Pediatrics

  • Allergic Reaction
  • APGAR
  • Bradycardia
  • Burn Chart
  • Cardiac Arrest
  • Cardiac Arrest
    PEA/Asystole
  • Cardiac Arrest
    VF/VT
  • Croup
  • Fever
  • GCS
  • Hypoglycemia
  • Intraosseous Infusion
  • Jump START Triage
  • Meconium Staining
  • Narrow Complex
    Tachycardia
  • Newborn Care
  • Newborn Resuscitation
    Time of Delivery
  • Newborn Resuscitation
    Flow Chart
  • Non Cardiogenic Shock
  • Obstructed Airway
    Conscious Infant
  • Obstructed Airway
    Conscious Child
  • Obstructive or Reactive Airway Diseases
  • Opiate OD
  • Pain Scale Infant
  • Pain Scale Visual
  • Pediatric Pit Crew CPR
  • Post Cardiac Arrest Care Pediatrics
  • Safe Transport of Pediatric Patients
  • Seizures
  • Smoke Inhalation
    Responsive
  • Smoke Inhalation
    Unresponsive
  • Tracheosotomy / Ventilator Management
  • Wide Complex
    Tachycardia

Pediatric
Allergic Reaction

BLS

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. Call for an ALS unit if patient has wheezing, stridor, or shows other signs of respiratory distress or nausea/vomiting.
  8.  

  9. If patient has a prescribed Epi auto-injector and is experiencing stridor and/or hypotension, assist patient with or administer one dose of the patient’s own Epi auto-injector.
  10.  

  11. If patient does not have a prescribed Epi-auto injector and displays signs of anaphylaxis, administer epinephrine 1mg/mL (1:1000) at the following dose and route:
  12.  

    1. Pediatric (less than 25kg) 0.15 mg IM in the anterolateral thigh

     

  13. If signs of anaphylaxis and hypoperfusion persist following the first dose of epinephrine, additional IM epinephrine can be repeated every 5-15 minutes at above noted doses.

 

ALS
IF suspected anaphylaxis, proceed directly to epinephrine administration

 

  1. Establish a saline lock or an IV with 0.9% NaCl. Titrate fluids to a SBP of 90 mmHg.
  2.  

  3. Apply cardiac monitor.
  4.  

  5. Medicate according to signs/symptoms as below.

 

Isolated Itchy Rash/Hives

 

    Administer Diphenhydramine 0.5 mg/kg IV or IM. (Max 50 mg)

 

Rash/Hives & Wheezing

 

  1. Administer 0.01 mg/kg Epinephrine 1:1,000 IM. (Max 0.3 mg)
  2.  

  3. Administer 2.5 mg nebulized Albuterol at a flow sufficient to produce of mist.
  4.  

  5. Administer Diphenhydramine 0.5 mg/kg IV or IM. (Max 50 mg)

 

Stridor &/or Hypotension

 

  1. Administer 0.01 mg/kg Epinephrine 1:1,000 IM. (Max 0.3 mg)
  2.  

  3. Administer 2.5 mg nebulized Albuterol.
  4.  

  5. Be prepared for emergent airway management.
  6.  

  7. Administer Diphenhydramine 0.5 mg/kg IV or IM. (Max 50 mg)
  8.  

  9. If condition is unchanged after 3 min. or worsens, administer additional dose of 0.01mg/kg Epinephrine 1:1,000 IM.
  10.  

  11. If after 3 minutes and second dose of epinephrine condition remains unchanged, mix and infuse epinephrine drip at 0.25mcg/kg/min (max 5mcg/min). Contact medical control if need for titration.

 

Epinephrine drip: Inject 1mL of epinephrine 1:1000 (also known as epinephrine 1 mg/ml for anaphylaxis) into a 1-liter saline bag and mix.

 

This yields a final medication concentration of 1mcg epinephrine / 1mL fluid. You must label the medication “Epi Drip: 1mcg/mL”

 

Use of a 20 gtt drip set is preferred. A 20 gtt drip set allows for:
Adult dosing: Drip rate of 100 drops/min yields drug infusion rate of 5 mcg/min.
Drip rate can be easily calculated by counting number of drops over 15 seconds then multiply by 4.

 

Weight
(Estimated by
Broselow tape)
4 kg
6 kg
8 kg
10 kg
12 kg
16 kg
> 20 kg or
Adults
Drug
Infusion
Rate
1
mcg/min
1.5
mcg/min
2
mcg/min
2.5
mcg/min
3
mcg/min
4
mcg/min
5
mcg/min
10
gtt set
10
drops/min
15
drops/min
20
drops/min
25
drops/min
30
drops/min
40
drops/min
50
drops/min
15
gtt set
15
drops/min
23
drops/min
30
drops/min
38
drops/min
45
drops/min
60
drops/min
75
drops/min
20
gtt set
20
drops/min
30
drops/min
40
drops/min
50
drops/min
60
drops/min
80
drops/min
100
drops/min

Pediatric
APGAR

Pediatric
Bradycardia

BLS

 

BRADYCARDIA CRITERIA: Heart rate <60/minute for children (1-15) and adults; <80/minute in infants. Bradycardia with hemodynamic compromise is an ominous sign of impending cardiac arrest in infants and children.

 

SYMPTOMATIC CRITERIA: Bradycardia with signs of poor perfusion and altered mentation, chest pain or dyspnea with associated hypotension.

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. If patient is symptomatic, call for ALS unit. If the BLS crew is able to deliver the patient to an emergency room within the same time it would take the ALS crew to respond to the scene, the BLS crew should emergently transport the patient.

 

ALS

 

  1. Apply cardiac monitor and obtain 12-lead EKG
  2.  

  3. If patient is symptomatic, establish a saline lock or IV with 0.9% NaCl. If an IV cannot be established and an urgent need for vascular access exists, establish IO access.
  4.  

  5. If patient remains symptomatic, perform the following in a step-wise fashion. Reassess after each step and proceed to the next step if there is no improvement.
  6.  

  7. Perform CPR if clinically indicated
  8.  

  9. Intubate only if BVM ventilations/oxygenation is inadequate
  10.  

  11. Administer epinephrine 0.01 mg/kg (1:10,000, 0.1 mL/kg) IV or IO every 3-5 minutes.
  12.  

  13. For increased vagal tone or primary AV block administer atropine 0.02 mg/kg (min. dose 0.1 mg, max single dose 0.5 mg) IV or IO; may repeat one time 3-5 minutes after initial dose.
  14.  

  15. Continue searching for possible reversible causes of hypoxia

Pediatric
Burn Chart

Pediatric
Cardiac Arrest, General Care

Prior to transport, the patient should receive 15 minutes of high quality CPR OR have received at least 3 doses of Epinephrine administered according to the appropriate cardiac arrest protocol.

 

Oxygenation and ventilation are of utmost importance in pediatric cardiac arrest care! Most pediatric cardiac arrests are secondary to a primary respiratory arrest.

 

Use the Broselow® tape (or appropriate equivalent) to obtain approximate weight and determine correct dosing regimen.

 

For EMS witnessed cardiac arrest, quick defibrillation is key – do not delay defibrillation!

