Published on January 18, 2008
Medical Emergencies: Medical Emergencies Lesson 5 Slide2: This lesson will focus on assessment and management of non-traumatic causes of pediatric emergencies including: NON-TRAUMATIC Causes: NON-TRAUMATIC Causes Hypoperfusion (shock) Cardiopulmonary failure Altered mental state Seizures Fever Poisoning/allergies Diabetic emergencies Sudden Infant Death Syndrome What’s the Connection?: What’s the Connection? A child has repeated vomiting and diarrhea. A curious toddler finds Mom’s “special M&M’s” in her purse and greedily eats them up. A few minutes later, she is unresponsive. An infant has a soaring fever, diaper rash and cannot be comforted. Slide5: While each problem is very different, hypoperfusion and cardiopulmonary failure are possible for any of these children, if untreated. This lesson deals with a variety of common medical emergencies, unrelated except in their life threatening potential. Hypoperfusion (Shock) Review: Hypoperfusion (Shock) Review Hypoperfusion is a “low flow state” of perfusion (also called shock). Oxygenated blood supply is insufficient to support normal function of all organs and tissues. Pecking order of perfusion initially protects critical organs. Slide7: The circulatory system needs three elements for adequate perfusion: A heart capable of pumping a sufficient volume of blood. A large volume of blood containing a high concentration of oxygen. Blood vessels capable of carrying blood volume. Heart: Heart In children, the heart muscle is usually healthy and so, myocardial infarction is rare. Heart rates that are too slow or too fast (less than 60/min or too fast to count) may indicate a pumping problem is the cause of hypoperfusion. Slide9: When the rate is too slow, less blood volume is being circulated. When the rate is too fast, the heart’s ventricles do not fill with blood, due to shortened time between contractions. Each contraction of the heart pumps out less blood than normal. Blood: Blood Blood is about 55% plasma (liquid) and 45% blood cells (solid). Blood volume (plasma) can be lost without bleeding. Plasma is lost due to repeated vomiting and/or diarrhea. Blood Vessels: Blood Vessels Vascular tone is the term for the forces that constrict (clamp down) and dilate (relax) the diameters of blood vessels. Balanced pressure required to maintain adequate perfusion. When vessels are too dilated, there is not enough pressure to move blood through the vessels. Slide12: When blood vessels are extensively dilated, blood takes longer to return to the heart, so less blood is available to be pumped. Blood vessels that are torn or damaged are a source of whole blood loss. Non-Traumatic Hypoperfusion: Non-Traumatic Hypoperfusion Children maintain perfusion to vital organs by increasing heart rate and constricting peripheral blood vessels. Respiratory rate increases to supply additional oxygen to sustain increased heart rate. These increases eventually deplete the energy stores of the child. Early Hypoperfusion: Early Hypoperfusion In early hypoperfusion, increases in heart rate and peripheral constriction are slight but rising. RFI may appear close to normal due to compensation for low blood flow. Initial assessment may reveal few findings. Early Hypoperfusion: Early Hypoperfusion Focused history questions may alert EMTs to cause of urgent condition. Repeat Initial Assessment frequently. Initiate treatment and transportation based on the urgency of the child’s condition. Late Hypoperfusion: Late Hypoperfusion As greater increases in heart rate and vasoconstriction occur, energy supplies are depleted and the child tires. RFI reveals more obvious signs of an urgent condition. The child’s condition appears urgent. EMTs should support ABC’s and transport without delay. Slide17: Early recognition and treatment are the keys to survival. Follow RFI steps. Repeat Initial Assessment frequently. Transportation is the priority when the child appears urgent. Slide18: EMTs should not expect to make precise diagnoses in the field and should not spend additional time on the scene attempting to do so. EMTs should make an early decision to transport any child who they suspect to be in any stage of hypoperfusion. Early transport is a crucial piece of recognition and assessment of hypoperfusion. Progression of Hypoperfusion: Progression of Hypoperfusion Eventually, the effort and energy to maintain perfusion will exhaust the child, as is seen in late hypoperfusion. As the child tires, compensatory abilities fail, leading to cardiopulmonary failure. Cardiopulmonary Failure: Cardiopulmonary Failure Cardiopulmonary failure occurs when a child experiences respiratory failure together with late hypoperfusion. Cardiopulmonary arrest occurs