Pediatric Treatment Protocols Flashcards
(43 cards)
Apparent Life-Treatening Event (≤2 y/o)
PTP-01
Initial Medical care: Comprehensive physical exam: •General appearance •Skin color •Extent of interaction •Evidence of trauma
Consider vascular access
√BGL:
Child BGL
Apparent Life-Treatening Event [ALTE] (≤2 y/o):
Definition
PTP-01
Definition of Apparent Life-Threatening Event (≤2):
1-ALTE formerly known as near-miss SIDS episode.
2-Is an episode that is frightening to the observer (may think the infant has died) and involves some combination of:
•Apnea (Central/Obstructive)
•Color change (cyanosis/pallor/erythmea, plethora)
•Marked ∆ in muscle tone (limpness).
•Choking/Gagging
3-Usually ≤12mo, can be ≤24; w/ above S/S may be ALTE
4-Most have normal physical exam when assessed in field.
5-50-60% have no known etymology
6-40-50% have known etiology (i.e. Child Abuse, SIDS, swallowing disfunction, infection, bronchitis. seizures, CNS anomalies, tumors, cardiac disease, chronic respiratory disease, upper airway obstruction, metabolic disorders, anemia)
Apparent Life-Treatening Event [ALTE] (≤2 y/o):
Documentation
PTP-01
ALTE Documentation:
1-Assume description of symptoms is accurate
2-Determine severity, nature, and duration of the episode.. Was the patient awake/sleep at time of episode? Details of the resuscitation required
3- Obtain MHx
•known chronic disease
•evidence of seizure activity
•current or recent infections
•gastroesophageal reflux
•inappropriate mixture of formula
•recent trauma or suspected non-accidental trauma
•Rx Hx
PALS: Cardiac Arrest:
VF/VT Algorithm
PTP-02
*For use after CCR, or if CI to CCR
CCR CI in children ≤8 y/o
PALS: VF/VT Algorithm:
{1}-[Start CPR/Give O2/Attach Monitor]
Shockable?
No–» Go to Asystole/PEA Algorithm
{2}-Yes–»VF/VT
{3}-Shock @ 2J/kg
{4}[CPR-2min, IV/IO]
Shockable?
No–» Go to Asystole/PEA Algorithm
{5}Yes–»VF/VT –»Shock @ 4J/kg
{6} CPR-2min
Epi 0.01mg/kg (0.1mL/kg of 1:10,000) q3-5min;
May give Epi 0.1mg/kg (0.1mL/kg of 1:1000) if no IV/IO
Consider Advanced Airway/Capnography
Shockable?
No–» Go to Asystole/PEA Algorithm
{7}Yes–»VF/VT –»Shock ≥ 4J/kg, max of 10J/kg or Adult J
{8} CPR-2min
Amiodarone 5mg/kg bolus during cardiac arrest, may repeat up to 2x’s for refractory VF/Pulseless VT
*Treat reversible causes
Shockable?
No–» Go to Asystole/PEA Algorithm
{7}Yes–»VF/VT –»≥ 4J/kg, max of 10J/kg or Adult J
Repeat until rhythm changes or ROSC
PALS: Cardiac Arrest:
Asystole/PEA Algorithm
PTP-2.01
*For use after CCR, or if CI to CCR
CCR CI in children ≤8 y/o
PALS: Asystole/PEA Algorithm
{1}-[Start CPR/Give O2/Attach Monitor]
Shockable?
Yes–» Go to VF/VT Algorithm
{9}No–» Asystole/PEA
{10} CPR-2min
Epi 0.01mg/kg (0.1mL/kg of 1:10,000) q3-5min;
May give Epi 0.1mg/kg (0.1mL/kg of 1:1000) if no IV/IO
Consider Advanced Airway/Capnography
Shockable?
Yes–» Go to VF/VT Algorithm step 5 or 7
No–» Asystole/PEA
{11}[CPR-2min/Tx reversible causes]
Shockable?