 

BLS

 

  1. Follow established AHA BLS guidelines for pediatric cardiac arrest
  2.  

  3. Attach AED and follow prompts.
  4.  

    1. Utilize pediatric pads or pediatric key as appropriate to the AED for children < 8 years old or < 25 kg. The use of an adult AED is acceptable if pediatric supplies are not available

    2. Pads should be placed in the anterior-posterior position.

    3. If "no shock advised," perform CPR for 2 minutes, then check pulse. Re-analyze rhythm if no pulse is found.

     

  5. Initial airway management
  6.  

    1. OP/NP - Only if gag reflex absent

    2. Provide good bag valve mask ventilation with mask that forms an adequate seal around the mouth.

     

  7. If the patient regains a pulse, follow Peds - Post Cardiac Arrest Care Protocol.

 

ALS

 

  1. Establish an IV/IO with 0.9% NaCl
  2.  

  3. Apply cardiac monitor and follow appropriate Cardiac Arrest Dysrhythmia protocol
  4.  

  5. Defibrillation is the treatment priority when advised by the AED. Bare and dry chest. Place patient on hard surface.
  6.  

    1. Defibrillate as described in the appropriate protoco

     

  7. Try to minimize interruptions in chest compressions
  8.  

  9. Respiratory rate of 10 breaths/minute (1 breath every 6 seconds) is adequate for patients in cardiac arrest when an advanced airway is in place – do not hyperventilate.

  10. Place ETCO2 in line with the bag.

Pediatric
Cardiac Arrest - PEA/Asystole

Consider possible reversible causes of PEA such as hypovolemia, hypoxia, tension pneumothorax, cardiac tamponade, hypothermia, acidosis, drug overdose, hyperkalemia, massive acute MI, or pulmonary embolism

 

Consider possible reversible causes of Asystole such as hypoxia, preexisting acidosis, drug overdose, or hypothermia.

 

ALS

 

  1. High quality CPR has priority over any ALS intervention.
  2.  

  3. If the rhythm is unclear and possibly ventricular fibrillation, defibrillate as for VF.
  4.  

  5. BVM is the preferred method of ventilation. Proceed to advanced airway only if BVM ventilation/oxygenation is inadequate. Use in-line ETCO2.
  6.  

  7. Establish IV (or an IO line, if IV access is not available)
  8.  

  9. Administer 0.01 mg/kg epinephrine: (1:10,000, 0.1 mL/Kg) IV or IO every 3-5 minutes (max dose is 1 mg).

Pediatric
Cardiac Arrest - VF/VT

BLS

 

  1. Perform chest compressions until defibrillator is attached. (Provide 2 minutes of chest compressions prior to defibrillation for unwitnessed arrest.) Compressions should be performed at a rate of 100-120/minute.
  2.  

  3. Refer to Cardiac Arrest General Care guidelines

 

ALS

 

 

Persistent or Recurrent VF/VT

 

  1. Defibrillate, if indicated at 2 J/Kg. Subsequent shocks should be at 4 J/Kg.
  2.  

      The use of pediatric defibrillation pads is preferred if age < 8 or < 25 kg. If adult pads are used, they should be placed in an anterior-posterior configuration.

     

  3. Defibrillate, immediately resume CPR for 2 minutes. Establish an IV (or an IO line, if IV access is not available).
  4.  

  5. BVM is the preferred method of ventilation. Proceed to advanced airway only if BVM ventilation/oxygenation is inadequate. Use in-line ETCO2.
  6.  

  7. Administer 0.01 mg/Kg (0.1 mL/Kg) 1:10,000 epinephrine IV or IO every 3-5 minutes (max dose is 1mg)
  8.  

  9. Check for an organized rhythm at 2-minute intervals. Shock if indicated. Immediately resume CPR.
  10.  

  11. If persistent VF/VT after first epinephrine dose and subsequent shock, administer amiodarone 5 mg/Kg IV or IO (max dose is 300 mg).
  12.  

  13. Resuscitative efforts should rotate on 2 minute cycles. Pattern should be shock, CPR, drug.

 

Once VF/VT has Resolved

 

  1. Contact medical control for further instructions.
  2.  

Pediatric
Croup

CRITERIA: If the patient with difficulty breathing is at least 6 months of age and the cause is suspected to be croup (e.g., the patient has stridor at rest with retractions and/or accessory muscle use):

 

BLS

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration Protocol.
  6.  

  7. If the patient is in moderate to severe respiratory distress per the Oxygen Administration Protocol, call for a paramedic unit.
  8.  

  9. If possible, administer humidified oxygen via the blow-by method.
  10.  

    ALS

     

    1. Administer one of the following treatments:
    2.  

      1. The preferred treatment is 0.5 ml of 2.25% racemic epinephrine (Vaponephrine) diluted with 4.5 ml of 0.9% normal saline (for a total volume of 5 ml) and administered by nebulizer with 5-6 lpm oxygen.
      2.  

      3. If racemic epinephrine is unavailable administer 5 ml of 1:1,000 epinephrine by nebulizer with 5-6 lpm oxygen.

       

    3. Apply the cardiac monitor.
    4.  

    5. If the patient becomes unresponsive or is markedly short of breath, a nebulizer may be connected to a BVM using a "flex connector" to administer racemic epinephrine or epinephrine. Two oxygen connections will be required. The nebulizer will require an oxygen connection at 5-6 lpm in addition to a high flow connector for the BVM.

     

Pediatric

Fever

    Fever is defined in this protocol as 100.4 degrees F or higher (> 38°C).
    Temperatures taken by the patient or family with their own thermometer that documents fever is acceptable.
    Do not administer acetaminophen if any acetaminophen product has been given in the previous 4 hours.
    This protocol does not apply to environmentally induced cases of fever such as heat stroke.
    Acetaminophen does not improve survival in sepsis or serious infection and its administration should not delay transport.

     

    Pediatric Fever

     

    If patient is older than 6 months and is able to take PO, administer 10mg/kg PO acetaminophen (max dose 650mg).

 

 

Pediatric Acetaminophen Dosages
Oral
Mild Pain
or
Fever > 100.4oF / 38oC
Conc: 650 mg in 20.3 ml
or
160 mg in 5 ml
Dose: 10 mg/kg
For patients older than 6 months who are able to take PO

 

lbs

Kg

Dose

Volume

 
lbs

Kg

Dose

Volume

3

30 mg

1 ml

20

200 mg

6.3 ml

4

40 mg

1.3 ml

22

1.3 mg

6.9 ml

5

50 mg

1.6 ml

24

240 mg

7.6 ml

6

60 mg

1.9 ml

26

280 mg

8.2 ml

7

70 mg

2.2 ml

28

280 mg

8.8 ml

8

80 mg

2.5 ml

30

300 mg

9.4 ml

9

90 mg

2.8 ml

32

320 mg

10 ml

10

100 mg

3.2 ml

34

340 mg

10.6 ml

11

110 mg

3.4 ml

36

360 mg

11.2 ml

12

120 mg

3.8 ml

84

38

380 mg

11.8 ml

13

130 mg

4 ml

88

40

400 mg

12 ml

14

140 mg

4.4 ml

97

44

440 mg

14 ml

15

150 mg

4.6 ml

106

48

480 mg

15 ml

16

160 mg

5 ml

114

52

520 mg

16 ml

17

170 mg

5.4 ml

123

56

560 mg

17 ml

18

180 mg

5.6 ml

132

60

600 mg

19 ml

19

190 mg

6 ml

Use adult dose if > 60 kg

 

Indianapolis EMS

Open Resources
Conistent with 2020 Indianapolis Metro Area EMS Protocols
V1.08

Pediatric
Glasgow Coma Scale

(for use with children less than school age)
Eye Opening Spontaneous
4
To Sounds
3
To Painful Stimuli
2
None
1
Verbal Response Appropriate Words or Social Smile
5
Cries but Consolable
4
Persistently Irritable
3
Restless, Agitated
2
None
1
Verbal Response Spontaneous Movement
6
Localizes to Pain
5
Withdraw to Pain
4
Flexion to Pain
3
Extension to Pain
2
None
1
Total  
3 - 15

Pediatric
Hypoglycemia

BLS

 

  1. Begin Initial Medical Care and call for ALS.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. Investigate for possible causes (medical history, medications, medic alert tag, recent trauma).
  8.  