when a child's heart and lungs stop functioning. Cardiopulmonary Failure: Cardiopulmonary Failure Although children rarely die from sudden cardiac death, cardiopulmonary failure is a major cause of death in children. Cardiopulmonary failure develops gradually. Slide22: Death is due to low blood oxygen delivery to the vital organs and tissues. Oxygen deprivation severely damages the organs and tissues so that they cannot be made functional, despite resuscitation efforts. Cardiopulmonary Failure Signs: Cardiopulmonary Failure Signs Observe a combination of findings from respiratory failure and late hypoperfusion including: weak respiratory effort slow, shallow breathing pale or blue skin tones in the chest region These signs indicate the immediate need for assisted ventilation. Slide24: Slow pulse rate Weak or absent peripheral pulses Cool extremities Delayed capillary refill time Altered mental status (P or U - AVPU) Slow heart rate with signs of poor perfusion indicate the need for chest compressions. Cardiopulmonary Failure Management: Cardiopulmonary Failure Management AIRWAY Use head tilt with chin lift to open airway when trauma is not suspected. Avoid hyperextension of the head and neck as this causes airway obstruction. Cardiopulmonary Failure Management: Cardiopulmonary Failure Management BREATHING Mask size and seal are essential. Use E-C Clamp method. Attach high concentration oxygen source. Ventilate over 1 - 1.5 seconds with only enough volume to cause chest rise at a rate of 20/min. Cardiopulmonary Failure Management: Cardiopulmonary Failure Management CIRCULATION Check central pulse for presence and rate. If absent or rate less than 60/min with signs of hypoperfusion, begin chest compressions. Chest Compressions - Infant: Chest Compressions - Infant EMTs should begin chest compressions in addition to assisted ventilation when: An infant has a pulse rate slower than sixty beats per minute with signs of hypoperfusion or poor peripheral perfusion. An infant has no pulse. Chest Compressions - Infant: Chest Compressions - Infant Using two fingers, compress the lower half of the sternum about one third to one half the depth of the chest or about 0.5 to 1 inch at a rate of at least 100/minute. Deliver five compressions for each ventilation until the pulse rate exceeds 60/minute. Chest Compressions - Child: Chest Compressions - Child EMTs should begin chest compressions in addition to assisted ventilation when: A child has no pulse or a pulse rate slower than sixty beats per minute with signs of hypoperfusion or poor peripheral perfusion. Chest Compressions - Child: Chest Compressions - Child Using the heel of the hand, compress the lower half of the sternum about one third to one half the depth of the chest or about 1.0 to 1.5 inches at a rate of 100/minute. Deliver five compressions for each ventilation until the pulse rate exceeds 60/minute. Altered Mental Status: Altered Mental Status Altered mental status (AMS) is a sign that the brain is not working properly. AMS in children often results in: change in behavior change in responsiveness to parents to surroundings Altered or Normal MS? - How To Tell: Altered or Normal MS? - How To Tell A child with normal mental status is Alert Easily awakened from sleep Responsive to parents Aware of the EMTs Parents can tell if the child is simply “not acting right.” AMS Signs : AMS Signs Children with AMS may appear Unusually agitated Combative Sleepy Difficult to rouse from sleep Totally unresponsive Rapid First Impression - AMS: Rapid First Impression - AMS Rapid First Impression findings: unusual agitation reduced responsiveness abnormal muscle tone or body position for the child's age In addition, look for excess breathing effort pale skin Children can develop AMS due to:: Children can develop AMS due to: Respiratory failure Hypoperfusion Head trauma Low blood sugar Seizures Poisoning Brain tumor Infection with fever Initial Assessment - AMS: Initial Assessment - AMS Findings include signs of Airway compromise Respiratory failure Hypoperfusion AVPU of A - with unusual agitation or confusion AVPU of V, P, or U Focused History for AMS: Focused History for AMS Findings include: History of trauma or seizures Poisoning Infection with fever Brain tumor History of diabetes Poor appetite Detailed Physical Exam - AMS: Detailed Physical Exam - AMS Look for: signs of head injury unequal pupils weakness or unequal strength in extremities Treatment of AMS: Treatment of AMS ASSURE AN OPEN AIRWAY. If the child has good muscle tone, Provide high concentration oxygen by non-rebreather mask. Obtain focused history regarding: Recent falls? Last oral intake? Seizures? Poisons? Medical History? Treatment of AMS: Treatment of AMS A child with