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Scott County EMS PEDIATRIC Protocols April 2016

PEDIATRIC-1

IOWA EMS TREATMENT PROTOCOLS

Section 3 Pediatric Treatment Protocols

Page Protocol PEDIATRIC- 2 Pediatric Initial Patient Care Protocol PEDIATRIC- 4 Pediatric Abdominal Pain (non-traumatic) PEDIATRIC- 5 Pediatric Airway PEDIATRIC- 7 Pediatric Allergic Reaction PEDIATRIC- 9 Pediatric Altered Mental Status PEDIATRIC-10 Pediatric Apparent Death PEDIATRIC-11 Pediatric Asthma PEDIATRIC-12 Pediatric Behavioral PEDIATRIC-13 Pediatric Burns PEDIATRIC-16 Pediatric Cardiac Arrest / Arrhythmia PEDIATRIC-19 Pediatric Difficulty Breathing PEDIATRIC-20 Pediatric Heat Emergencies PEDIATRIC-21 Pediatric Hypothermia PEDIATRIC-22 Pediatric Nausea and Vomiting PEDIATRIC-23 Pediatric Near Drowning PEDIATRIC-25 Newborn Resuscitation and Care PEDIATRIC-28 Pediatric Overdose PEDIATRIC-29 Pediatric Pain Control PEDIATRIC-31 Pediatric Poisoning PEDIATRIC-33 Pediatric Seizures PEDIATRIC-34 Pediatric Selective Spinal Immobilization PEDIATRIC-35 Pediatric Sepsis PEDIATRIC-37 Pediatric Shock PEDIATRIC-38 Pediatric Suspected Child Abuse PEDIATRIC-39 Pediatric Trauma


PEDIATRIC-2

PEDIATRIC INITIAL CARE PROTOCOL

1. Scene Size Up a) Review the dispatch information b) As you approach the scene consider safety for yourself and

your patient. c) Observe universal precautions d) After determining the number and location of patients,

consider the need for additional resources e) Determine mechanism of injury and/or nature of illness f) Reassess the situation often

2. Primary Survey a) Obtain general impression of patient, chief complaint, and

priority problems b) Determine responsiveness c) Assess airway d) Assess breathing e) Assess circulation f) Maintain cervical stabilization/immobilization if indicated g) Utilize length/weight based tape to determine appropriate

medications and equipment

3. Initial Interventions a) Treat airway/breathing problems b) Treat circulation problems c) Apply Oxygen titrated to an SPO2 of 94% or greater or if

responder believes the patient will benefit from the treatment

d) Maintain normal body temperature

4. Secondary Survey a) Perform secondary assessment after initial interventions

are completed b) Address problems identified in the secondary survey

utilizing the appropriate protocol(s) c) Obtain vital signs., including blood glucose if available and

indicated d) Assess and treat pain or nausea if present


PEDIATRIC-3

PEDIATRIC INITIAL CARE PROTOCOL

(Continued)

5. Ongoing Assessment and treatment

a) Establish IV/IO access if indicated b) Apply cardiac monitor if indicated c) Apply pulse oximetry or EtCO2 monitor if available and

indicated d) Repeated evaluation of patient

Vitals every 5 minutes for unstable patients Vitals every 15 minutes for stable patients

**Patients who are transported should have a second set of vitals when possible

e) Assess effect of interventions

6. Transport/Contact Medical Control a) Patients should be transported as soon as feasible to an

appropriate medical facility. Immediate transport with treatment en-route is recommended whenever patient condition warrants.

b) Tier with an appropriate service if level of care indicates or assistance is needed and can be accomplished in a timely manner

c) Contact medical direction as soon as feasible in accordance with local protocol for further orders

d) For seriously injured or critically ill patients, give a brief initial report from the scene to medical direction when possible, with a more detailed report given as available


PEDIATRIC-4

PEDIATRIC ABDOMINAL PAIN

(Non-traumatic)

1. Follow Initial Patient Care Protocol for all patients

BASIC CARE GUIDELINES

a) Give nothing by mouth b) Transport in position of comfort

ADVANCED CARE GUIDELINES

a) Establish IV Access if patient condition warrants b) Consider a fluid bolus if indicated of Normal Saline

10 mL/kg for patients 0-30 days, or 20 mL/kg for patients 30 days to puberty

c) Evaluate the need for pain and nausea control


PEDIATRIC-5

PEDIATRIC AIRWAY

1. Follow Initial Patient Care Protocol


Breathing spontaneous on initial assessment with adequate ventilation

a) Maintain oxygenation with cannula, mask, or blow-by if oxygen saturations are below 94%, titrate to 94% or greater

Breathing spontaneous without adequate ventilation or not breathing

a) Open the airway b) Attempt assisted ventilation using an appropriate adjunct with

high-flow 100% oxygen. If unable to ventilate first reposition airway and again attempt to ventilate

c) If ventilation still unsuccessful check airway for obstruction and attempt to dislodge with age appropriate techniques


d) Establish IV Access if patient condition warrants e) If unsuccessful establish direct view of object and attempt to

remove it with Magill forceps. If obstruction cleared


a) Assist ventilation and provide oxygen


b) If adequate ventilation is NOT maintained proceed to an advanced airway as appropriate for patient size