  9. Perform Blood Glucose analysis if available. If hypoglycemic, administer oral glucose if patient can tolerate oral medication.
  10.  

  11. If the patient has respiratory depression and a history suggestive of possible opiate overdose, initiate BVM ventilation first, then administer intranasal naloxone. Wait 2 minutes before providing another dose of naloxone – ensure adequate BVM ventilation is being provided during this time.
  12.  

ALS

 

  1. Establish a saline lock or an IV with 0.9% NaCl.
  2.  

  3. Apply cardiac monitor. Obtain a 12-lead electrocardiograph (ECG).
  4.  

  5. If an IV cannot be established and an urgent need for vascular access exists, establish IO access.
  6.  

  7. Perform blood glucose analysis.

     

    1. Perform blood glucose analysis. Hypoglycemia for neonates is < 40, pediatrics < 60.
    2.  

    3. For neonate (< 30 days), infants or older children give 5 ml/Kg 10% dextrose IV (max 100ml). Alternatively, use:
      1. For Neonates (< 30 days): Only use 10% dextrose
        For infants or older children: 2 mL/Kg 25% dextrose IV push (max 50 ml)
        For older children: 1 mL/Kg of 50% dextrose (not to exceed 25 mL)
    4. If unable to establish IV after 2 attempts, administer glucagon 0.5 mg IM or intra-nasal for children < 20 Kg, 1 mg IM or intra-nasal for children ≥ 20Kg.
    5.  

    6. Oral glucose may be considered for patients that, in the provider’s best judgment, can tolerate oral medications.

Pediatric
IO Infusion

ALS

 

  1. Place the child in the supine position.
  2.  

  3. Identify the tibia tuberosity, 1-3 cm below the tuberosity on the medial surface of the tibia, approximately one finger's breath below and just medial to the tuberosity.
  4.  

    1. Alternatively, 1 - 2 cm proximal to the medial malleolus on the anteromedial surface of the distal tibia.

     

  5. Clean the skin.
  6.  

  7. The leg should be supported on a firm surface. Grasp the thigh and knee above and lateral to the insertion site. Do not allow any portion of your hand to rest behind the insertion point.
  8.  

  9. With the stylette in place, insert the needle at a 90o angle to the skin.
  10.  

    1. Using gentle pressure that is steady, begin to advance the needle through the skin until you touch the bone, then check needle depth. If at least 5mm of needle remains exposed (the last black line) drill through the bone.
    2.  

    3. Stop advancing the needle when a sudden decrease in resistance to forward motion of the needle is felt. Do not pull back or recoil when entering the medullary space. Unscrew the cap and remove the stylet. It may be possible to aspirate bone marrow at this point with a 20 or 30 mL syringe.

     

  11. Stabilize the IO.
  12.  

  13. If the patient is awake and alert, prime all tubing with lidocaine instead of saline and administer 1 mL 2% lidocaine over 60 seconds, and then allow 30-60 seconds to affect the visceral nerves. Follow with a brisk 10 mL irrigation of saline. A second dose of 0.5 mL 2% lidocaine may be repeated in the same manner
  14.  

  15. Check for any signs of increased resistance to injection, increased circumference of the soft tissues of the calf, or increased firmness of the tissue.
  16.  

    1. The needle is in the bone marrow when:
    2.  

      1. there is a lack of resistance
      2.  

      3. the needle passes through the cortex
      4.  

      5. the needle stands upright without resistance
      6.  

      7. there is no infiltration
      8.  

      9. blood and marrow are aspirated (less common)
      10.  

      11. fluid flows freely through the needle without evidence of subcutaneous infiltration
      12.  

  17. Attach the IV tubing and begin the infusion. A pressure infusion bag or in-line 60 mL syringe may be required to infuse the solution.
  18.  

  19. If unsuccessful, remove the needle and move to the other leg.
  20.  

  21. Secure tubing and use commercial stabilizer if available or secure with tape.

 

Complications

 

    Abscess from prolonged insertion
    Leakage around the needle with compartment syndrome
    Tibia fractures
    Osteomyelitis from prolonged insertion
    Potential injury to the bone marrow cavity
    Skin necrosis

Pediatric
JumpSTART Triage

Jump-START is a modification of the START triage guidelines for pediatric patients and takes into account the normal variation in respiratory rate on the basis of age, and the fact that primary respiratory failure can be corrected easily.

 

An apneic child is more likely to have a primary respiratory problem than an adult. Perfusion may be maintained for a short time and the child may be salvageable.

 

A respiratory rate of 30 may either over-triage or under-triage a child, depending on age.

 

Capillary refill may not adequately reflect peripheral hemodynamic status in a cool environment.

 

Obeying commands may not be an appropriate gauge of mental status for younger children.

 

Criteria (Ages 1 - 8)
Tag
Move the walking wounded
Minor
Apneic or irregular respirations: Open airway
Resume breathing?
Immediate
Still apneic and no peripheral pulse?
Dead / Dying
Still apneic but has a peripheral pulse
Mouth-toMask for 15 seconds (4-5 breaths)
Resume breathing?
Immediate
Still apneic?
Dead / Dying
Respirations <15 or >45
Immediate
Pulse: No peripheral pulse (least injured extremity)
Immediate
Mental status: Unresponsive or responsive to pain only
Immediate
Otherwise
Delayed
Age <1:
If all Jump-START “delayed” criteria are satisfied and there are no significant external injuries, the child may be classified as “ambulatory” and tagged.
Minor
Developed by Lou Romig MD, FAAP, FACEP at Miami Children’s Hospital

Pediatric
Meconium Staining

Presence of green amniotic fluid or green/black particulate material on face or in upper airway.

 

  1. After completion of delivery, using a catheter or bulb syringe, suction mouth and then nose of newborn ONLY if there are signs of obvious obstruction or if the baby requires positive pressure ventilation (PPV).
  2.  

  3. Wipe away any collection of meconium in the upper airway with gauze-wrapped finger.
  4.  

    BLS

     

    1. Request ALS if not already en route and initiate transport. Contact receiving facility for further orders if ALS is not on scene.

