If HR remains <60bpm after 30 seconds of CPR:
-Epinephrine 1:10,000 per drug chart IV/IO SO
-MR x2 q3-5" SO
-MR q3-5" BHO

24

S-167 Pediatric Respiratory Distress BLS

-Ensure patent airway
-Dislodge any airway obstruction
-O2 saturation prn
-Transport in position of comfort
-Reassurance
-Carboxyhemoglobin monitor prn, if available
-O2 and/or ventilate prn
-May assist patient to self-medicate own prescribed MDI ONE TIME ONLY. Base Hospital contact required to any repeat dose

Hyperventilation:
-Coaching/reassurance
-Remove patient from causative environment
-Consider underlying medical problem

Toxic Inhalants (CO exposure, smoke, gas, etc.):
-Consider transport to facility with hyperbaric chamber for suspected carbon monoxide poisoning for unconscious or pregnant patient

Respiratory Distress with croup-like cough:
-Aerosolized saline or water 5ml via oxygen powered nebulizer/mask. MR prn

25

S-167 Pediatric Respiratory Distress ALS

-Monitor EKG
-IV SO adjust prn
-BVM prn
-Capnography monitoring SO prn

Respiratory Distress with bronchospasm:
-Albuterol per drug chart via nebulizer SO. MR SO
-Atrovent per drug chart via nebulizer added to first dose of Albuterol SO

If severe respiratory distress with bronchospasm or inadequate response to Albuterol/Atrovent, consider:
-Epinephrine 1:1,000 per drug chart IM SO.
MR x2 q5" SO

Respiratory Distress with stridor at rest:
-Epinephrine 1:1,000 per drug chart via nebulizer SO. MR x1 SO
-Epinephrine 1:1,000 per drug chart IM SO.
MR x2 q5" SO

26

S-167 Pediatric Respiratory Distress Notes

-If history suggests epiglottitis, do NOT visualize airway. Utilize calming measure.
-Avoid Albuterol in Croup.
-Consider anaphylaxis if wheezing in the patient with prediatric distress, especially if no history of asthma. Refer to Allergic Reaction/Anaphylaxis Protocol (S-162).

<2 years old with no prior Albuterol use (broncholitics) consider:
-Suctioning of nose with bulb suction prn
-Capnography, assessing respirations with a one minute count
-Provide position of comfort
-O2 saturation prn pulse <90% and/or respiratory distress (tachypnea, retractions, grunting)
-BVM to assist ventilation prn for significant respiratory distress, grunting, ALOC

27

S-168 Pediatric Shock BLS

-O2 saturation prn
-O2 and/or ventilate prn
-Control obvious external bleeding
-Determine peripheral pulses and capillary refill
-Assess level of consciousness
-Obtain baseline temperature
-Keep warm
-Treat associated injuries
-NPO, anticipate vomiting

28

S-168 Pediatric Shock ALS

-Monitor EKG
-IV/IO SO
-Capnography SO prn

Shock (non cardiogenic):
-IV/IO fluid bolus per drug chart SO.
MR SO if without rales

Shock (cardiac etiology):
-IV/IO fluid bolus per drug chart SO
MR BHPO- to maintain adequate perfusion if without rales

29

S-168 Pediatric Shock Notes

"Shock" is defined by the following criteria:
Patients age: <15 years
Exhibiting any of the following signs of inadequate perfusion:
A. Altered mental status (decreased LOC, confusion, agitation)
B. Tachycardia (<5yrs >180, >5yrs >160)
C. Pallor, mottling, or cyanosis
D. Diaphoresis
E. Comparison (difference) of peripheral vs. central pulses
F. Delayed capillary refill
G. Systolic BP < [70+(2x age)]

30

S-169 Pediatric Trauma BLS

-Ensure patent airway, protecting C-spine
-Control obvious bleeding
-Spinal motion restriction prn (except in penetrating trauma without neurological deficits)
-O2 saturation prn
-O2 and/or ventilate prn
-Keep warm
-Hemostatic gauze

Abdominal trauma:
-Cover eviscerated bowel with saline pads

Chest Trauma:
-Cover open chest wound with three-sided occlusive dressing; release dressing if suspected tension pneumothorax develops
-Chest seal

Extremity Trauma:
-Splint neurologically stable fractures as they lie.
-Use traction splint as indicated
-Grossly angulated long bone fractures with neurovascular compromise may be reduced with GENTLE unidirectional traction for splinting BHO
-Apply tourniquet in severely injured extremity when direct pressure or pressure dressing fails to control life-threatening hemorrhage SO
-In mass casualty, direct pressure not required prior to tourniquet application

Impaled Objects:
-Immobilize and leave impaled objects in place
-Remove BHPO
EXCEPTION: may remove impaled object in face/cheek, or from neck if there is total airway obstruction

Neurological Trauma (Head & Spine injuries):
-Assure adequate airway and ventilate without hyperventilation

Traumatic Arrest:
-CPR
-Consider pronouncement at scene BHPO