Yes–» Go to VF/VT Algorithm step 5 or 7
No–» Asystole/PEA go to step 10 repeat until rhythm
changes or ROSC
PALS: Cardiac Arrest:
Reversible Causes
PTP-02.01
PALS: Reversible Causes: •Hypovolemia - Fluid bolus •Hypoxia - Airway/Oxygen •H+ (acidosis) •Hypokalemia •Hyperkalemia •Hypothermia - Warmth/handle gently •Tension Pneumothoax •Tamponade - Cardiac •Toxins - OD •Thrombosis - PE •Thrombosis - coronary
Pediatric Tachycardia (With pulse and poor perfusion) PTP-03
Identify and treat underlying cause: •Maintain patent airway/assist as indicated •O2 •Cardiac monitor to ID rhythm, BP, Sp02 •IV/IO •12-Lead if available, don't delay Tx
QRS duration:
Narrow (≤0.09sec) —» Probable Sinus Tach or SVT
Wide (≥0.09sec)—» Possible Ventricular Tachycardia
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Probable Sinus Tachycardia: •Compatible Hx consistent with known cause: •Pwaves present/normal •Variable R-R, constant PRI •Infants: rate usually
Pediatric Bradycardia (With a Pulse and Poor Perfusion) PTP-04
Identify and treat underlying cause: •Maintain patent airway/assist as indicated •O2 •Cardiac monitor to ID rhythm, BP, Sp02 •IV/IO •12-Lead if available, don't delay Tx
Cardiopulmonary compromise continues?
•Hypotension
•Acutely altered mental status
•Signs of shock
No: Support ABC's Give O2 Observe Consider OMD \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Yes:
CPR if HR
Respiratory Arrest/Insufficiency - Bronchospasm
PTP-05
Establish airway
Preform ventilations at 12-20/min; 8-10 if intubated
Establish IV Lock/ fluids as indicated; but don’t delay Tx
Administer: Albuterol: 2.5mg diluted with 3cc NS; -may add- Atrovent: 0.5mg (2.5cc) -may administer 3 doses of Albuterol for total of 7.5mg and 2 doses of Atrovent for a total of 1mg max
Consider:
Methylprednisolone: 2mg/kg IV/IM up to 125mg
Consider: If child is in severe respiratory distress and not responding to SVN Tx -
Magnesium Sulfate: 25-50 mg/kg in 50ml NS/LR IV over 20 min. (Max dose of 2 G)
Symptoms resolving?
Yes: Courtesy Notification
No: OMD
Respiratory Arrest/Insufficiency - Bronchospasm:
Indications of severe respiratory distress
PTP-05
Indications of severe respiratory distress: •inspiratory/expiratory wheezes •little/no air mvmt. on auscultation •too tight to wheeze •retractions •nasal flaring •use of accessory muscles •worsening dyspnea •cough •skin color changes •body positioning •Altered LOC
Respiratory Arrest/Insufficiency - Bronchospasm:
Ventilation notes
PTP-05
Ventilation notes:
•BVM with 100% O2 at 12-20/min with sufficient pressure to move the chest
•Gastric decompression allows for adequate tidal volumes, use 10-16 Fr. Naso-gastric catheter if BVM used ≥ 2min.
Respiratory Distress - Croup/Stridor
PTP-06
Assess ABC's Establish/secure airway Admin 100% O2 VS Apply monitor
For severe respiratory distress:
•if ≤4y/o:
administer Epinephrine 1:1000 SVN: 2.5mg with 3cc NS
•if ≥5y/o:
administer Epinephrine 1:1000 SVN 5mg with 3cc NS
Symptoms resolving?