     

    ALS

     

    1. See Newborn Resuscitation Protocol.

Pediatric
Narrow Complex Tachycardia QRS < 0.12 sec

BLS

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. If patient is symptomatic, call for ALS

 

ALS

 

  1. Apply cardiac monitor and obtain 12-lead EKG
  2.  

  3. If patient is symptomatic, establish a saline lock or IV with 0.9% NaCl. If an IV cannot be established and an urgent need for vascular access exists, establish IO access.
  4.  

  5. If the patient has no signs or symptoms of pulmonary edema, administer 20 mL/kg bolus of 0.9% NaCl solution. Repeat 20 mL/kg boluses every 5 minutes as long as SBP remains below 90 mmHg and no signs of pulmonary edema exist.
  6.  

  7. If patient remains symptomatic, perform the following in a step-wise fashion. Reassess after each step and proceed to the next step if there is no improvement.
  8.  

  9. For pediatric patients, refer to Pediatric Emergency weight/length-based tape
  10.  

    Urgent:
    Infants - rate usually > 220/min
    Children - rate usually > 180/min

     

    1. Have patient perform Valsalva maneuver using the REVERT method.
    2.  

        Have patient blow into 10ml syringe to slowly move the plunger (~15 seconds); then quickly position patient supine with legs lifted >45 degrees

       

    3. If rhythm has not converted to a sinus rhythm, and in your judgment the rhythm is believed to be SVT, administer:
    4.  

      1. Adenosine 0.1 mg/kg (max 6 mg) RIVP, followed with 10 mL fluid flush.
      2.  

      3. Second dose of adenosine, 0.2 mg/kg (max 12 mg) RIVP, followed by 10 mL fluid flush.

     

    Emergent:
    Hypotension, acutely altered mentation, signs of shock

     

    Perform synchronous cardioversion in an escalating fashion. Start at 0.5-1 Joules/kg then 2 J/kg

    If still conscious, consider 0.1mg/kg (max 2.5 mg) IV midazolam or 0.2mg/kg IN (max 2.5mg) before cardioversion. Use capnography if given

Pediatric
Newborn Care

  1. Stimulate, position and warm. Dry with towels, stimulate with gentle rubbing or heal flicks. Suction only if an obvious obstruction is seen or the neonate requires positive pressure ventilation.
  2.  

    Note – In premature infants with estimated gestational age < 30 weeks DO NOT towel dry. Instead, wrap in plastic or put infant in a plastic bag (not the head) and put on a hat if available.

     

  3. If any of the following are present, immediately start newborn resuscitation protocol.
  4.  

      Non-vigorous newborn
      Apneic or gasping
      Heart rate < 100

      If none of the above are present, continue below.

     

  5. Keep baby at the same level of the perineum for at least 1 minute. Clamp and cut the cord. Place one clamp six inches from the infant, the second clamp three inches distal from the first clamp. Cut the cord between the clamps. If cord continues to bleed, apply additional clamps.
  6.  

  7. Record the time of birth. Determine APGAR scores at one and five minutes after birth. Normal respiratory rate is 40-60/minute and pulse is 120-160/minute. See below for normal preductal oxygen saturations in the neonatal period (in the right arm.)
  8.  

  9. Contact the receiving facility for early notification. Protect newborn from hypothermia.
Targeted Preductal SpO2 After Birth
1 min
60% - 65%
2 min
65% - 70%
3 min
70% - 75%
4 min
75% - 80%
5 min
80% - 85%
10 min
85% - 95%

Pediatric
Newborn Resuscitation at Time of Delivery

Perform the following procedures in a stepwise fashion as indicated.
Reassess after each step before proceeding to the next.

 

BLS

 

  1. If infant is apneic, gasping, or has a HR < 100/min begin Positive Pressure Ventilation (PPV) with a bag-valve-mask (infant preferred) at rate of 40-60 breaths per minute for 30 seconds. (Caution: risk of barotrauma – bag only enough for chest rise and fall.). Positive pressure ventilation and thermoregulation are the most important priorities in newborn resuscitation.
  2.  

    1. Start oxygen saturation monitoring with pulse oximeter, if available.
    2.  

    3. Consider 3-lead monitoring (for purposes of obtaining heart rate)
    4.  

    5. If available, begin resuscitation with 21% oxygen.

     

  3. Reassess after 30 seconds of PPV:
  4.  

    1. If HR is < 100/min but > 60/min PPV, ensure good seal and airway position. Continue to perform PPV.
    2.  

    3. If HR < 60/min, begining chest compressions with a ratio of 3:1 compressions to breaths (90 compressions and 30 respirations per minute)
    4.  

  5. If HR >100/min, transport to closest pediatric facility with continued close monitoring
ALS

 

  1. If infant is apneic, gasping, or has a HR < 100 begin Positive Pressure Ventilation (PPV) with a bag-valve-mask (infant preferred) at rate of 40-60 breaths per minute for 30 seconds (Caution: risk of barotrauma – bag only enough for chest rise and fall.) Positive pressure ventilation and thermoregulation are the most important priorities in newborn resuscitation.
  2.  

    1. Start oxygen saturation and heart rate monitoring with pulse oximeter, if available
    2.  

    3. Consider 3-lead monitoring
    4.  

    5. If available, begin resuscitation with 21% oxygen.

     

  3. Reassess after 30 seconds of PPV:
  4.  

    1. If HR is < 100/min but > 60/min, ensure good seal and airway position. Continue to perform PPV.
    2.  

    3. If HR < 60/min begin chest compressions with a ratio of 3:1 compressions to breaths (90 compressions and 30 respirations per minute)
    4.  

      1. Reassess after additional 30 seconds of PPV and compressions. If HR < 60 BPM, administer epinephrine 0.01mg/kg of 1:10,000 IV/IO and continue compressions and ventilation.
      2.  

      3. Reassess after additional 30 seconds. If HR still < 60 bpm, administer 0.9% NS bolus 10ml/kg, slow IV push over 5-10 minutes.

     

  5. If HR does not improve despite performance of good PPV and HR does not respond thenintubate and use meconium aspirator to suction thick secretions that may be obstructing the airway (this is not necessarily meconium.)
  6.  

  7. If HR >100/min, transport to closest pediatric facility with continued close monitoring.
  8.  

  9. If HR >100/min, transport to closest pediatric facility with continued close monitoring. Protect newborn from hypothermia.
Targeted Preductal SpO2 After Birth
1 min
60% - 65%
2 min
65% - 70%
3 min
70% - 75%
4 min
75% - 80%
5 min
80% - 85%
10 min
85% - 95%

Pediatric
Newborn Resuscitation Flowchart

Click on the image for a larger version
General Considerations
(From 2015 AHA Guidelines)
    Initial resuscitation steps should be completed within 60 seconds as illustrated.

    The decision to progress beyone initial steps is based on an assessment of respirations (apnea, gasping, labored, or unlabored breathing) and heart rate (>/< 100 bpm)

 

Assisting Venitlations
    Assist ventilations at a rate of 40-60 breaths per minute to maintain HR > 100
    Use 2 person BVM when possible

 

Chest Compressions
    Indicated for HR < 60 despite adequate ventilation with supplemental O2 for 30 seconds.
    2 thumbs-encircling hands technique preferred
    Allow full chest recoil
    Coordinate with ventilations so not deliverd simultaneously
    3:1 ratio for compressions to ventilations
Medications
    Epinephrine is indicated if the newborn's heart rate remains less than 60 beats/min after 30 seconds of PPV with 100% O2 AND another 60 seconds of chest compressions coordinated with PPV using 100% O2.
Intubation
    Intubation is only to be performed if all other measures listed have been attempted and the patient continues to have HR < 60 beats/min.