PEDIATRIC-6

PEDIATRIC AIRWAY

(CONTINUED) If obstruction not cleared

a) Attempt endotracheal intubation and try to ventilate the patient b) If endotracheal intubation is not successful, perform needle

cricothyrotomy and needle insufflation

Not breathing on initial assessment


a) Open airway with head tilt chin lift or modified jaw thrust if

trauma is suspected If successful assist ventilations at an adequate rate & depth and reassess

b) If head tilt chin lift not successful check airway for obstruction and clear if needed

c) After airway clear, assist ventilation with appropriate basic adjunct and oxygen


d) If adequate ventilation is not possible, proceed to an advanced

airway e) Establish an IV or IO. f) Apply appropriate patches and monitor EKG. g) Consider Intubation or other advanced airway h) Be prepared to treat dysrhythmias according to ACLS guidelines.

*For advanced airway placement, patient packaging must include backboard and cervical collar


PEDIATRIC-7

PEDIATRIC ALLERGIC REACTION

1. Follow Initial Patient Care Protocol 2. It is important to act on the history and exposure rather than the

condition, as these patients can and do degrade quickly.


a) Assess airway via Airway Protocol b) If the patient has a physician prescribed Auto-injectable

Epinephrine assist with administration and monitor for signs of anaphylaxis.

c) Tier with a Paramedic level service when available. d) Continuously reassess airway, breathing and circulation status. e) Treat for shock and be prepared to initiate CPR and AED as

necessary during transport. Continue transport without delay. When using auto-injector remove safety cap and place tip of auto-injector against the patient’s lateral thigh midway between the waist and the knee. Push the injector firmly against the thigh and hold firmly until the injector activates and medication is injected (10) count). If unable to use this site an alternative site is the shoulder at the fleshy portion of the upper arm.


f) Administer EPINEPHRINE 1:1,000 IM according to a length

/weight based tape. May repeat in 15 minutes if symptoms warrant.

g) Establish IV / IO access. h) DIPHENHYDRAMINE (BENADRYL) 1.0 mg/kg IV or IM, up to a

maximum dose of 50 mg

i) Consider administration of IPRATROPIUM BROMIDE 0.5mg/ALBUTEROL 2.5mg (DUONEB) in 3mL NS by nebulizer X 1 for respiratory distress if > age 5 and no history of glaucoma OR ALBUTEROL 2.5mg by nebulizer if respiratory distress

j) Consider early intubation if severe anaphylaxis exists. k) For cases of anaphylaxis (systolic BP less than 90, respiratory

distress, altered LOC) consider administration of IV EPINEPHRINE as follows:


PEDIATRIC-8

PEDIATRIC ALLERGIC REACTION (CONTINUED)

Add 1 mg EPINEPHRINE to 1 liter normal saline (either 10 ml

1:10,000 or 1 ml 1:1000) Affix a label stating “1 mg

EPINEPHRINE added”

Attach micro drip tubing to the bag with EPINEPHRINE

Administer IV piggyback at a rate of 60 micro drops per minute

into a fast running IV of Normal Saline


PEDIATRIC-9

Pediatric Altered Mental Status



a) Follow Airway Protocol to ensure adequate ventilation b) Obtain Blood Glucose c) Patient conscious – give oral GLUCOSE for children over 2 years

of age


d) Establish IV / IO access

If Hypoglycemic

d) Establish IV access at a TKO rate.

e) Monitor EKG and treat dysrhythmias following the appropriate protocol(s).

e) Administer DEXTROSE 0.5-1.0 g/kg slowly IV/IO up to 25 grams If unable to obtain IV access give GLUCAGON 0.025 mg/kg IM up to 1 mg maximum

f) Evaluate the need for NALOXONE 0.1 mg/kg IV up to maximum dose of 2.0 mg per dose

g) Evaluate the need for intubation f) If there is evidence of shock or a history of dehydration,

administer a fluid bolus of Normal Saline at 20 ml/kg over 10-15 minutes

g) Reassess patient, if signs of shock persist, bolus may be repeated at the same dose up to two times for a maximum total of 60 ml/kg.


PEDIATRIC-10

Pediatric Apparent Death


Apparent death indications are as follows:

Signs of trauma are conclusively incompatible with life

Physical decomposition of the body Rigor Mortis and/or Dependent lividity

If apparent death is confirmed, continue as follows:


a) The county Medical Examiner and law enforcement shall be

contacted. b) Where possible, contact Iowa Donor Network at 800-831-4131.