limp muscle tone or who cannot be roused may have an airway obstruction. Loss of muscle tone affects internal structures as well as skeletal muscle. Check for secretions (gurgling) Snoring caused by tongue Treatment of AMS: Treatment of AMS Focus first on the airway: Provide positioning (tongue) and suctioning (secretions),prn Give high-concentration oxygen. Provide assisted ventilation if necessary. Treatment of AMS: Treatment of AMS Head position should be neutral if: trauma is suspected or cause of AMS is unknown. Always immobilize the cervical spine in an unresponsive patient if there is any possibility of trauma or when the cause is unknown. Treatment of AMS: Treatment of AMS Provide oxygen and assist ventilations, if needed. A child should respond to increased oxygenation by improved responsiveness. Change in MS: Change in MS Mental status can improve in response to interventions. Mental status can also worsen if the child’s airway, breathing, or circulation worsens. If MS worsens, reassess ABC status. Seizures: Seizures Involve abnormal electrical activity of the brain cells. 4 to 6 percent of all children will have at least one seizure before age 16. Most seizures are brief, lasting less than 2 minutes, and do not harm the child. Seizures: Seizures During a seizure, the child may have: altered mental status behavioral changes uncontrolled muscle movements Loss of bowel or bladder control may occur. Seizure Treatment: Seizure Treatment Protect child from injury while seizing, but do not attempt to restrain the child. Loosen restrictive clothing. During any seizure: Put nothing in the mouth. Turn child on his left side (recovery position) if trauma is not involved. NOTHING in the Mouth? Why?: NOTHING in the Mouth? Why? During an active seizure: Bite blocks or oropharyngeal airways may break, causing choking. A broken bite block can lacerate the mouth. Unbreakable bite blocks can damage the teeth if a child bites down hard. Status Epilepticus: Status Epilepticus For EMS, a seizure that: Is ongoing when EMTs arrive at the patient’s side, or Lasts more than 5 minutes, or Leaves the child unresponsive is treated as status epilepticus. Dangers of Status Epilepticus: Dangers of Status Epilepticus Low blood oxygen occurs due to lack of ventilation. Airway and breathing problems due to decreased muscle tone and function. Risk of aspiration due to vomiting. Brain damage or death can result if left untreated. Status Epilepticus Treatment: Status Epilepticus Treatment Because continuing seizures are more dangerous than brief seizures, they require more aggressive management. If the child is actively experiencing a seizure, the airway is unprotected. Status Epilepticus Treatment: Status Epilepticus Treatment EMTs should call for ALS backup if available. Provide initial interventions and rapid transport without delay. Status Epilepticus Treatment: Status Epilepticus Treatment If the child has uncontrolled muscle movements, support the head, maintain the airway. Protect from injury. Post Seizure Treatment: Post Seizure Treatment Place in recovery position, if there is no indication of trauma. Provide high concentration oxygen by non-rebreather face mask. Be prepared to suction. Post Seizure Treatment: Post Seizure Treatment If trauma is not suspected, place child in “sniffing” position and open airway. If the child vomits, position on left side to reduce risk of aspiration. Post Seizure Treatment: Post Seizure Treatment If there is history or evidence to suggest trauma to the head or neck Place the child in a neutral position. Immobilize the spine. Post Seizure Treatment: Post Seizure Treatment Manage the airway: Provide gentle suctioning as needed. Give high-concentration oxygen. Post Seizure Treatment: Post Seizure Treatment If the patient shows signs of respiratory failure or arrest, begin assisted ventilation and initiate transport. CUPS Assessment of Pediatric Seizures: CUPS Assessment of Pediatric Seizures Category Assessment Actions Critical: Critical Assessment Absent Airway Breathing Circulation AVPU= U Ongoing Seizure Action Perform initial interventions and transport simultaneously; consider ALS backup if available. Unstable: Unstable Assessment Compromised Airway Breathing Circulation AVPU=V or P; history of brief seizure that has ended Action Perform rapid initial assessment and interventions; transport as soon as possible; consider ALS backup if available Potentially Unstable: Potentially Unstable Assessment Normal Airway Breathing Circulation AVPU=A or V that quickly improves to A; history of brief seizure that has ended Action Perform initial assessment and interventions, provide oxygen, monitor airway and ventilation, and transport promptly; do focused history