Pediatric
Non-Cardiogenic Shock

BLS

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. Request ALS if not already en route. If the BLS crew is able to deliver the patient to an emergency room within the same time it would take for the ALS crew to respond to the scene, the BLS crew should transport the patient.
  8.  

  9. If evidence of trauma or hemorrhage present see Initial Trauma Care Protocol
  10.  

  11. Consider other causes of shock

 

ALS

 

  1. Administer 20 mL/kg IV or IO NaCl solution as rapidly as possible.
  2.  

  3. Reassess vital signs and peripheral perfusion; reassess for signs of pulmonary edema.
  4.  

  5. If no improvement in vital signs, peripheral perfusion, and no indication of pulmonary edema is present, repeat NaCl bolus of 20 mL/kg
  6.  

  7. In cases of hypotension involving infants, perform glucose analysis. If blood glucose suggest hypoglycemia administer 4 mL/kg D25
    If hypoglycemic, see hypoglycemia in ALOC protocol.

Pediatric
Obstructed Airway - Conscious Infant

BLS

 

  1. Determine complete airway obstruction.
  2.  

  3. Deliver cycles of alternating chest thrusts and back slaps until the obstruction is relieved or the patient becomes unconscious.
  4.  

  5. Do not perform blind finger sweeps.
  6.  

  7. If patient becomes unconscious, see Obstructed Airway - Unconscious.

Pediatric
Obstructed Airway - Conscious Child/Adult

BLS

 

  1. Determine complete airway obstruction.
  2.  

  3. Deliver abdominal thrusts until the obstruction is relieved or the patient becomes unconscious (Chest thrusts can be substituted in obese or pregnant patients.)
  4.  

  5. If patient becomes unconscious, see Obstructed Airway - Unconscious.

Pediatric
Obstructive or Reactive Airway Diseases

  1. Administer oxygen as indicated - (See Oxygen Administration Protocol)

 

BLS

 

  1. If the patient presents with shortness of breath related to a known diagnosis of COPD or asthma, determine if the patient has physician-prescribed hand-held inhaler or nebulizer. If available, assist with one of the following:
  2.  

    1. Metered Dose Inhalers **Use with spacer device if possible**
      1. Albuterol (with or without Ipratropium) – one dose (2-4 puffs)
      2. Levalbuterol – one dose (2 puffs)

       

    2. Nebulizers (EMTs may connect nebulizer to oxygen at 6 LPM)
      1. Albuterol, Albuterol/Ipratropium (Combivent), or Levalbuterol – one dose as prescribed by patient’s physician.

     

  3. Reassess patient. Anticipate need for assisting ventilations with BVM and high flow O2.

     

  4. Request ALS if not already en route. If the BLS crew is able to deliver the patient to an emergency room within the same time it would take for the ALS crew to respond to the scene, the BLS crew should transport the patient.

 

Common Inhaled Medications
 

    Albuterol aka: Proventil, Ventolin, Combivent
    Ipratropium bromide aka: Atrovent
    Xoponex aka: levalbuterol

 

ALS

 

If difficulty breathing is suspected from reactive airway disease or obstructive airway disease and there is no improvement from prescribed inhaler or if no inhaler was administered:

 

  1. Administer albuterol, 2.5 mg and ipratropium 0.5 mg nebulized with 5-6 lpm of oxygen
  2.  

      No more than three doses of ipratropium should be administered.
      Albuterol dose should be increased to 5 mg if the patient uses an albuterol nebulizer regularly.
      Nebulizer treatments should be repeated as needed.
      If you suspect the SOB is due to CHF, refer to the CHF protocol

     

  3. Apply the cardiac monitor, pulse oximeter, and waveform capnography to the patient.
  4.  

  5. Initiate a peripheral IV, if necessary.
  6.  

    If the patient has a history of asthma and presents in
    respiratory arrest, impending respiratory failure
    (such as altered mental status, poor respiratory effort),
    or status asthmaticus administer epinephrine IM.
    For Pediatric patients over 2 years old,
    administer 0.01 mg/kg Epinephrine 1:1,000 IM.
    (Max 0.3 mg)

     

  7. If the child is markedly short of breath, hypoxemic (oxygen saturation <92% on non-rebreather), BVM ventilations may be initiated immediately in conjunction with medication therapies with in-line treatments
  8.  

  9. If the patient is over the age of 2 years with a KNOWN history of asthma and continues to decline despite treatments administer
    0.01 mg/kg Epinephrine 1:1,000 IM. (Max 0.3 mg) if not already given
  10.  

  11. If the patient is over the age of 2 years with a KNOWN history of asthma AND are receiving a 2nd nebulized treatment, give ONLY ONE of the following treatments.
    1. Oral Prednisone 50-60 mg IF able to swallow pills and >30kg
    2. Methylprednisolone 2 mg/kg IV (maximum dose 125 mg IV)

     

  12. If a treatment was initiated by a fire department, you must document the exact dose given in the assessment/treatment of EMR.
  13.  

Pediatric
Opiate Overdose

BLS

 

  1. Begin Initial Medical Care and call for ALS.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. Investigate for possible causes (medical history, medications, medic alert tag, recent trauma).
  8.  

  9. Perform Blood Glucose analysis if available. If hypoglycemic, administer oral glucose if patient can tolerate oral medication.
  10.  

  11. If the patient has respiratory depression and a history suggestive of possible opiate overdose, initiate BVM ventilation first, then administer intranasal naloxone. Wait 2 minutes before providing another dose of naloxone – ensure adequate BVM ventilation is being provided during this time.
  12.  

ALS

 

  1. Establish a saline lock or an IV with 0.9% NaCl.
  2.  

  3. Apply cardiac monitor. Obtain a 12-lead electrocardiograph (ECG).
  4.  

  5. If an IV cannot be established and an urgent need for vascular access exists, establish IO access.
  6.  

  7. Perform blood glucose analysis.
  8.  

    1. If the patient has respiratory depression and a history suggestive of possible opiate overdose, initiate ventilation using BVM, and administer 0.1 mg/kg (up to 2mg) naloxone IVP or intra-nasally.
    2.  

    3. If respiratory depression persists after 2 minutes, contact medical control for recommendations for any further dosing.