Yes: Courtesy Notification
No: OMD
Allergic Reaction/Anaphylaxis
PTP-07
Establish airway
Preform ventilations at 12-20/min; 8-10 if intubated
Establish IV Lock/ fluids as indicated; but don’t delay Tx
Anaphylaxis or Allergic reaction: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Anaphylaxis: •Shock - "looks sick" •Severe facial angioedema •Severe respiratory distress •Drooling
Tx:
Epinephrine IM: 0.01mg/kg (0.01ml/kg) 1:1000
Max 0.3mg (0.3ml)/dose
Diphenhydramine IV/IO/IM:
1.0mg/kg (max dose 50mg)
Methylprednisolone IV/IM:
2mg/kg (max dose 125)
Albuterol SVN:
2.5mg in 3cc NS for Respiratory distress, repeat as needed
__________________________
Allergic Reaction: •Rash •Itching, isolated urticaria •Nausea •No respiratory distress
Tx:
Diphenhydramine IV/IO/IM:
1.0mg/kg (max dose 50mg)
Methylprednisolone IV/IM:
2mg/kg (max dose 125)
Epinephrine IM: 0.01mg/kg (0.01ml/kg) 1:1000
Max 0.3mg (0.3ml)/dose
Albuterol SVN: 2.5mg in 3cc NS for Respiratory distress, repeat as needed \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Symptoms resolving? Yes: Courtesy Notification No: OMD
Allergic Reaction/Anaphylaxis:
Indications of severe respiratory distress
PTP-07
Indications of severe respiratory distress: •inspiratory/expiratory wheezes •little/no air mvmt. on auscultation •too tight to wheeze •retractions •nasal flaring •use of accessory muscles •worsening dyspnea •cough •skin color changes •body positioning •Altered LOC •shock •Tachycardia •Abdominal pain •generalized urticaria •edema: face, lips, tongue
Altered Level of Consciousness - Non-Traumatic
PTP-08
Establish airway
Preform ventilations at 12-20/min; 8-10 if intubated with 100% O2
Apply monitor
√BGL
Establish IV lock/fluids as indicated: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ BGL 1y/o: 1G/kg of D25 IV *Prepare solution by: Dilute D50 1:1 with NS
If unable to establish an IV:
Glucagon 0.5mg IM; if ≥8y/o 1mg IM
Are symptoms resolving? (Allow 8-10min for Glucagon)
Yes: Courtesy Notification
No: OMD
___________________________
BGL>50:
Consider other passible causes and treat appropriately.
Consider Airway mgmt. and/or volume infusion of 20cc/kg
If opiate suspected:
Naloxone IV/IM/IO:
20kg or >5y/o - 2mg
Initial dose may be repeated every 3-5min to a max dose of 5 doses.
Are symptoms resolving?
Yes: Courtesy Notification
No: OMD
Altered Level of Consciousness - Non-Traumatic:
Possible causes
PTP-08
Possible causes for Altered LOC: •hypoxemia - ventilate •hypovolemia - fluid •tension pneumothorax - NCD •Hyperthermia - cool •hypothermia - warm •Overdose •Hypo/hyperglycemic •Postictal State
Seizures
PTP-09
Establish an airway Ventillate at 12-20/min (8-10 if intubated) with 100% O2 Consider IV access, if appropriate. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ BGL 1y/o: 1G/kg of D25 IV *Prepare solution by: Dilute D50 1:1 with NS \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ BGL>50: Has vascular access been obtained?
Yes: Seizure >5min W/ IV access Lorazepam IV (1st Choice) •≤12Kg: 0.05-0.1 mg/kg over 2-5min (Max of 4mg) •13-40kg: 2mg IM??? •≥40kg: 4mg IM??? May repeat once in 10-15min if necessary -or- Midazolam IV or IN •IV: 0.05mg/kg slow •IN: 0.2-0.3mg/kg Maximum 10mg per/dose Must use 5mg/ml concentration Split dose between nostrils. Repeat once if needed -or- Diazepam IV/IO: IV:0.2-0.3mg/kg every 15-30 min, max 1mg/kg, not to exceed 10mg/dose Administer over 3min or until seizure activity subsides IO:Consider IO if seizure activity lasts longer than 30min. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ For Seizure >5min with no IV access Midazolam IM (1st Choice): •≤12kg: 0.2mg/kg IM •13-40kg: 5mg IM •≥40kg: 10mg IM May repeat once in 10-15min if necessary -or- Midazolam IN: •IN: 0.2-0.3mg/kg Maximum 10mg per/dose Must use 5mg/ml concentration Split dose between nostrils. Repeat once if needed -or- Lorazepam IM: •0.05-0.1mg/kg over 2-5min (Max 4mg) May repeat in 10-15 min.