and physical exam during transport if time allows Stable: Stable Assessment Normal Airway Breathing Circulation AVPU=A; no history of seizure Action Perform initial assessment and interventions; do focused history and detailed physical exam Focused History: Focused History Seek information that can help hospital personnel determine the cause of the seizure, including: Length of seizure Specific seizure activity child's degree of responsiveness the location and characteristics of abnormal muscle movements loss of bladder or bowel control Slide66: The number of seizures Exposure to a toxic substance or medication Fever Head injury or recent trauma History of seizures or seizure disorder Medications being taking for a seizure disorder and time of last dose Additional Focused History: Additional Focused History Consider possible causes of low blood sugar: Diabetes in children of all ages Alcohol poisoning Not eating due to illness in infants and toddlers Detailed Physical Exam: Detailed Physical Exam Examine the child for: signs of head injury a purplish skin rash that accompanies septic shock (hypoperfusion caused by infection) injuries to extremities caused by muscle movements during the seizure Treat as needed Transport immediately Head Injury and Seizures: Head Injury and Seizures Seizures following a head injury are more common in children than in adults. Find out the time and cause of injury. How long after the injury the seizure occurred. Whether a period of unresponsiveness or signs of breathing problems followed the injury. Seizures and Fever: Seizures and Fever Children 6 months to 6 years can sometimes experience febrile seizures Cause is rapid climb of high fever. Results in brief seizures with no long term harm to the child. Notable exception is meningitis. Life-threatening infection involving the brain and spinal cord. Requires immediate medical care. Fever: Fever Definition: Rectal temp. 100.5 degrees Fahrenheit or higher. Usually caused by a minor viral or bacterial infection. May be caused by serious or even life threatening infection. Urgent Fever Signs: Urgent Fever Signs Consider any child as Urgent when fever is accompanied by: Altered mental status Respiratory distress Signs of hypoperfusion A history of recent seizures A bruise-like or spotty rash on the trunk or extremities A stiff neck Fever and Age: Fever and Age More of a concern for young infants than for older children. Any child with fever should be evaluated by a physician. Special Risk Children: Special Risk Children The ability to fight infection is compromised in children who have: Sickle cell anemia HIV infection Recent cancer therapy Children who have no spleen and infants aged younger than three months are also at risk. Fever Assessment : Fever Assessment Common findings include: Slightly increased respiratory rate Slightly increased pulse rate Fever and Heat Stroke: Fever and Heat Stroke Heat stroke occurs when a child has a rectal temperature higher than 106 degrees Fahrenheit. Heat stroke can occur from exposure to a very warm environment, such as a closed car on a hot day. Older children and adolescents may develop heat stroke from exercising strenuously during hot weather. Signs of Heat Stroke: Signs of Heat Stroke A child with heat stroke will have: AMS with decreased responsiveness Can progress to unresponsiveness Limp muscle tone Slow, shallow breathing Red, flushed skin initially Can progress to pale skin with signs of hypoperfusion Heat Stroke Treatment: Heat Stroke Treatment Remove child to cool environment. Assess and manage airway. Provide high concentration oxygen Assist ventilations, as needed. Transport immediately. Heat Stroke Treatment: Heat Stroke Treatment Cool the child Remove clothing Place cold packs or damp towels against skin. Cover with a dry sheet. If shivering occurs, remove cold packs and keep child covered with a dry sheet. Fever Treatment: Fever Treatment Treat assessment findings: Respiratory distress, hypoperfusion, or altered mental status Give high-concentration oxygen and assist ventilation if necessary. Consider hypoperfusion from septic shock (hypoperfusion caused by infection) Comparative Assessment Findings for Septic shock: Comparative Assessment Findings for Septic shock Early septic shock fast pulse rate slow capillary refill time warm, pink skin bounding pulses Other shock fast pulse rate slow capillary refill time cool, pale skin weak pulses Fever: To Cool or Not Too Cool: Fever: To Cool or Not Too Cool Fever helps the immune system fight infections. Risks of cooling include hypothermia inadvertent production of additional body heat by inducing shivering CUPS Assessment of Pediatric Fever: CUPS Assessment of Pediatric Fever Category Assessment