Taking Control of the Pediatric EMS CallTaking Control of the Pediatric EMS Call

Never let them Never let them see you sweatsee you sweat

Lou Romig MD, FAAP, FACEP

It’s hardly ever good when the rescuer’s pulse or respiratory rate

is greater than that of their pediatric patient.

Romig’s Rule of Vital Sign ComparisonsRomig’s Rule of Vital Sign Comparisons

Romig’s Rules

GoalsGoals

Tell you the secrets of how many good “pedi people” control tough kid calls (even though

they might not realize they’re doing it).

To turn “How do they do that?” into

“I can do that!”using the PREP approach

The 3 P’s of ControlThe 3 P’s of Control

Preparation

Practice

Perception

The 3 P’s of ControlThe 3 P’s of Control

Preparation

Practice

Perception

PP

RR

EE

PP

Physiology

Responses

Equipment

Protocols

Using PREP, Using PREP, half of your half of your scene control scene control can be done can be done before you before you even arrive. even arrive.

How’d you like to be caught unprepared for this?

PREP before arrival: PREP before arrival: PPhysiologyhysiology

Given the available dispatch information on a pediatric

call, what should you anticipate?

PREP before arrival: PREP before arrival: PPhysiologyhysiology

What is the anticipated age of the child? How does their age influence:

Physiology

Physiologic weaknesses and strengths

Yes, EMTs can do this too!

PREP before arrival: PREP before arrival: PPhysiologyhysiologyWhat is the reported mechanism of injury (MOI) or chief complaint?

What are the most likely injuries based on the age/size and MOI?

What are the most common illnesses that present with this complaint?

What interventions are the child most likely to need on scene/in transit?

PREP before arrival: PREP before arrival: Rescuer Rescuer RResponsesesponses

Given the age and MOI/chief complaint:

What kind of emotional reactions can you expect within yourself before, during and after the call?

How about in your crewmates?

PREP before arrival: PREP before arrival: Rescuer Rescuer RResponsesesponses

Identify crew strengths and weaknesses

Who among the crew is most confident with children?

Should usual task assignments be modified for this call?

High stress/critical calls are not the time to practice weak skills

PREP before arrival: PREP before arrival: Rescuer Rescuer RResponsesesponses

The Huddle:

Reinforce need for personal control if call is likely to be emotionally-charged.

Reinforce ability to relax if call is not emergent.

Reinforce the need to be able to change gears if the unexpected occurs.

PREP before arrival:PREP before arrival:Non-rescuer Non-rescuer RResponsesesponses

The Patient

Assuming normal brain development for age, how is the patient likely to react to you and the situation?

“I would worry if …”

PREP before arrival:PREP before arrival:Non-rescuer Non-rescuer RResponsesesponses

Family/caregivers

Child with chronic illness?

Set-up for guilt reactions?

Set-up for aggression?

What may be the expectations of the caregivers?

PREP before arrival:PREP before arrival:Non-rescuer Non-rescuer RResponsesesponses

Designate a crew member with good communications skills to be the liaison with

the family/caregivers.

PREP before arrival:PREP before arrival:Non-rescuer Non-rescuer RResponsesesponses

Bystanders

Will the emotional environment of the scene be stable and safe?

Are the bystanders likely to become a distraction?

What may be the expectations of the bystanders? How might they react if you don’t do what they expect?

PREP before arrival: PREP before arrival: EEquipmentquipment

Based upon your analysis of the expected physiology:

What kinds of gear are you most likely to need?

What sizes?

Where is the equipment?

What goes with you to the patient’s side?

PREP before arrival: PREP before arrival: EEquipmentquipment

Use your memory aids!!!!

PREP before arrival: PREP before arrival: PProtocolsrotocols

Based upon your analysis of the expected physiology:

What protocols/drugs are you most likely to use?

Where are your drugs? Do they need special preparation?

Based on your protocols, what are your alternatives for patient disposition? Might there be consent issues?

PREPPREPare for the worst.are for the worst.Hope for the best.Hope for the best.

Do practice runs as drills!

PREPPREParation: After Arrival aration: After Arrival

Your first clue upon arrival:Your first clue upon arrival:The WaverThe Waver

PREP after arrivalPREP after arrival

Scene size-up:

Safety

Mechanism of injury or illness

“OBTWs” (Oh-by-the-ways)Completely different complaintAdditional patientsEmotional atmosphereNeed to change the game plan?

PREP after arrival: PREP after arrival: PPhysiologyhysiology

Should guide most actions during the rest of the call

Rapidly determine:

How sick is the child?

How quickly do you need to intervene?