See Appendix (Guidelines for initiating organ donation) c) At least one EMS provider should remain at the scene until the

appropriate authority is present (Police, Medical Examiner.) d) Provide psychological support for grieving survivors. e) Document the reason that resuscitation was not initiated. f) Preserve the crime scene if present. g) In all other circumstances (except where: NO CPR/DNR protocol

applies; see Appendix EMS Out of hospital DNR Protocol) full resuscitation must be initiated.


PEDIATRIC-11

Pediatric Asthma



a) Use Airway Protocol to evaluate the airway and adequacy of

ventilation b) Keep patient at rest and in a position of comfort. c) If patient has a physician prescribed, hand-held metered dose

inhaler, contact medical direction for approval to give inhaler treatment

d) Reassess patient and repeat second dose if necessary per medical direction


e) If patient condition indicates establish IV access. f) Apply appropriate patches and monitor EKG. g) IPRATROPIUM 0.5 mg/ALBUTEROL 2.5 mg (DUONEB) in 3mL

Normal Saline by nebulizer X 1 for respiratory distress if < age 5 yrs and no history of glaucoma

OR ALBUTEROL 2.5 mg in 3.0mL NS by nebulizer for respiratory distress for patients age < 5 yrs or with a history of glaucoma

h) Administer EPINEPHRINE 1:1,000 IM according to a length/weight based tape

i) Evaluate the need for advanced airway, intubation preferred (see Airway Protocol)


PEDIATRIC-12

Pediatric Behavioral Emergencies


a) If there is evidence of immediate danger, protect yourself and

others by summoning law enforcement to help ensure safety


b) Consider medical or traumatic causes of behavior problems

c) Keep environment calm


d) For severe anxiety or threat of safety to patient or crew,

administer

i. MIDAZOLAM (Versed) 0.15 mg/kg IV, IO, IM, or

Intranasal repeat as needed.

Or in the event of a medication shortage of midazolam

ii. DIAZEPAM (Valium) IV: 0.25 mg/kg slow IV push 15

minutes up to 10mg maximum

e) For Excited Delirium patients greater than 10 years of age,

consider administering KETAMINE

200 mg IM Injection up to 69kg

300 mg IM Injection 70-89kg

400 mg 90kg or greater

may repeat once in 3-5 minutes if needed

f) Excited delirium patients will be flushed, diaphoretic and hot to

the touch and require medication if the patient is a risk to

themselves or others.

When safe, Establish IV access and apply a cardiac monitor.


PEDIATRIC-13

PEDIATRIC BURNS

1. Follow Initial Patient Care Protocol Thermal burns:


a) Initially stop the burning process with water or saline

b) Perform primary survey with attention to airway and ventilation

c) Estimate percent of body surface area injured and depth of injury

d) If wound is less than 10 % Body Surface Area, cool down burn with Normal Saline

e) Remove smoldering clothing and jewelry and expose area

f) Continually monitor the airway for evidence of obstruction

g) Cover the burned area with plastic wrap or a dry clean dressing

h) Do not break blisters

i) Do not use any type of ointment, lotion, or antiseptic

j) Maintain normal body temperature


a) Establish an IV. For severe burns (defined as greater than 20% partial thickness or greater than 10% full thickness), administer 20ml/kg Normal Saline up to 500ml total volume.


PEDIATRIC-14

PEDIATRIC BURNS (Continued)

b) Treat pain per Pain Control Protocol

c) Transport to the most appropriate medical facility

Chemical Burns:


a) Attempt to identify contaminant and consider need for Haz

Mat response and refer to Haz Mat Protocol

b) Brush off powders prior to flushing.

c) Immediately begin to flush with large amounts of water

d) Continue flushing the contaminated area while enroute to the receiving facility

e) Do not contaminate uninjured areas while flushing

f) Transport to the most appropriate medical facility

g) Estimate percent of body surface area injured and estimate the depth of burn as superficial, partial thickness or full thickness


a) Treat pain per Pain Control Protocol

Toxin in the Eye:


a) Attempt to identify contaminant and consider need for Haz

Mat response and refer to Haz Mat Protocol


PEDIATRIC-15

PEDIATRIC BURNS (Continued)

b) Flood eye(s) with lukewarm water or Normal Saline and have patient blink frequently during irrigation. Use caution to not contaminate other body areas

c) Continue flushing the eye(s) while enroute to the receiving facility

d) Transport to the most appropriate medical facility


a) Establish a large bore IV if indicated.

b) Treat pain per Pain Control Protocol

Electrical Burns:


a) Ensure source of electrical burns has been removed

b) Treat soft tissue injuries associated with the burn with dry dressing.

c) Treat for shock if indicated.

d) Transport to the most appropriate medical facility.

e) Estimate percent of body surface area injured and estimate depth

of burn as superficial, partial thickness or full thickness.