 

 

Pediatric Naloxone Dosages
PEDs - IV / IO /IN
Respiratory Depression
Conc: 1 mg in 1 ml
Dose: 0.1 mg/kg

 

lbs

Kg

Dose

Volume

 
lbs

Kg

Dose

Volume

3

0.3 mg

0.3 ml

20

2 mg

2 ml

4

0.4 mg

0.4 ml

22

2 mg

2 ml

5

0.5 mg

0.5 ml

24

2 mg

2 ml

6

0.6 mg

0.6 ml

26

2 mg

2 ml

7

0.7 mg

0.7 ml

28

2 mg

2 ml

8

0.8 mg

0.8 ml

30

2 mg

2 ml

9

0.9 mg

0.9 ml

32

2 mg

2 ml

10

1 mg

1 ml

34

2 mg

2 ml

11

1.1 mg

1.1 ml

36

2 mg

2 ml

12

1.2 mg

1.2 ml

84

38

2 mg

2 ml

13

1.3 mg

1.3 ml

88

40

2 mg

2 ml

14

1.4 mg

1.4 ml

97

44

2 mg

2 ml

15

1.5 mg

1.5 ml

106

48

2 mg

2 ml

16

1.6 mg

1.6 ml

114

52

2 mg

2 ml

17

1.7 mg

1.7 ml

123

56

2 mg

2 ml

18

1.8 mg

1.8 ml

132

60

2 mg

2 ml

19

1.9 mg

1.9 ml

Use adult dosing if > 60 kg

 

Indianapolis EMS

Open Resources
Conistent with 2020 Indianapolis Metro Area EMS Protocols
V1.08

Pediatric
Infant Pain Scale Assessment Tool

Behavior
Scoring
0
1
2
3
Facial
Neutral/smiling
Frowning/grimacing
Clenched teeth
Full cry expression
Body Movement
Calm, relaxed
Restless/fidgeting
Moderate agitation or moderate mobility
Thrashing, flailing, incessant agitation or strong voluntary immobility
Sleep
Sleeping quietly with easy respirations
Restless while asleep
Sleeps intermittently (sleep/awake)
Sleeping for prolonged periods of time interrupted by jerky movements or unable to sleep
Verbal/Vocal
No cry
Whimpering, complaining
Pain crying
Screaming, high pitched cry
Consolability
Neutral
Easy to console
Not easy to console
Inconsolable
Response to
Movement/Touch
Moves easily
Winces when touched/moved
Cries out when moved/touched
High-pitched cry or scream when touched or moved

Wong Baker Pain Scale

0
No hurt
2
Hurts little bit
4
Hurts little more
6
Hurts even more
8
Hurts whole lot
10
Hurts worst

Pediatric
Pit Crew CPR

Pit crew CPR is a high performance model of CPR that maximizes compressions and minimizes interruptions by pre-assigning provider roles based on order of arrival to the patient. Below is a description of the positions that are to be assumed by those arriving on scene to a cardiac arrest.

 

NOTE: The positions for Pediatric Pit Crew CPR are slightly different to emphasize the importance of Oxygenation and Ventilation
  1. Pit Crew CPR applies to all cardiac arrest patients (VT, VF, PEA and asystole)
  2.  

  3. Positions:
  4.  

    1. Position #1: (Patient’s right hand side)
    2.  

      1. Check pulses and initiate first 2 minutes of compressions
      2. Alternate compressions with Position #4 on 2 minute interval
      3. Compressions should be continuous until BVM is set up then switch to ratio of 15 compressions:2 breaths

       

    3. Position #2: (Patient’s head)
    4.  

      1. Initiate BVM with 100% Oxygen
      2. Focus on achieving and maintaining an excellent seal with 2 handed technique

       

    5. Position #3: (Patient’s head right/left)
    6.  

      1. Assist Position #2 with BVM and airway management
      2. Maintain quality CPR with 15:2 ratio
      3. Alternate with Position #2 holding the mask in case of fatigue

       

    7. Position #4: (Patient’s left hand side)
    8.  

      1. Attach AED and follow prompts
      2. Alternate compressions with Position #1 on 2 minute intervals

       

    9. Position #5: First arriving EMT-P after Positions 1-4 are filled.
    10.  

      1. Obtain IV/IO access and administer medications as per current Indianapolis Metropolitan Area EMS Protocols
      2. Directs PALS interventions based on rhythm, EtCO2 and pulse
      3. Temporarily slide to position #3 if advanced airway required

       

    11. Position #6: “Quality Assurance”
    12.  

      1. Utilizes checklist (see appendix) to verify positions are appropriately filled and performing required interventions
      2. Records rhythm and if shock delivered every 2 minutes
      3. Records time of administration of PALS medications
      4. IF ROSC OBTAINED – Utilizes Checklist to verify all tasks have been completed.

       

    13. Position #7: “Liaison” (if available)
    14.  

      1. Liaisons with family, bystanders and maintains scene safety.

Pediatric
Post Cardiac Arrest Care

  1. Applies to pediatric patients resuscitated from cardio-respiratory arrest who have a perfusing rhythm and pulse, and who remain unresponsive.
  2.  

  3. Continue to support respirations with BVM, attempting to time support with the patients own respirations
  4.  

  5. ETCO2 should be used in line with bag during BVM. If the patient is breathing and BVM is not necessary then nasal cannula ETCO2 should be placed on the patient.
  6.  

  7. Maintain normal ventilation. Initially, ventilate at 10 breaths per minute (1 breath every 6 seconds). Do NOT hyperventilate or hypoventilate.
  8.  

  9. Stabilize dysrhythmias:
  10.  

    1. Stable tachycardia or bradycardia – treat per protocols
    2. If initial arrest rhythm was v-fib or v-tach, give Amiodarone 5 mg/kg (max 300 mg) IV/IO over 10 minutes if not already given during resuscitation. If significant ventricular ectopy persists, repeat amiodarone per protocol

     

  11. Support blood pressure
  12.  

    1. Administer 10 mL/kg boluses of 0.9 NS to maintain adequate blood pressure for age (70 + 2xPatient Age)

    2. If the patient’s SBP is less than lower limit based on the above equation after first 10 ml/kg of fluid, call medical control for further instructions

     

  13. Obtain a 12-lead EKG.
  14.  

  15. Check glucose and treat per protocol
  16.  

  17. Seizure activity – monitor for seizure activity and treat per protocol.
  18.  

  19. Monitor for fever.

Pediatric
Safe Transport of Pediatric Patients

  1. These guidelines apply to every EMS response resulting in the need to transport pediatric patients and require the use of a safety seat or restraint (as defined below). Pediatric patients that do not require a child safety seat or restraint should be transported following the same procedure as adult patients. Unlike other situations, choice of safety restraints are directly related to the child’s size. Therefore, for the purposes of this protocol, child specific safety seats or restraints are required until the child has reached adult size by provider judgment (As a general guide, greater than 5 feet tall and 100 lbs. ).
  2.  

  3. These guidelines offer recommendations, as published by NHTSA, for the transportation of children in five (5) different possible situations:
  4.  

    1. A child who is not injured or ill.
    2. An ill or injured child whose condition does not require continuous and/or intensive medical monitoring/intervention.
    3. An ill or injured child who does require continuous and/or intensive monitoring/intervention.
    4. A child whose condition requires spinal motion restriction and/or lying flat.
    5. A child or children who require transport as part of a multiple patient transport (newborn with mother, multiple children, etc.).

     

  5. General Guidelines
  6.  

    1. Each agency is responsible for providing child restraint options that are compatible with their transporting vehicles. These guidelines do not comprehensively cover all possible situations and EMS provider judgment should be used if a situation is presented that is not addressed below.
    2.  

    3. The child’s age and weight shall be considered when determining an appropriate restraint system. Child seat models offer a wide range of age/weight limits, so each individual device must be evaluated to determine the appropriateness of use.
    4.  

    5. The child’s own safety seat is the preferred device unless the device has been involved in a motor vehicle crash, cannot be safely secured in the vehicle or the child needs care and monitoring that cannot be delivered with the child in the car seat.
    6.  