PPhysiology determines hysiology determines RResponseesponse

Intense goal-oriented rapid action focusing on the patient, with tight

emotional control by crew

OR

More relaxed family-centered approach with increased interaction between crew,

patient and others on scene

PPhysiology determines hysiology determines EEquipment and quipment and PProtocolsrotocols

What equipment is needed now? What might be needed later?

What kinds of treatment are indicated? Where should treatment take place?

Balance speed and efficiency

Determine patient disposition. Initiate additional notifications and responses if needed.

How sick? How quick?

The Pediatric Assessment Triangle The Pediatric Assessment Triangle (PAT)(PAT)

From the AAP’s Pediatric Education for Prehospital Professionals (PEPP) course. www.PEPPsite.com

The PATThe PAT

Can be considered a “patient size-up”

Is a pre-primary survey

Can be done in seconds

Often best done before getting close to the pediatric patient

Results in assignment of the patient into a “physiologic cubbyhole”

Can be done whenever you’re in the weeds!

The PATThe PAT

General Appearance

Work of Breathing

Circulation to the Skin

General AppearanceGeneral Appearance

Assesses higher brain function by looking mostly at interaction with the environment

Higher brain function depends on good oxygenation, ventilation and perfusion to the brain

Don’t be fooled by chronic features or dramatic physical findings that don’t affect function

General AppearanceGeneral Appearance

T Tone

I Interactiveness

C Consolability

L Look/gaze

S Speech/cry

Good general appearanceGood general appearance

Normal to well-compensated Normal to well-compensated physiologyphysiology

“Not sick”“Not sick”“Not quick”“Not quick”

Poor general appearancePoor general appearance

Inadequate physiologic Inadequate physiologic compensationcompensation

““Sick!Sick!””““Quick!Quick!””

Work of BreathingWork of Breathing

More informative in children than absolute respiratory rate

Reflects resistance in small air passages, dependence on diaphragm and weakness of chest wall muscles

Increased WOB (including tachypnea) is a compensatory mechanism

Decreased WOB (poor effort/slow breathing) means decompensation

Circulation to the SkinCirculation to the Skin

Decreased circulation to the skin is an early sign of compensation for a circulatory problem in kids (not always true in adults)

Cap refill is a good measure in kids, especially when done in serial fashion in a normothermic environment

Putting the PAT togetherPutting the PAT together

A B C PhysiologicCubbyhole

Sick?

Good Respiratory Distress

Poor Respiratory Failure

RespiratoryRespiratory

A B C PhysiologicCubbyhole

Sick?

GoodNonspecific Peripheral

Vasoconstriction

Poor Shock

CirculatoryCirculatory

A B C PhysiologicCubbyhole

Sick?

Poor Good GoodCNS

Dysfunction

Central Nervous SystemCentral Nervous System

Seizure/Postictal Head injuryIntoxication/Drug effect Meningitis/EncephalitisMetabolic Chronic disability

A B C PhysiologicCubbyhole

Sick?

Cardiopulmonary Failure!

The Last ChanceThe Last Chance

PREP after Arrival: PREP after Arrival: PPhysiologyhysiology

PAT = How sick? How quick?

Primary Survey (Initial Assessment) = More detailed assessment of physiologic disruption

Secondary Survey (Focused Assessment = More detailed assessment of anatomic disruption

PREP after Arrival: PREP after Arrival: RResponsesesponses

PAT = Quick/patient focused or Relaxed/Family focused

Use the PAT to show the family that the patient is doing well

PREP after Arrival: PREP after Arrival: EEquipment/quipment/PProtocolsrotocols

Major or “minor” but “sick” trauma patients

Minimal stabilization on sceneRapid disposition decisions

PREP after Arrival: PREP after Arrival: EEquipment/quipment/PProtocolsrotocols

Medical patients who are “not sick”

Initial assessment and management on scene (unless unsafe)

No rush to separate child and family

PREP after Arrival: PREP after Arrival: EEquipment/quipment/PProtocolsrotocols

“Sick” medical patients

Consider what is the most favorable environment in which to provide

initial assessment and intervention.Rapid disposition decision.

Emergency Departments rarely have anything

more to offer a sick child in the first minutes than

a well-equipped and well-trained ALS EMS

crew!And sometimes they have less…

Applying Applying the PREP the PREP ApproachApproach

PREP

A mislabeled prescription has caused a A mislabeled prescription has caused a mother to give her 4 month old daughter mother to give her 4 month old daughter

five times the normal dose of a cold five times the normal dose of a cold medicine – three times! The mother tells medicine – three times! The mother tells the dispatcher that the baby’s heart feels the dispatcher that the baby’s heart feels

like it’s racing and the child is acting like it’s racing and the child is acting “nervous”.“nervous”.