f) Treat pain per Pain Control Protocol


PEDIATRIC-16

Pediatric Cardiac Arrest / Arrhythmia

1. Follow Initial Care Protocol for Pediatric Patients

IF NO PULSE


a) Perform high quality CPR immediately, apply AED and follow

device prompts


b) Perform high quality CPR immediately, apply monitor and

check rhythm as soon as possible

VENTRICULAR FIBRILLATION OR VENTRICULAR

TACHYCARDIA

c) Defibrillate at 2J/kg, immediately resume CPR for two minutes

d) Organize therapies such as rhythm and pulse checks,

defibrillation, IV/IO access, medication administration and

airway management around two minute cycles of CPR

i. Second defibrillation at 4 J/kg

ii. Subsequent defibrillations increasing by 2 J/kg, to a

maximum of 10 J/kg, not to exceed maximum adult

dose

e) Evaluate for treatable causes

f) Administer EPINEPHRINE 1:10,000 according to

length/weight based tape every 3-5 minutes

g) Administer AMIODARONE according to length/weight based

tape, may repeat twice.


PEDIATRIC-17

Pediatric Cardiac Arrest / Arrhythmia

ASYSTOLE/PEA

h) Organize therapies such as rhythm and pulse checks, IV/IO

access, medication administration and airway management

around two minute cycles of CPR

i) Evaluate for treatable causes

j) Administer EPINEPHRINE 1:10,000 according to

length/weight based tape every 3-5 minutes as needed

CARDIAC ARRYTHMIAS WITH PULSE


k) Maintain oxygenation with cannula or mask if oxygen

saturations are below 94% titrate to 94% - 99%

l) Evaluate for treatable causes

BRADYCARDIA WITH SIGNS OF POOR PERFUSION DESPITE

OXYGENTATION AND VENILATION


Start CPR if pulse is less than 60 and altered mental status


a) Apply appropriate Establish IV Access.

b) patches and monitor EKG.

c) Administer EPINEPHRINE 1:10,000 according to

length/weight based tape every 3-5 minutes

d) Consider administration of ATROPINE according to

length/weight based tape


PEDIATRIC-18

Pediatric Cardiac Arrhythmia

TACHYCARDIA

(RATES GREATER THAN 180 IN CHILDREN OR 210 IN INFANTS)


e) If patient unstable:

i. Perform synchronized cardioversion according to

length based tape (consider sedation)

ii. Establish IV Access.

iii. Apply appropriate patches and monitor EKG

f) If patient stable

iv. Contact medical control


PEDIATRIC-19

Pediatric Difficulty Breathing (Wheezing, Stridor, Obstructed Airway)


Basic Care Guidelines

a) If patient has a physician prescribed, hand-held metered dose

inhaler b) Assist patient in administering a single dose if they have not done

so already c) Reassess patient and assist with second dose if necessary per

medical direction

Advanced Care Guidelines

j) If patient condition indicates respiratory failure establish IV. k) Apply appropriate patches and monitor EKG l) IPRATROPIUM 0.5 mg/ALBUTEROL 2.5 mg (DUONEB) in 3mL

Normal Saline by nebulizer X 1 for respiratory distress if < age 5 yrs and no history of glaucoma

OR ALBUTEROL 2.5 mg in 3.0mL NS by nebulizer for respiratory distress for patients age < 5 yrs or with a history of glaucoma

m) Administer EPINEPHRINE 1:1,000 0.01 mg/kg IM up to a maximum dose of .01mg/kg or 0.3 mg IM.

n) Evaluate the need for advanced airway, intubation preferred (see Airway Protocol)


PEDIATRIC-20

PEDIATRIC HEAT EMERGENCIES



a) Remove the patient from the hot environment and place in a cool

environment (back of air conditioned response vehicle). b) Loosen or remove clothing. c) Place in recovery position. d) Cool patient by fanning. e) Additionally cool patient with cold packs to neck, groin and axilla f) If alert, stable and not nauseated, you may have the patient slowly

drink small sips of water. g) If the patient is unresponsive or is vomiting, transport to an

appropriate medical facility with patient on their left side.


h) If patient's condition indicates, establish IV or IO access. i) Monitor EKG and treat dysrhythmias following the appropriate

protocol(s).


PEDIATRIC-21

PEDIATRIC HYPOTHERMIA



a) Remove the patient from the cold environment - protect from

further heat loss. b) Remove wet clothing and cover with blanket and keep warm. c) Handle the patient gently. d) If temperature less than 95 degrees F, hypothermia is confirmed.


e) Establish IV access. Use warmed IV fluid if possible f) Monitor EKG and treat dysrhythmias following appropriate

protocol. g) Avoid defibrillation until core temp is greater than 86 degrees

Fahrenheit.


