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  • 1

    SICK/NOT SICK

    Presented by

    Mike Helbock, M.I.C.P., NREMT-P Senior Paramedic, SEI

    MSO – King County Medic One Manager - Training and Education

    Seattle/King County EMS

    A True Guide to Pediatric Patient Assessment

    Make a Decision Within 60 Seconds

    SICK... NOT SICK

  • 2

    En route…… Consider (3) probable scenarios…

    …which in turn generate solutions

    *Entrapment…and what if? *Head injuries…and what if? *Airway considerations…and what if? *Unconsciousness…and what if?

  • 3

    Make a Decision...quickly!

    *Begin your assessment from across the room...

    *Without touching the patient *Your SICK/NOT SICK decision

    is critical in guiding the direction of this call!

    SICK The SICK child is one who you believe is physiologically unstable meaning... ...a serious abnormality in appearance, breathing or circulation/skin signs.

    SICK

    The SICK child requires immediate and aggressive BLS and ALS

    intervention.

  • 4

    SICK

    This patient could die en route!

    SICK - The patient is a six-year-old female, involved in an auto-pedestrian incident. She was found lying in the crosswalk. She appears quiet and is not crying. - Her respirations are non-labored at 32 per minute and capillary refill time (CRT) is three seconds. She has an angulated left-sided femur fracture and a closed forearm fracture.

    NOT SICK The NOT SICK child is one who you believe is physiologically stable meaning... ...no or minimal abnormality in appearance, breathing and circulation/skin signs.

  • 5

    NOT SICK The NOT SICK child does not need

    aggressive BLS treatment or immediate ALS intervention,

    but... still requires BLS care and may

    require ALS evaluation!

    NOT SICK

    Patient appears stable at this time…

    NOT SICK - You are dispatched to a three-year-old male complaining of breathing difficulty. When you arrive you see the patient sitting on his mother’s lap. He is alert and is making appropriate eye contact. - Mother states that he briefly choked on some candy and at this time his breathing appears non-labored with no abnormal airway sounds. His skin is pink, warm and dry. His CRT less than 2 seconds.

  • 6

    SICK or NOT SICK?

    Make a decision within 60 seconds!

    Common Mistakes

    *Delaying the initial decision *Failing to respond to new info *Tunnel vision

    Other Factors Affecting SICK/NOT SICK

    *Nature of Illness (NOI) *Mechanism of Injury (MOI) *Index of Suspicion (IOS)

    Always include these concerns in your plan!

  • 7

    Pediatric Triangle

    The Pediatric Triangle

    The Pediatric Triangle

    Together…the Triangle provides an excellent picture of the child’s underlying…

    * cardiopulmonary status

    * neurologic status

    * metabolic status Pediatric Triangle

    The Pediatric Triangle - An easy way to do a rapid, initial assessment of any child using only visual and auditory clues…

    It will: * establish a level of severity

    * the urgency of care

    * identify key physiologic problems Pediatric Triangle

  • 8

    Ap pe

    ar an

    ce

    Pediatric Triangle

    The Pediatric Triangle

    Appearance *Look at the patient from

    across the room *This is an important

    indicator of oxygenation, brain perfusion and overall CNS function

    Appearance *Alertness *Eye contact *Distractibility *Consolability *Speech/cry *Spontaneous motor activity

  • 9

    SICK!

    Ap pe

    ar an

    ce

    Pediatric Triangle

    The Pediatric Triangle

    Ap pe

    ar an

    ce Breathing

    Pediatric Triangle

    The Pediatric Triangle

  • 10

    Breathing

    *Abnormal body position *Audible or abnormal airway

    sounds *Retractions

    Breathing

    A child with abnormal breath sounds needs high flow oxygen

    and ALS intervention!

    SICK!

  • 11

    Ap pe

    ar an

    ce Breathing

    Pediatric Triangle

    The Pediatric Triangle Ap

    pe ar

    an ce Breathing

    Pediatric Triangle

    The Pediatric Triangle

    Circulation/Skin Color

    Circulation/Skin Signs

    *Color *Temperature *Capillary refill time *Pulse quality

    Reflects the overall status of the circulatory system

  • 12

    Circulation/Skin Signs

    Poor color equals... poor circulation equals...

    SICK!

  • 13

    SICK/NOT SICK Case Studies

    DECIDESICK NOT SICK

    Ap pe

    ar an

    ce Breathing

    Circulation/Skin Color

    Pediatric Triangle

    Make a Decision!

  • 14

    SICK!