Actions Critical: Critical Assessment Absent Airway Breathing Circulation AVPU=P or U Actions Perform initial interventions and transport simultaneously; consider ALS backup if available Unstable: Unstable Assessment Compromised Airway Breathing Circulation AVPU=V or P Actions Perform rapid initial assessment and interventions; transport promptly; consider ALS backup if available Potentially Unstable: Potentially Unstable Assessment Normal Airway Breathing Circulation AVPU=A with unusual agitation; history of fever with other risk factors Actions Perform initial assessment and interventions; begin focused history and physical exam; initiate transport promptly if risk factors are found Stable: Stable Assessment Normal Airway Breathing Circulation AVPU=A history of fever without other risk factors Actions Perform initial assessment and interventions; complete focused history and detailed physical examination; transport Poisoning: Poisoning Accidental poisoning is most common among young children. Generally involves one substance and child left unsupervised. Intentional poisoning is more common among adolescents. Multiple substances more common Intake of substance is intentional. Common Sources of Poisons: Common Sources of Poisons The most common substances involved in accidental poisonings are those found at home: cleaning agents plants cosmetics medications Drug Poisonings in Young Children: Drug Poisonings in Young Children Fewer than half of all poisonings involve drugs: Most common involve pain medications cold or cough preparations vitamins One of the most frequent drug poisonings in children is caused by acetaminophen, which is contained in many pain medications (such as Tylenol). Fatal Poisonings: Fatal Poisonings Supplemental iron tablets are the leading cause of fatal poisonings in children. Other potentially lethal medications include heart medications, medications for high blood pressure, and medications for psychiatric disorders. Poisonings in Young Children: Poisonings in Young Children Most frequently curious toddlers swallow poison at home. Unlocked cabinets invite exploration. Liquids that resemble juice Pills that resemble candies Adolescent Poisonings: Adolescent Poisonings Adolescents typically poison themselves through overdoses of alcohol or other drugs. These poisonings usually result after the youth intentionally swallows or inhales the agent, either in a suicide attempt or for recreational purposes. Slide94: Adolescents may also misuse products such as aerosol sprays, solvents, and chemicals, which can result in serious poisonings. More than one substance may be involved in adolescent poisonings. Other Types of Poisoning: Other Types of Poisoning Poisonings can also occur through skin contact with toxic substances such as pesticides or through breathing toxic fumes from fires or chemical sprays. Stings or bites from certain spiders, scorpions, snakes, and lizards can be poisonous. General Approach to Poisoning: General Approach to Poisoning Rapid First Impression Urgent or Non-urgent Transport decision Perform Initial Assessment Provide appropriate interventions Gather information about substances involved. Contact Poison Control Center (if allowed by protocol). The Substance 411: The Substance 411 As quickly as possible, ask questions and look for evidence to: Identify the toxic substance Type of exposure involved If the substance is known, transport it in its original container. If the substance is not known, or if multiple substances may be involved, transport all suspected poisons. Poison Control Center: Poison Control Center If protocols allow, contact a PCC. The PCC can quickly offer precise instructions on effective management of identified poisons. Assessment: Assessment Check for environmental findings: Fire, smoke, fumes Pesticides, chemicals Other hazardous materials Pills, alcohol or "recreational" drugs Toxic household products Poisonous plants Poisonous spiders or reptiles Urgent First Impression: Urgent First Impression First Impression findings that indicate an urgent condition due to poisoning: decreased responsiveness sweating drooling increased breathing effort Urgent Initial Assessment: Urgent Initial Assessment Initial Assessment findings that indicate an urgent condition due to poisoning: compromised airway signs of respiratory distress or failure wheezing or stridor Urgent Initial Assessment: Urgent Initial Assessment Pulse rate abnormally fast or slow Blood pressure abnormally high or low Signs of hypoperfusion Altered mental status (A with agitation, V, P, or U) Transport Without Delay: Transport Without Delay Poisonings that cause altered mental status vomiting or seizures can result in life-threatening airway and breathing