PEDIATRIC-22

Pediatric Nausea and Vomiting



a) Give nothing by mouth b) Transport in position of comfort


c) Initiate IV access. d) Consider fluid bolus if evidence of hypovolemia and lung

sounds are clear e) If patient nauseated or is vomiting administer anti-emetic

medication such as ONDANSETRON (Zofran) 0.1 mg/kg up to 4 mg maximum

f) Consider intubating patients with altered mental status who are vomiting and can’t protect their airway


PEDIATRIC-23

PEDIATRIC NEAR DROWNING



a) Establish patient responsiveness

b) If cervical spine trauma is suspected, manually stabilize the spine

c) Assess airway for patency, protective reflexes and the possible need for advanced airway management. Look for signs of airway obstruction

d) Open the airway using head tilt/chin lift if no spinal trauma is suspected, or modified jaw thrust if spinal trauma is suspected

e) Suction as necessary

f) Consider placing an oropharyngeal or nasopharyngeal airway adjunct if the airway cannot be maintained with positioning and the patient is unconscious

g) Assess breathing. Obtain pulse oximeter reading

h) If breathing is inadequate, assist ventilation using an appropriate adjunct with high-flow, OXYGEN100% concentration

i) Assess circulation and perfusion

j) If breathing is adequate, place the child in a position of comfort and maintain oxygenation with cannula, mask or blow-by if oxygen saturations are below 94% titrate to 94% or greater

k) Assess mental status


PEDIATRIC-24

PEDIATRIC NEAR DROWNING (Continued)

l) If spinal trauma is suspected, continue manual stabilization, apply a rigid cervical collar, and immobilize the patient on a long backboard or similar device

m) Expose the child only as necessary to perform further assessments. Maintain the child’s body temperature throughout the examination

n) If the child’s condition is unstable, perform focused history and detailed physical examination enroute

o) If the child’s condition is stable, perform focused history

and detailed physical examination on the scene, then initiate transport


p) If abdominal distention arises, consider placing a gastric tube to decompress the stomach if available

q) If the airway cannot be maintained by other means, including attempts at assisted ventilation, or if prolonged assisted ventilation is anticipated, consider advanced airway (see Airway Protocol).

r) Perform sedatives and paralytic agents, to aid with intubation as permitted by medical direction. Confirm placement of endotracheal tube using clinical assessment and end-tidal CO2 monitoring as per Airway Protocol

s) Initiate cardiac monitoring and determine rhythm. Consult the appropriate protocol for treatment of specific dysrhythmias. Refer to AHA guidelines

t) Obtain vascular access. Provide fluid bolus according to weight if patient condition warrants.


PEDIATRIC-25

NEWBORN RESUSCITATION AND CARE



a) Suction the airway using a bulb syringe as soon as the head

is delivered and before delivery of the body. Suction the mouth first, then the nose

b) Once the body is fully delivered, dry the baby, replace wet towels with dry ones, and wrap the baby in a thermal blanket or dry towel. Cover the scalp to preserve warmth

c) Open and position the airway. Suction the airway again using a bulb syringe. Suction the mouth first, then the nose

d) Assess breathing and adequacy of ventilation

e) If ventilation is inadequate, stimulate by gently rubbing the back and flicking the soles of the feet

f) If ventilation is still inadequate after brief stimulation, begin assisted ventilation at 40 to 60 breaths per minute using a bag-valve-mask device with 100% OXYGEN.

g) If ventilation is adequate and the infant displays central cyanosis, administer OXYGEN at 5 lpm via blow-by. Hold the tubing 1/2 to 1 inch from the nose

h) If the heart rate is slower than 60 beats per minute after 30 seconds of assisted ventilation with high-flow, 100% concentration OXYGEN, initiate the following actions:

Begin chest compressions at a combined rate of 120/minute (three compressions to each ventilation)


PEDIATRIC-26

NEWBORN RESUSCITATION & CARE (Continued)


i) If there is no improvement in heart rate after 30 seconds. Perform endotracheal intubation

j) If there is no improvement in heart rate after intubation and ventilation, administer

i. EPINEPHRINE 1:10,000 concentration at 0.1 mg/kg (maximum individual dose 10.0 mg) via endotracheal tube,

ii. or EPINEPHRINE 1:10,000 concentration at 0.01 mg/kg (maximum individual dose 1.0 mg) IV/IO

iii. Repeat EPINEPHRINE at the same dose every 3 to 5 minutes as needed

k) Initiate transport. Reassess heart rate and respirations enroute

If the heart rate is between 60 and 80 beats per minute, initiate the following actions:

Continue assisted ventilation with high-flow, 100% concentration oxygen. If there is no improvement in heart rate after 30 seconds, initiate management sequence described in step H above, beginning with chest compressions

Initiate transport. Reassess heart rate and respirations enroute

If the heart rate is between 80 and 100 beats per minute, initiate the following actions:

Continue assisted ventilation with high-flow, 100% concentration oxygen. Stimulate as previously described

Initiate transport. Reassess heart rate after 15 to 30 seconds


PEDIATRIC-27

NEWBORN RESUSCITATION & CARE (Continued)

If the heart rate is faster than 100 beats per minute, initiate the following actions:

Assess skin color. If central cyanosis is still present, continue blow by oxygen. Initiate transport. Reassess heart rate and respirations enroute

If thick meconium is present and infant is non-vigorous*

Initiate endotracheal intubation before the infant takes a first breath. Suction the airway using an appropriate suction adapter while withdrawing the endotracheal tube. Repeat this procedure until the endotracheal tube is clear of meconium. If the infant’s heart rate slows, discontinue suctioning immediately and provide ventilation until the infant recovers

*Note: If the infant is already breathing or crying (vigorous), this step may be omitted.