    NOT SICK!

    Case Study 1 Your unit is sent to an auto-pedestrian incident with a five-year-old female down.

    En route you and your partner discuss three probable injuries or scenarios:

    *multiple system trauma *trapped under car/spinal injury *massive head injury

    ##

  • 15

    - You arrive at the scene and see the girl who was knocked down by a vehicle that was pulling out of a parking stall. She is sitting in the parking lot, crying. She responds appropriately to your voice and follows your simple commands. She has a small hematoma on her forehead.

    - Breathing is normal with no audible airway sounds. Skin is warm and pink. CRT is less than 2 seconds. Radial pulse is present, full, and regular at about 100.

    DECIDESICK NOT SICK

    Ap pe

    ar an

    ce Breathing

    Circulation/Skin Color

    Pediatric Triangle

    Short Report to ALS

    Short Report to ALS

    Rapid Extrication

    Focused Hx/ Physical Exam

    Spinal Immobilization

    Rapid Trans- port/ALS

    Detailed Physical Exam

    *Rapid trauma assessment *Baseline vitals *SAMPLE history

    Focused Hx/ Physical Exam

    Detailed Physical Exam

    Appropriate Transport

    Extricate/ Immobilize

    Low/Moderate Flow O2

    *Focused trauma assessment *Baseline vitals *SAMPLE history

    100% O2 NRM or BVM

    Spinal Stabilization

    Ongoing Assess Keep

    Warm

    Ongoing Assess Keep

    Warm

    Crying, follows commands

    Pink and warm

    Normal

    Case Study 2 The call is for a three-year-old male with seizures.

    You and your partner discuss three probable injuries or scenarios while en route:

    *febrile seizures *epilepsy *head injury

    ##

  • 16

    -The boy’s mother meets you at the driveway with her son in her arms. He is lethargic and non- distractible. His only significant history is that of a fever for the past 48 hours (102.5 F). She describes the seizure as full body and lasting about 2 to 3 minutes.

    Breathing is non-labored. His skin is pale. CRT is 2 - 3 seconds, brachial pulse is rapid and weak.

    DECIDESICK NOT SICK

    Ap pe

    ar an

    ce Breathing

    Circulation/Skin Color

    Pediatric Triangle

    Short Report to ALS

    Short Report to ALS

    100% O2 NRM or BVM

    Focused Hx/ Physical Exam

    Appropriate Position

    Rapid Trans- port/ALS

    Detailed Physical Exam

    Ongoing Assess Keep

    Warm

    *Rapid medical assessment *Baseline vitals *SAMPLE history

    Focused Hx/ Physical Exam

    Appropriate Treatment

    Appropriate Transport

    Detailed Physical Exam

    Low/Moderate Flow O2

    *Focused medical assessment *Baseline vitals *SAMPLE history *OPQRST

    Ongoing Assess Keep

    Warm

    Lethargic

    Pale

    Non-labored

    Case Study 3 You respond to the home of a 3-month-old girl whose mother says “she stopped breathing” (approximately 30 seconds). Mother states the patient turned “blue” during the period of apnea.

    You consider the following as part of your plan:

    *airway obstruction *epiglottitis *sleep apnea

    ##

  • 17

    - On arrival you find a frantic mother holding her child. The child is conscious, but not too interested in all of the fuss. She appears tired to you.

    - Her breathing appears stable with no abnormal breath sounds or obvious retractions.

    - Her skin color is pink, warm and dry.

    - Within minutes of your arrival, her respiratory rate increases and she develops a stridor during the examination. Her mother again, confirms a brief period of apnea (2 - 3 minutes).

    DECIDESICK NOT SICK

    Ap pe

    ar an

    ce Breathing

    Circulation/Skin Color

    Pediatric Triangle

    Short Report to ALS

    Short Report to ALS

    100% O2 NRM or BVM

    Focused Hx/ Physical Exam

    Appropriate Position

    Rapid Trans- port/ALS

    Detailed Physical Exam

    Ongoing Assess Keep

    Warm

    *Rapid medical assessment *Baseline vitals *SAMPLE history

    Focused Hx/ Physical Exam

    Appropriate Treatment

    Appropriate Transport

    Detailed Physical Exam

    Low/Moderate Flow O2

    *Focused medical assessment *Baseline vitals *SAMPLE history *OPQRST

    Ongoing Assess Keep

    Warm

    Conscious, unattentive, tired

    Pink, warm, dry

    Brief apnea, stridor

    Case Study 4 You ar