problems. Transport these children immediately. Signs of Drug Poisoning: Signs of Drug Poisoning Alcohol, narcotics, barbiturates, and benzodiazepines (such as Valium) cause slow, shallow breathing when consumed in large doses. Alcohol can cause low blood sugar. Barbiturates and narcotics cause the pupils to get smaller. Slide105: Transport any child who has swallowed an unknown substance, even if assessment findings are normal. Some poisonings may have delayed onset of abnormal findings: Transport without delay Onset may be abrupt Condition may rapidly deteriorate. Detailed Physical Examination: Detailed Physical Examination Common findings include: Abnormally large or small pupils Abdominal pain and tenderness Burns involving the lips and tongue may indicate that the child has swallowed a caustic substance can be life threatening Detailed Physical Examination: Detailed Physical Examination Swollen lips and tongue with soot around the mouth Drooling Difficulty swallowing A hoarse voice are signs of inhalation injury to the airway caused by breathing in superheated air or chemical fumes. Detailed Physical Examination: Detailed Physical Examination Unusual breath odors such as: A smell like nail polish remover (possible alcohol poisoning) A bitter almond smell (cyanide) A garlic smell (arsenic, many pesticides) Report these findings to the PCC. Focused History: Focused History When, how much and what has happened since the occurrence are the main areas of the focused history. When the substance was swallowed but the specific substance is unknown, find out what medications are in the house. If necessary, bring all medications to the hospital with the child. Treatment: Treatment Treat based on assessment findings. Support ABC’s. Contact PCC, if allowed. Transport without delay. CUPS Assessment of Pediatric Poisonings: CUPS Assessment of Pediatric Poisonings Category Assessment Actions Critical: Critical Assessment Absent Airway Breathing Circulation Perform initial assessment; begin interventions and transport simultaneously; call for ALS backup if available Unstable: Unstable Assessment Compromised Airway Breathing Circulation AVPU=V, P, or U Perform initial assessment and interventions; begin transport; call for ALS backup if available Potentially Unstable: Potentially Unstable Assessment Normal Airway Breathing Circulation AVPU=V or A with agitation; poison carries risk for altered mental status, seizures, shock, or respiratory distress Perform initial assessment and interventions; provide oxygen; transport promptly; maintain and monitor airway and ventilation Stable: Stable Assessment Normal Airway Breathing Circulation AVPU=A; no risk for altered mental status, seizures, shock or respiratory distress Complete initial assessment, focused history, and detailed physical exam; transport as necessary Poison in Eyes - Treatment: Poison in Eyes - Treatment If poisoning involves eyes Flush with water for at least 20 minutes. Begin prior to transport and continue through transport. Poison on Skin -Treatment: Poison on Skin -Treatment If poisoning involves skin: Use gloves for protection. Remove any of the child's clothing that has been contaminated. Flush the skin well with water. Transport as soon as possible. Activated Charcoal Treatment: Activated Charcoal Treatment Activated charcoal binds with many toxic substances. This action prevents poisons from being absorbed into the body. Most beneficial in areas with long transport times. Check local protocols. Activated Charcoal Treatment: Activated Charcoal Treatment Before attempting activated charcoal administration: PCC or Medical Control must be contacted and give permission for charcoal use. The child must be alert, cooperative and willing to drink the charcoal. Activated Charcoal Contraindications: Activated Charcoal Contraindications Can be harmful or fatal if the patient accidentally inhales it. Never give it to a patient who is not fully alert and able to swallow. Do not attempt to force it on a young patient who is uncooperative. Activated Charcoal Contraindications : Activated Charcoal Contraindications Contraindications include: A non-alert child. An uncooperative child. A swallowed hydrocarbon. Hydrocarbons including kerosene, gasoline, and pine oil. Contraindications to Activated Charcoal Treatment: Contraindications to Activated Charcoal Treatment A swallowed caustic substance. Caustic substances include lye and drain cleaner. Caustic substances can severely damage the inside of the throat if the child vomits. Special Considerations: Special Considerations Hydrocarbons can cause pneumonia and respiratory distress or failure if aspirated. Do not give activated charcoal or syrup of ipecac for swallowed caustic