APGAR SCORING ( OBTAIN AT 1 & 5 MINUTES) Criteria 0 1 2

Appearance Entire body blue or pale

Pink core, blue limbs

Completely pink

Pulse No pulse < 100 > 100 Grimace None Slight facial grimace Grimace, coughs,

sneezes, cries Activity Limp Slight flexion Active movement Respiration None Slow, weak cry Good respirations,

strong cry


PEDIATRIC-28

PEDIATRIC Overdose


Basic Care Guidelines

a) Obtain blood glucose

Advanced Care Guidelines

b) Establish IV access. c) Monitor EKG and treat dysrhythmias following the appropriate

protocol(s). h) If blood sugar is less than 60 mg/dL administer DEXTROSE 0.5-

1.0 g/kg slowly IV/IO up to 25 grams If unable to obtain IV access give GLUCAGON 0.025 mg/kg IM up to 1 mg maximum

h) Evaluate the need for NALOXONE 0.1 mg/kg IV up to maximum dose of 2.0 mg per dose

i) Evaluate the need for intubation i) If there is evidence of shock or a history of dehydration,

administer a fluid bolus of normal saline at 20 ml/kg over 10-15 minutes

j) Reassess patient, if signs of shock persist, bolus may be repeated at the same dose up to two times for a maximum total of 60 ml/kg.


PEDIATRIC-29

PEDIATRIC PAIN CONTROL

1. Follow Initial Patient Care Protocol 2. First attempt to manage all painful conditions with basic care


a) Splint extremity injuries Place the patient in a position of comfort


b) Consider administration of pain medications for patients that have significant pain, do not have a decreased level of consciousness, are hemodynamically stable, and have oxygen saturations above 94%

Examples: MORPHINE 0.1 mg/kg (maximum individual dose

10 mg) via intravenous or subcutaneous route OR FENTANYL 1 mcg/kg (maximum individual dose 50

mcg to a total of 100 mcg) via IV or Intranasal route

May be repeated every five minutes if needed

c) Monitor ECG and O2 saturations

d) The patient must have vital signs taken prior to and after each dose and be monitored closely. Administration of narcotic medication must stop if at any time there is a

Decreased level of consciousness, Decrease in oxygen saturation below 94% Blood pressure drops to 90 mmHg or less


PEDIATRIC-30

PEDIATRIC PAIN CONTROL

Before and after drug administration, reassess the patient using the following pain scale

e) Consider administration of ONDANSATRON (Zofran) 0.1mg/kg IV up to 4mg slow IV push after Morphine or Fentanyl to reduce nausea from the medication administration.

f) Give NALOXONE (Narcan) 0.1mg/ kg IV, IM or Intranasal up to 1mg for respiratory depression from narcotics. May repeat x 1 if needed


PEDIATRIC-31

PEDIATRIC POISONING

1. Follow Initial Patient Care Protocol 2. Consider Haz-Mat request if needed 3. Identify contaminate and call Poison Control and follow directions

given to provide care: 1-800-222-1222 or 1-800-352-2222 4. Contact Medical Direction as soon as possible with information

given by Poison Control and care given.


INGESTED POISONS:

a) Identify and estimate amount of substance ingested. Take container to receiving facility when feasible.

b) Contact your Medical Direction facility as soon as possible with the substance ingested, so they can contact the Poison Control Center if indicated.

c) DO NOT induce vomiting unless directed to do so by Medical Direction.

INHALED POISONS:

a) Remove patient to fresh air

b) Administer high flow oxygen.

c) Identify substance inhaled. Bring all containers, bottles, labels etc.

of poison agents to receiving facility.

d) Estimate duration of exposure to inhaled poison.

e) Contact medical direction immediately, and advise of the nature of

the problem and substance.

ABSORBED POISONS:

a) Identify contaminate! If it will be a hazard to you, use

protective clothing and extreme caution.


PEDIATRIC-32

PEDIATRIC POISONING INJECTED POISONS:

a) Be alert for respiratory difficulty. Maintain airway and give high flow oxygen.

b) Check patient for marks, rashes or welts c) Try to identify injected substance


d) Establish IV access e) Monitor EKG and treat dysrhythmias if indicated following the

appropriate protocol.


PEDIATRIC-33

PEDIATRIC SEIZURES

1. Follow Initial Patient Care Protocol ACTIVE SEIZURE:


a) Protect airway b) Protect patient from injury, by clearing area of all possible

hazards. c) Monitor duration and type of seizure d) Check blood glucose level, if available, and treat hypoglycemia if

present


e) Monitor EKG and treat dysrhythmias if indicated following the

appropriate protocol. f) Administer MIDAZOLAM (Versed) 0.15mg/kg up to 5mg IV, IM,

IO or Intranasal via MAD device.