      1. With the exception of a minor vehicle crash (e.g. “fender-bender”), avoid using the child’s own safety seat if the seat was involved in a motor vehicle crash. However, using the child’s own seat can be considered if no other restraint systems are available and the seat shows no visible damage/defect.

       

    7. Transportation of a child in any of the following ways is NEVER appropriate:
    8.  

      1. Unrestrained;
      2. On a parent/guardian/other caregiver’s lap or held in their arms;
      3. Using only horizontal stretcher straps, if the child does not fit according to cot manufacturer’s specifications for proper restraint of patients;
      4. On the multi-occupant bench seat or any seat perpendicular to the forward motion of the vehicle, even if the child is in a child safety seat.

       

  7. Situation Guidelines
  8.  

    *Ideal transport method is in bold & highlighted, with acceptable alternatives listed.

     

    1. The uninjured/not ill child shall be transported:
    2.  

      1. In a vehicle other than a ground ambulance using a properly installed, size-appropriate child restraint system.
      2. In a size-appropriate child seat properly-installed in the front passenger seat of the ambulance with the airbags off or in another forward-facing seat.
      3. In a size-appropriate child seat properly-installed on the rear-facing EMS provider’s seat.
      4. Consider delaying the transport of the child (ensuring appropriate adult supervision) until additional vehicles are available without compromising other patients on the scene. Consult medical direction/operations.

       

    3. The ill/injured child not requiring continuous intensive monitoring/interventions, shall be transported:
    4.  

      1. In a size-appropriate child restraint system secured appropriately on the cot.
      2. In the EMS provider’s seat (captain’s chair) in a size-appropriate restraint system.
      3. On the cot using three horizontal straps (chest, waist, knees) and one vertical restraint across each shoulder (X formation).

       

    5. The ill/injured child whose condition requires continuous intensive monitoring or intervention, shall be transported:
    6.  

      1. In a size-appropriate child restraint system secured appropriately to cot.
      2. On the cot using three horizontal straps (chest, waist, knees) and one vertical restraint across each shoulder (X formation). If assessment/intervention requires the removing of restraint strap(s), restraints should be re-secured as quickly as possible.

       

    7. The ill/injured child who requires SMR or lying flat, shall be transported:
    8.  

      1. Secured to a size-appropriate LBB, then secure the LBB to the cot, head first, with a tether at the foot (if possible) to prevent forward movement, and three horizontal restraints (chest, waist, and knees) and a vertical restraint across each shoulder (X formation).
      2. Secured to a standard LBB with padding added as needed and secure using the strap configuration listed above.

       

    9. The child or children requiring transport as part of a multiple patient transport.
    10.  

      1. If possible, for multiple patients, transport each as a single patient according to the guidance provided for situations 1 through 4. For mother and newborn, transport the newborn in an approved size-appropriate restraint system in the rear-facing EMS provider seat with a belt-path that prevents both lateral and forward movement, leaving the cot for the mother.
      2. Consider the use of additional units to accomplish safe transport, remembering that non-patient children should be transported in non-EMS vehicles, if possible.
      3. When available resources prevent meeting the criteria for situations 1 through 4 for all child patients, transport using space available in a non-emergency mode, exercising extreme caution and driving at a reduced speed.
      4. Note: Even with childbirth in the field, it is NEVER appropriate to transport a child held in the parent/guardian/caregiver’s arms or on a parent/guardian/caregiver’s lap.

       

      Reference: Working Group Best-Practice Recommendations for the Safe Transportation of Children in Emergency Ground Ambulances. National Highway Traffic Safety Administration (NHTSA), September 2012, available at www.ems.gov

Pediatric
Seizures

  1. Administer high flow oxygen. (See Oxygen Administration)
  2.  

  3. Protect patient from injury while patient is seizing. DO NOT RESTRAIN PATIENT. DO NOT FORCE A BITE STICK INTO THE PATIENT'S MOUTH. Determine the duration of the seizure. Observe the type of seizure activity and what part(s) of the body it affects.

 

Not in Status Seizures

 

  1. Initiate transport.

 

Status Seizures

 

Criteria: Continuous seizure activity for longer than 3 minutes or two or more consecutive seizures without regaining consciousness.

 

BLS

 

  1. Assist ventilations. (See Airway Management Protocol)
  2.  

  3. Contact receiving facility for further orders if ALS is not on scene. Request advanced life support.
  4.  

  5. Perform Blood Glucose analysis if available. If hypoglycemic, follow hypoglycemia BLS protocol in ““Altered Level of Consciousness”.

 

ALS

 

    1. Perform blood glucose analysis. If blood glucose suggests hypoglycemia, refer to hypoglycemia protocol in “Altered Level of Consciousness”.
    2.  

    3. Apply the cardiac monitor and pulse oximeter.
    4.  

    5. Administer midazolam IV, IM, or intra-nasal:
    6.  

      1. 0.2 mg/kg of midazolam (up to a maximum of 5 mg) IM or Intra-nasal. If intra-nasal, divide the dose so that each nares receives half
      2. 0.1 mg/kg of midazolam (up to a maximum of 5 mg) IV
      3. The dose may be repeated once in 5 minutes if needed.

       

    7. Contact the receiving facility for further instructions or additional dosing if needed.
Note: Patient must be placed on nasal waveform capnography.

Pediatric
Smoke Inhalation - Responsive

BLS

 

  1. Assess for and manage trauma or burns per the appropriate protocol.
  2.  

  3. Carbon monoxide and cyanide toxicity should be considered for any patient who experiences smoke inhalation in an enclosed space. See Carbon Monoxide Poisoning Protocol.
  4.  

  5. Apply the cardiac monitor, pulse oximeter, and waveform capnography to the patient. (Pulse oximetry monitors may give false readings in patients exposed to carbon monoxide.)
  6.  

    1. Provide high flow O2
    2.  

    3. Request ALS if not already en route
ALS

 

No evidence of significant cyanide toxicity

 

  1. Provide high flow O2 by NRB mask
Soot in airway and 1) altered level of consciousness or 2) hypotension

 

  1. Ensure an airway and provide high flow O2
  2.  

  3. For wheezing or stridor, treat with 2.5-5 mg nebulized albuterol as needed.
  4.  

  5. Establish an IV
  6.  

  7. Draw blood samples
  8.  

  9. If available, mix one or both Cyanokit® 2.5 g vials, each with 100 cc of 0.9% NaCl, and administer 70 mg/Kg over 15 minutes.
  10.  

  11. If hypotensive, consider fluid challenge(s)
  12.  

  13. Transport emergently to closest appropriate hospital

Pediatric
Smoke Inhalation - Unresponsive

BLS

 

  1. Assess for and manage trauma or burns per the appropriate protocol.
  2.  

  3. Carbon monoxide and cyanide toxicity should be considered for any patient who experiences smoke inhalation in an enclosed space. See Carbon Monoxide Poisoning Protocol.
  4.  

  5. Apply the cardiac monitor, pulse oximeter, and waveform capnography to the patient. (Pulse oximetry monitors may give false readings in patients exposed to carbon monoxide.)
  6.  