substances or hydrocarbons. Activated Charcoal Treatment Not Effective: Activated Charcoal Treatment Not Effective Does not absorb: cyanide alcohols iron lithium most solvents Activated Charcoal Dosage: Activated Charcoal Dosage The usual pediatric dose is one gram of activated charcoal for every kilogram (roughly two pounds) of body weight. Check local protocols for more specific instructions. Syrup of Ipecac Treatment: Syrup of Ipecac Treatment Ipecac causes vomiting. It should be given only under direct orders of the PCC or medical control. Give ipecac only if the poison was not a hydrocarbon or caustic substance, and the child is alert and able to swallow. Contraindications to Ipecac: Contraindications to Ipecac DO NOT give ipecac to: Infants younger than six months. Children who cannot maintain their airway or who have altered mental status. Children who have swallowed caustic substances or hydrocarbons. Concerns of Ipecac Treatment: Concerns of Ipecac Treatment Onset to vomiting is lengthy: (18 - 30 minutes) Duration of vomiting is up to 1 hour. Many of the most dangerous toxins children may swallow can produce seizures or coma, within fifteen to twenty minutes. Concerns of Ipecac Treatment: Concerns of Ipecac Treatment By the time ipecac is administered, it is usually too late to prevent these effects. Child now is at great risk for airway compromise as mental status diminishes and vomiting begins. Concerns of Ipecac Treatment: Concerns of Ipecac Treatment If the patient does not vomit, ipecac itself is a toxin. Always contact a PCC before using Ipecac. Ipecac Dosage: Ipecac Dosage For infants of 6 months to1 year ten milliliters (two teaspoons) For children aged one to five years fifteen milliliters (three teaspoons) For children older than five years thirty milliliters (one ounce, or two tablespoons) Diabetic Emergencies: Diabetic Emergencies Diabetic emergencies arise when blood sugar levels are too low or too high. Children with high and low blood sugar may have some of the same assessment findings. Hypoglycemia means abnormally low blood sugar: Hypoglycemia means abnormally low blood sugar Characteristics Rapid onset Signs of hypoperfusion possible Altered mental status irritable agitated decreased responsiveness Low Blood Sugar Assessment: Low Blood Sugar Assessment First impression findings: Irritability or agitation Trembling, weakness Pale skin, sweating Behavioral changes Decreased responsiveness Focused History Low Blood Sugar: Focused History Low Blood Sugar Most often there is a history of diabetes with sudden onset of symptoms. Ask about hunger, nausea, decreased appetite or missed meals. Try to determine if the patient is irritable or confused; has changed behavior; complained of headaches or tiredness. Has there been a seizure? Focused History Low Blood Sugar: Focused History Low Blood Sugar If on medication, determine how much insulin or oral anti-diabetic medication was last taken and when. Ask about unusually strenuous exercise or any other significant change in the child’s routine. Detailed Physical Exam: Detailed Physical Exam Shaky movements of arms and hands weakness in legs lack of coordination Severity of findings increases as blood sugar decreases. muscular contractions seizures CUPS Assessment of Diabetic Emergencies: CUPS Assessment of Diabetic Emergencies Category Assessment Actions Critical: Critical Assessment Signs of high blood sugar together with signs of late shock; signs of low blood sugar and AVPU=U Action Give high-concentration oxygen; provide initial interventions and transport simultaneously; call for ALS backup Unstable: Unstable Assessment Signs of low or high blood sugar together with signs of early shock and AVPU=P or V Action Give high-concentration oxygen; provide initial interventions and call for ALS backup to give IV glucose; transport ASAP Potentially Unstable: Potentially Unstable Assessment Signs of low or high blood sugar OR mechanism for low or high blood sugar; AVPU=A Action Give high-concentration oxygen; oral glucose if child is able to swallow; begin focused history and physical exam; transport. Stable: Stable Assessment Normal initial assessment with no signs of high or low blood sugar Action Complete focused history and physical exam; transport. Low Blood Sugar Treatment: Low Blood Sugar Treatment If the patient: can drink without assistance AND has a CUPS status of S or P, AND has an AVPU of A or V. Attempt to boost the patient's blood sugar according to protocol. Low Blood Sugar Treatment: Low Blood Sugar Treatment Have the child slowly sip juice or regular soda (not diet drinks). Start with about one-half cup of liquid. Stop if the child chokes. Low Blood Sugar Treatment: Low Blood Sugar Treatment Give