In the event that MIDAZOLAM is unavailable.

g) Consider DIAZEPAM (Valium) 0.25mg/kg up to 2.5mg PER DOSE slow IV / IO push titrated for response up to a maximum dose of 10 mg

POST SEIZURE:


a) Protect / Open Airway and place Pt in recovery position. b) Check blood sugar level, if available, and treat hypoglycemia if

present


a) Establish IV access. Monitor EKG and treat dysrhythmias

following the appropriate protocol(s). a) Administer DEXTROSE 2.4ml/kg of 25% up to 50ml IV/IO push if

blood sugar less than 60 mg/dL, especially if no prior history of seizure disorder.


PEDIATRIC-34

PEDIATRIC SELECTIVE SPINAL IMMOBILIZATION

(Previously: Assessment Based Spinal Management)

Revised 2015



2. Patient Presentation:

a) This protocol is intended for patients who present with a traumatic

mechanism of injury.

b) Immobilization may not be necessary for patients who have penetrating

trauma who do not have a suspected spine related neurological deficit.

3. Patient Management:

c) Assessment:

i. Assess for mental status, neurological deficits, spinal pain,

tenderness, any evidence of intoxication, or other severe injuries.

ii. While maintaining spinal alignment, examine the spine for

tenderness on palpation or deformities.

d) Treatment and Interventions:

i. Apply cervical restriction if there is any of the following:

1. Patient complains of neck pain.

2. Any neck tenderness on palpation.

3. Any abnormal mental status, including extreme agitation,

or neurological deficit.

4. Any evidence of alcohol or drug intoxication

5. There are other severe or painful injuries present.

6. Any communication barrier that prevents accurate

assessment.

ii. Immobilize Patient with cervical collar and a long spine

board, full body vacuum splint, scoop stretcher, or similar

device if:

1. Patient complains of midline back pain

2. Any midline back tenderness

Note 1: Distracting injuries or altered mental status does not necessitate long spine board use.

Note 2: Patients should not routinely be transported on long boards, unless the clinical

situation warrants long board use. An example of this may be facilitation of

multiple extremity injuries or an unstable patient where removal of a board will

delay transport and/or other treatment priorities. In these rare situations, long

boards should be padded or have a vacuum mattress applied to minimize

secondary injury to the patient.


PEDIATRIC-35

PEDIATRIC SEPSIS

Initial Treatment Protocol I. Suspected/Known Sepsis

A. Follow Initial Protocols for All Patients B. Emergency Medical Care:

1. If medical or trauma emergency, refer to appropriate protocol. 2. Allow position of comfort. 3. Take proper body substance isolation. 4. Give nothing by mouth.

Sepsis Box #1-Risk Factors for Sepsis *Nursing Home Resident *Recent influenza/viral illness *Immunosuppression *Splenectomy *Recent surgery/invasive procedure *Recent hospitalization *Productive cough *Diarrhea *Fever, chills, rigors *Alteration in mental status If patient presents with a Risk Factor for Sepsis, proceed to Box #2 additional “History Questions”

Sepsis (Suspected or Known) Sepsis Box #2-History Questions Suggestive of New Infection 1. Pneumonia? 2. UTI/Urinary bladder catheter? 3. Acute abdominal infection? 4. Meningitis? 5. Skin/soft tissue/wound infection? 6. Bone/joint infection? 7. Peripheral IV/PICC line infection 8. Endocarditis 9. Implantable device infection If “yes” to any of the above “History Questions” proceed to Box #3, SIRS criteria


PEDIATRIC-36

PEDIATRIC SEPSIS (continued) Sepsis Box #3- Systemic Inflammatory Response Syndrome (SIRS) Criteria 1. Temperature > 100.9 or < 96.8F? 2. End tidal CO2 of < 32 mm Hg? 3. HR > 90/min? 4. RR > 20/min? 5. Acutely altered mental status? 6. Glucose > 120 mg/dL?

Special Considerations

Advise the receiving facility of a “Sepsis Alert” if the answer is “YES” to at least one question in each of the first two Sepsis boxes, and at least two questions in the third box.


a) Transport in position of comfort. Place patient on oxygen if

patients condition warrants


b) Establish IV access and administer Normal Saline:

10 mL/kg for patients 0-30 days, or 20 mL/kg for patients 30 days to puberty

c) Initiate IO access if unable to establish IV access

d) Monitor EKG and treat dysrhythmias following the appropriate

protocol(s).