Before ArrivalBefore Arrival

Physiology:

Cold meds usually stimulate the sympathetic system

Kids tolerate sympathetic stimulation well

Seizures can occur with marked toxicity

Has mom called Poison Control yet?

Before ArrivalBefore Arrival

Responses:

Mom’s liable to be frantic and feeling very guilty.

Crew members who are not comfortable with infants will not be very comfortable with this patient.

Before ArrivalBefore Arrival

Equipment:

Be ready to monitor basic vital signs.

Take in suction. Mom may have been instructed to make child vomit.

Seizures are a possibility so anticipate them.

Before ArrivalBefore Arrival

Protocols

Contact Poison Control?

Administer charcoal?

Seizure management

Upon ArrivalUpon Arrival

Mom is anxious but controlled

Rx was mislabeled. Mom gave three doses of an antihistamine/decongestant over 18 hrs, each one 5 times the usual dose.

Child has been “hyperactive” and unable to sleep.

This is what you see …This is what you see …

PREP on scenePREP on scenePhysiology

Good general appearance

No increased WOB

Good skin circulation

PAT says NOT SICK

HR 170’s, RR 30’s, BP 114/73

Exam normal except the baby is a little cranky on and off and moves around a lot

PREP on scenePREP on scene

Responses

Crew can relax and take their time

Try to reassure mom

Keep child with mom as much as possible.

PREP on scenePREP on scene

Equipment

Basic monitoring during transport

Remain prepared for seizure

PREP on scenePREP on sceneProtocols

Consider calling Poison Control on scene

Consider charcoal

IV probably not needed

Calculate anticonvulsant dose in case it’s needed. Be prepared to give rectally

Transport to pediatric-capable facility with mother (ALS)

You respond to a 6 month old with vomiting and diarrhea for a week. The child doesn’t want to drink.

Mom states “He looks at me but he doesn’t seem to see me!”

You respond to a 6 month old with vomiting and diarrhea for a week. The child doesn’t want to drink.

Mom states “He looks at me but he doesn’t seem to see me!”

Before ArrivalBefore Arrival

Physiology:

Child’s been sick for a while

Dehydration most likely cause of any serious problems. Worst case is shock.

Consider low blood glucose.

“Not seeing me” doesn’t sound good.

Before ArrivalBefore Arrival

Responses:

Mom’s liable to be alarmed or hysterical as well as exhausted.

This may be a really sick kid who needs vascular access and fluids badly.

Before ArrivalBefore Arrival

Equipment:

Be ready to monitor vital signs manually or electronically.

Be prepared to keep infant warm.

IV equipment (including IO), glucometer, oxygen, pulse ox

Stretcher

Before ArrivalBefore Arrival

Protocols

Vascular access

Shock

Hypoglycemia

May need critical care facility

Where to start interventions?

This is what you see and This is what you see and hear…hear…

PREP on scenePREP on scene

Physiology

POOR general appearance

Retracting but good effort, RR 60

HR 200, CR 4 sec, skin pale and cool in distal extremities

PAT says this child is SICK and you need to move QUICKLY! This is early cardiopulmonary failure.

PREP on scenePREP on scene

Physiology

Further exam confirms clinical impression of shock. BP 78/58.

Oxygen saturation not obtainable on fingers/toes

Rapid blood sugar is 83

PREP on scenePREP on scene

Responses

This is the time to focus energies and defer emotions.

Most capable team member goes for IV access. Don’t let the rest of the call get lost in the search for an IV.

Stay calm to keep mom calm.

PREP on scenePREP on scene

Equipment

You need all the stuff you thought you might need and

were prepared with.

PREP on scenePREP on scene

Protocols

Shock. Probably will need rapid, repeated boluses. Monitor HR, skin signs and general appearance as indicators of improvement.

Sugar is OK for now

PREP on scenePREP on scene

Protocols

The house may be the best place to secure vascular access and begin fluid replacement.

If BLS, need fastest possible access to ALS by call-in, intercept or transport to closest pediatric capable facility.

Needs pediatric critical care facility.

The 3 P’s of ControlThe 3 P’s of Control

Preparation

Practice

Perception

PP

RR

EE

PP

Physiology

Responses

Equipment

Protocols

SummarySummary

Use dispatch information to PREPare before you make patient contact.

Use the PREP approach to analyze and control the scene once you get there.

SummarySummary

The PAT is the anchor tool for the PREP approach

The Boy Scouts have it right…

“Always be PREPared!”

Questions or Comments?Questions or Comments?

Lou Romig

Louromig@bellsouth.net

JEMS, May 2001

www.jumpstarttriage.com

Thank you!