Establish vascular access \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Are symptoms resolving? Yes: Courtesy Notification No: OMD
Seizures:
TX and Rx Notes
PTP-09
- Use Diazepam only if Lorazepam and Midazolam are unavailable
- Gastric decompression allows adequate pulmonary tidal volumes; use 10-16 Fr. nano-gastric catheter if BVM used longer than 2 min.
- IM injections in infants and children should be given in the mid-lateral thigh
- D5W contraindicated in critical pediatric patients
- Rectal Diazepam is approved for administration to children ≤6y/o
Submersion Incident - Category 1*
PTP
*Applies to Pt’s with no spontaneous pulse or respirations, or flaccidity, or Altered LOC’s
Establish an airway with spinal immobilization
Begin CPR if indicated
Preform Ventilations ar 12-20/min (8-10 if intubated) with 100% O2 and Peep of 5
Don’t delay transport: Complete following in en route:
Establish IV/IO of NS: Fluid resuscitation @ 20cc/kg as indicated; repeat as necessary.
Place OG tube if Pt has been ventilated with BVM ≥2min
Maintain body temperature
Consider possible causes: •Hypoxia (ventilation) •acidosis (ventilation, Sodium Bicarb) •Tension Pneumothorax (NCD) •Hypothermia (Warm to 92º) •Trauma/Hypovolemia (Fluid) •Hypoglycemia (√BGL admin. Dextrose)
Online Medical Direction
Submersion Incident - Category 1*
Tx notes
PTP
Tx notes for Submersion Incident - Category 1 •Transport to nearest pediatric ICU: -Banner Thunderbird -Phoenix Children's Hospital -Banner Cardon Children's Medical Center -Maricopa Medical Center
- Rapid Transport is of utmost importance. ALS may be attempted on scene, but should be transported to nearest appropriate emergency facility
- Repeat VS after each fluid bolus
Submersion Incident - Category 2*
PTP-11
*Applies to Pt’s alert and oriented with spontaneous respirations and pulse:
Establish an airway with spinal immobilization
Perform ventilations and oxygenate as indicated.
Preform ABCDE’s
Assess VS
Apply monitor
Maintain Temperature and prevent Pt heat loss
Consider IV/IO of NS as indicated
Are symptoms resolving?
Yes: Courtesy Notification
No: OMD
•Transport to nearest pediatric ICU:
- Banner Thunderbird
- Phoenix Children’s Hospital
- Banner Cardon Children’s Medical Center
- Maricopa Medical Center
Hypotension - Non-traumatic
PTP-12
Establish an airway; ventilate at 12-20 (8-12 intubated) with 100% O2
Don’t delay transport, complete as many the following en route:
Establish an IV/IO of NS:
Fluid resuscitation @ 20cc/kg
VS and lung auscultation after each bolus
Repeat as necessary
Place NG/OG if BVM≥2min
Maintain body temperature.
Nausea/Vomiting
PTP-13
Assure airway and adequate oxygenation
Place Pt in POC
Establish IV lock or IV fluids as indicated
Consider:
Ondansetron IV as needed for nausea/vomiting
(IV form may be given PO)
8-15kg = 2mg 16-30kg = 4mg >30kg = 4-8mg
-or-
4-8 ODT PO
Trauma
PTP-14
If indicated: Establish airway with spinal immobilization
If known or suspected TBI, or Mult-System Trauma requiring intubation:
Follow EPIC-TBI Protocol—» Titrate ETCO2 to ±40
Preform ventilations with 100% O2
0-24mo: 25 bpm
2-14years: 20 bpm
>15years: 10 bpm
Assess and treat ABCDE’s (seal open chest wounds, stabilize flail segments, Tension Pneumothorax —» lift dressing or NCD, √BGL and Tx if