PEDIATRIC-37

Pediatric Shock

1. Follow Initial Patient Care Protocol 2. Consider etiology of shock, refer to Allergic Reaction protocol as

appropriate


a) Assess airway via Airway Protocol

b) Assess circulation and perfusion

c) Control external bleeding

d) Assess mental status

e) Expose the child only as necessary to perform further assessments

f) Initiate transport. Perform focused history and detailed physical examination enroute to the hospital if possible


g) Initiate cardiac monitoring

h) Establish IV of Normal Saline using a size-appropriate large-bore catheter with a macro drip tubing. If intravenous access cannot be obtained in a child, proceed with intraosseous access. Do not delay transport to obtain vascular access

i) Administer a fluid bolus of Normal Saline if hypotension is present

Age Fluid Bolus

0 to 30 Days 10ml/kg over 10 to 15 minutes 30 Days 20 ml/kg over 10 to 15 minutes

Reassess patient after fluid bolus. If signs of shock persist, fluid bolus may be repeated up to two times


PEDIATRIC-38

Suspected Child Abuse



a) Approach child slowly to establish rapport (except in life-threatening situations), then perform exam

b) Treat obvious injuries according to appropriate protocol

c) BE alert to immediate scene and document what you see! Touch only what you need to touch at the scene.

d) Do not disturb any evidence unless necessary for treatment

of patient. (If necessary to disturb evidence, DOCUMENT WHY and HOW it was disturbed).

e) Interview child separate from parents, if possible

f) Transport if permitted by parents

g) If parents do not allow transport, notify law enforcement for assistance

h) Communicate vital information to necessary emergency services (law enforcement, first responders and transport agencies) – additional info can be given to attending RN and/or Physician on arrival

i) Preserve evidence, such as clothing you may have had to remove for treatment, and make sure that it is NEVER left unattended at any time, to preserve "chain of evidence".

j) Record observations and factual information on run report

k) Report all suspected abuse to the IDPH Human Services Hotline at 1-800-362-2178 within 24 hours of your contact of the patient. This will be an oral report only

l) Within 48 hours of oral reporting, you must submit a written report for all suspected abuse to the Department of Human Services.


PEDIATRIC-39

PEDIATRIC TRAUMA

1. Follow Initial Patient Care Protocol 2. Follow the Out-of-Hospital Trauma Triage Destination Decision

Protocol for the identification of time critical injuries, method of transport and trauma facility resources necessary for treatment of those injuries.

3. The goal should be to minimize scene time with time critical injuries, including establishing IVs enroute.


a) Follow Shock Protocol if shock is present

Hemorrhage Control:


a) Control bleeding with direct pressure. Large gaping wounds may need application of a bulky sterile gauze dressing and direct pressure by hand

b) If unable to control hemorrhage with direct pressure apply a tourniquet

c) Apply a topical hemostatic agent with direct pressure added (especially if a tourniquet cannot be applied).


d) Establish IV of Normal Saline using a size-appropriate large-bore catheter with a macro drip tubing. If intravenous access cannot be obtained in a child, proceed with intraosseous access. Do not delay transport to obtain vascular access.

e) Monitor EKG if possible and treat dysrhythmias if indicated following the appropriate protocol.


PEDIATRIC-40

PEDIATRIC TRAUMA (Continued)

Chest Trauma:

BASIC CARE GUIDELINES a) Seal open chest wounds immediately. Use occlusive dressing

taped down. If the breathing becomes worse, loosen one side of

the dressing to release pressure and then reseal

b) Impaled objects must be left in place and should be stabilized by

building up around the object with multiple trauma dressings or

other cushioning material, ensuring that the penetrating object is

not allowed to do further damage

Abdominal Trauma:

a) Control external bleeding. Dress open wounds to prevent further contamination

b) Evisceration should be covered with a sterile saline soaked occlusive dressing

c) Impaled objects should be stabilized with bulky dressings for transport

Head, Neck, and Face Trauma:

Establish and maintain manual spinal immobilization

a) Place the head in a neutral in-line position unless the patient

complains of pain or the head does not easily move into this

position

b) Consider manual stabilization, apply a rigid cervical collar, and

immobilize the patient on size appropriate backboard or


PEDIATRIC-41

similar device as appropriate per the Selective Spinal

Immobilization Protocol.

PEDIATRIC TRAUMA (Continued)

c) Consider eye shield for any significant eye trauma. If globe of

eye is avulsed, do not put it back into socket: Cover with moist saline dressing and place a cup over it.

d) Closely monitor the airway. Provide suctioning as needed. Be

prepared to log roll the patient if they vomit while maintaining

manual spinal stabilization

d) Reassess vitals, GCS and pupillary response frequently


e) Establish large bore IV. Give fluid challenge per Shock

Protocol.

f) Start second large bore IV if patient condition warrants

g) IV lines should be started enroute to the hospital, except when there is an unavoidable delay as a result of a prolonged extrication, etc.

h) Monitor EKG if possible and treat dysrhythmias if indicated

following the appropriate protocol.

i) Activate a Field Trauma Alert if patient condition meets Trauma Alert Criteria (Appendix)

j) Consider needle chest decompression (Chest Trauma) enroute

to ED unless an unavoidable delay exists if signs and symptoms of a tension pneumothorax exist.


PEDIATRIC-42

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