    1. Establish airway with OP, NP or non-visualized airway
    2.  

    3. Provide high flow O2 by NRB mask or BVM
    4.  

    5. Request ALS if not already en route
    6.  

    7. If BLS can transport the patient before ALS can arrive at the scene, do so.
ALS

 

  1. Ensure an airway and provide high flow O2
  2.  

  3. For wheezing or stridor, treat with 2.5-5 mg nebulized albuterol as needed.
  4.  

  5. Establish an IV; if patient is in cardiac arrest, establish 2 IVs
  6.  

  7. Draw blood samples
  8.  

  9. If available, mix one or both Cyanokit® 2.5 g vials, each with 100 cc of 0.9% NaCl, and administer 70 mg/Kg over 15 minutes.
  10.  

  11. If hypotensive, consider fluid challenge(s)
  12.  

  13. Transport emergently to closest appropriate hospital

Pediatric
Tracheosotmy / Ventilatory Management

 

If a patient is in significant respiratory distress, is not breathing or is in cardiac arrest with a tracheostomy, replacement of the tracheostomy tube may be lifesaving.
BLS providers should immediately direct trained caregivers to replace trach tube.
ALS providers should locate emergency replacement trach tubes that are usually kept near the patient and attempt tube replacement.

 

BLS

 

  1. Existing Tracheostomy Care
  2.  

    Suctioning

     

    1. Utilize appropriate PPE.
    2.  

    3. Suction tracheostomy as needed using appropriate sized soft suction catheter.
    4.  

      1. Sterile technique is preferred when suctioning. Clean technique may also be utilized if sterile technique cannot be performed
      2.  

      3. Pre-oxygenate if at all possible.
      4.  

      5. Suction no more than 4-6” or until resistance is felt. For pediatric patients, refer to safe suction card for appropriate suction depth
      6.  

      7. Apply suction only after insertion and upon withdrawing the catheter.
      8.  

      9. Suction for no more than 10 seconds at a time.

     

    Ventilation

     

    1. Most adult tracheostomy tubes require an inner cannula to adapt to a standard BVM. Pediatric tracheostomy tubes naturally attach to a standard BVM. The use of omni-flex/accordion tubing can make attaching easier and give better flexibility
    2.  

    3. Utilize capnography when ventilating a patient using an existing tracheostomy.

     

    Displaced Tracheostomy Tube

     

    1. In the event of tracheostomy tube dislodgement ALS intervention is preferred.

       

    2. BLS providers may place a gloved finger or palm over the stoma area and provide BVM ventilations via nose and mouth until ALS arrives or if the patient is breathing adequately provide supportive care.
    3.  

      1. If ventilation via the nose and mouth does not work use a small BVM mask and ventilate over the stoma.
      2.  

      3. In some cases it may be necessary to occlude the nose and mouth to obtain chest rise.

     

    ALS

     

    1. If the patient is breathing inadequately determine if a spare tracheostomy tube is available on the scene - (if no spare tracheostomy present go to Step 4)
    2.  

    3. Insert the new tracheostomy tube using the same size of the existing trach tube into the existing stoma carefully and secure into place. If tube does not fit, skip to step 3
    4.  

      1. For adults, a soft suction catheter may be inserted thru the new tracheostomy tube and used as a guide (see photo)
      2.  

      3. If patient is still in distress, attempt suctioning to appropriate depth
      4.  

      5. If patient does not respond to suctioning after an appropriate amount of time or suction catheter does not reach correct depth go to Step 3
      6.  

      7. Confirm the placement utilizing waveform capnography

       

       

    5. Same sized Trach Tube does not fit: Utilize the smaller/emergency trach tube
    6.  

      1. Insert the new tracheostomy tube using the existing stoma carefully and secure into place (if smaller size tracheostomy tube does not go in, skip to Step 4
      2.  

      3. If patient is still in distress, attempt suctioning to appropriate depth
      4.  

      5. c. If patient does not respond to suctioning after an appropriate amount of time or suction catheter does not reach correct depth go to Step 4

       

    7. If the same size and smaller size tracheostomy tube does not insert into the stoma, does not allow appropriate suction depth to be achieved or relieve distress with good suctioning, or the tracheostomy tubes are not available, use an ET tube. For most adults, first attempt using a 6.0 ET tube. For pediatric patients, use an ET tube the same size diameter as the patient’s tracheostomy tube.
    8.  

      1. Advance the ET tube so that the balloon advances into the stoma and inflate the balloon, DO NOT force the ET tube
      2.  

      3. Utilize waveform capnography to confirm placement
      4.  

      5. Secure the ET tube in place and monitor for leaks

       

    9. If these procedures fail consider intubation or ventilation via BVM covering the stoma

     

    Ventilator Patients

     

    1. Many tracheostomy patients will be on portable ventilator systems.
    2.  

    3. If the patient is NOT in cardiorespiratory arrest and the ventilator is determined to be functioning appropriately it may be in the best interest of the patient to be transported on their own ventilator.
    4.  

      1. Family members typically are well trained in the operation of portable ventilators and should be transported with the patient to operate the ventilator.
      2.  

      3. If a family member is not available to operate the ventilator and the EMS provider is not familiar with the ventilator the patient should be transported using BVM ventilation via their existing tracheostomy.
      4.  

      5. If there is a question regarding the appropriate functioning of the ventilator then patient should be removed from the ventilator and ventilated using BVM attached to the existing tracheostomy.

       

    5. If a patient is removed from a portable ventilator the portable ventilator should be transported with the patient if at all possible.
    6.  

    7. Settings for the portable ventilator should be noted and relayed to the receiving hospital.
    8.  

    9. In-line capnography should be utilized if available and documented.

Pediatric
Wide Complex Tachycardia QRS > 0.12 sec

BLS

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. If patient is symptomatic, call for ALS

 

ALS

 

  1. Apply cardiac monitor and obtain 12-lead EKG
  2.  

  3. If patient is symptomatic, establish a saline lock or IV with 0.9% NaCl. If an IV cannot be established and an urgent need for vascular access exists, establish IO access.
  4.  

  5. If the patient has no signs or symptoms of pulmonary edema, administer 250 mL bolus of 0.9% NaCl solution. Repeat 250 mL boluses every 5 minutes as long as SBP remains below 90 mmHg and no signs of pulmonary edema exist. (For peds, 20 mL/kg boluses)
  6.  

  7. If patient remains symptomatic, perform the following in a step-wise fashion. Reassess after each step and proceed to the next step if there is no improvement.
  8.  

  9. For pediatric patients, refer to Pediatric Emergency weight/length-based tape
  10.  

    Asymptomatic

     

    1. Establish IV access and contact medical control for further instructions

     

    Mild Symptoms
    Chest pain or dyspnea

     

    1. Contact medical control for further instructions

     

    Serious Symptoms
    Hypotension, acutely altered mentation, signs of shock

     

    1. Perform synchronous cardioversion beginning with 0.5-1 j/kg; if not effective, increase to 2 j/kg
      If still conscious, consider 0.1mg/kg (max 2.5 mg) IV midazolam or 0.2mg/kg IN (max 2.5mg) before cardioversion. Use capnography if given.
    2.  

    3. Contact medical control for further instructions
    4.  

    Unconscious without Pulses

     

    Treat as Cardiac Arrest, VF/VT