glucose paste or other commercial preparation (such as Glucola) if available. Consult medical control for dose or follow regional protocols. When In Doubt, Give Glucose: When In Doubt, Give Glucose When it is unclear if blood sugar is low or high: Give oral glucose provided the patient can swallow without choking. It will dramatically help the patient with low blood sugar. It will not harm a patient with high blood sugar. Assessment and Managementof High Blood Sugar: Assessment and Management of High Blood Sugar High blood sugar is called hyperglycemia. Develops gradually, over days Common assessment findings include a history of increased fluid intake and frequent urination. Breathing may be deep and rapid with a fruity odor. High Blood Sugar Assessment : High Blood Sugar Assessment First impression findings: decreased responsiveness slow speech flushed skin High Blood Sugar Assessment: High Blood Sugar Assessment Initial Assessment findings include: deep, rapid breathing breath odor like fruit or nail polish remover fast pulse rate weak peripheral pulses slow capillary refill time warm or hot, flushed skin AVPU of P or U Focused History Findings: Focused History Findings History of diabetes Recent illness continuing for days or weeks Extreme thirst and increased drinking Frequent urination Weight loss; tiredness, vomiting Missed insulin doses Overate for amount of insulin taken Detailed Physical Examination: Detailed Physical Examination Look for signs of dehydration: sunken eyes lack of tears skin that remains "tented" after EMTs gently pinch a fold abdominal pain Special ConsiderationsHigh Blood Sugar: Special Considerations High Blood Sugar Critical patient has: signs of high blood sugar and altered mental status and hypoperfusion and needs Immediate transport High Blood Sugar Treatment: High Blood Sugar Treatment For a non-urgent patient: Give high-concentration oxygen. Treat for signs of hypoperfusion. Assess for dehydration when transport is underway. Sudden Infant Death Syndrome: Sudden Infant Death Syndrome Sudden infant death syndrome (SIDS) is the unexpected death of an apparently healthy infant. Not predictable or preventable. Cause remains unknown. In SIDS, no explanation for the death is found. Sudden Infant Death Syndrome: Sudden Infant Death Syndrome More prevalent in the winter months. Majority of victims are under six months old, most are two to four months old. They appear healthy immediately before their deaths, although some have mild cold symptoms. Death occurs while sleeping. SIDS and Child Abuse: SIDS and Child Abuse While severe child abuse occasionally results in death, SIDS is not caused by child abuse. Never accuse a parent of child abuse or neglect. Approach to SIDS : Approach to SIDS EMTs have two primary goals when dealing with an apparent SIDS: To provide appropriate emergency care to the infant To provide supportive care for the family until further help arrives or until transported to the hospital. SIDS Assessment: SIDS Assessment Rapid First Impression findings: absence of movement no chest rise pale or bluish-grey skin color Initial assessment findings confirm: unresponsiveness apnea pulselessness Initiation of CPR: Initiation of CPR If there are no signs of “obvious death” rigor mortis (stiffening) extreme dependent lividity (extensive bruised appearance to dependent areas of the skin). EMTs are obligated to begin CPR and to transport the infant to the hospital Detailed Physical Exam: Detailed Physical Exam Other common findings include: foamy or blood-tinged secretions around the baby's mouth or nose, on blankets, or on clothing; flattened appearance to nose or face if infant died lying face down cool skin temperature (warm if death was recent) unusual body position if muscle spasms occurred before death. Controversies in Resuscitating SIDS Victims: Controversies in Resuscitating SIDS Victims Arguments for resuscitation include: The parents know that all possible actions were taken to save their child. EMTs have no lingering doubts about their actions. Parents gain access to hospital services for support they need. Controversies in Resuscitating SIDS Victims: Controversies in Resuscitating SIDS Victims Arguments against resuscitation include: Ties up equipment and personnel that may be needed elsewhere. CPR presents a slight risk of infection for EMTs. Emergency transport, with lights and siren, increases the risk of motor vehicle crashes, injury, and death. Transport of SIDS Victims: Transport of SIDS Victims If EMTs provide transport, they should: Inform parents of transport location. Allow the parents to ride in the transport vehicle or secondary vehicle. Give the parents a chance to briefly touch the baby while continuing CPR.