STATE OF WASHINGTON

Emergency Medical Services Prehospital Pediatric Guidelines

DOH 530-137 December 2011

Emergency Medical Services Prehospital Pediatric Guidelines

On Behalf of the Washington State Department of Health, the State Pediatric Technical Advisory Committee (TAC) was charged with drafting pediatric guidelines that the EMS agencies in Washington States’ thirty-nine counties could use in setting a standard for emergency medical care and treatment to the children of Washington State.

The Department of Health does not mandate the use of these protocol guidelines by Washington State EMS agencies. The protocol guidelines are meant to assist in the development of local or regional protocols. It is the committee’s hope that county or regional EMS agencies will review these guidelines with their respective Medical Program Directors and legal counsel when drafting their own individualized protocols.

2 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Washington State Pediatric TAC

February 15, 2011

Brian Johnston, MD; Chief of Pediatrics, Harborview Medical Center, Seattle Brianna Enriquez, MD; Pediatric Emergency Physician, Seattle Children’s Hospital, Seattle Carolyn Blayney, RN; Nurse Manager Burn/Pediatric Trauma ICU Harborview Medical Center, Seattle Carolynn Morris, RN; Mary Bridge Children’s Hospital, Tacoma Christi Mabbott, RN; Pediatric Trauma Coordinator, Sacred Heart Medical Center, Spokane Cynde Rivers, RN; EMS Coordinator, Mary Bridge Children's Hospital, Tacoma Debbie Mitchell, RN; Trauma Nurse Coordinator, Auburn Regional Medical Center, Auburn Deborah Woolard, MD; Pediatric Emergency Physician, Mary Bridge Children’s Hospital, Tacoma Jean Rickerson, President - SportsConcussions.org, Family Representative, Sequim Joanne Price, RN MN; Airlift Northwest, Seattle Karen Kilian, ARNP; Pediatric Nurse Practitioner, Emergency Department, Seattle Children’s Hospital, Seattle Kelly M. Allen, RN, MSN; Trauma Coordinator, Providence Everett Medical Center, Everett Kim Stone, MD; Pediatric Emergency Physician, Seattle Children’s Hospital, Seattle Mary Borges, Department of Health, Office of Community Health Systems, Safe Kids Mike Lopez, Washington State Department of Health, Office of Community Health Systems Mike Davis, MD; Attending Physician, Pediatric Critical Care Medicine, Seattle Children’s Hospital & Harborview Medical Center, Seattle Pam Sheldon, RN; Pediatric ED Nurse Manager, Sacred Heart Medical Center, Spokane Paul A. Berlin, PM; Medical Division Chief, Pierce Co. Fire Dist #5, Gig Harbor Rachel Zamora, RN; Clinical Services Manager; Northwest MedStar; Spokane René Perret Williams; Executive Director, NW Region EMS Sam Sharar, MD; Pediatric Anesthesiology, Harborview Medical Center & UW, Seattle Sandra W. Horning, MD; WA State Pediatric TAC Chair, Pediatric Emergency Medicine Physician, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane Scott Hogan, MHA; Washington State Department of Health, EMS-C Manager; Office of Community Health Systems Steve Engle, PM, Captain, MSO; North Kitsap Fire & Rescue; Kingston Chair of NW Region EMS Ted Walkley, MD; Director Emergency Dept., Mary Bridge Children’s Hospital, Tacoma Tony Woodward, MD; Director, Emergency Services, Seattle Children’s Hospital, Seattle T.J. Bishop; Clinical Division Chief, North Country EMS; Yacolt

3 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

INDEX Pediatric General Assessment ...... 4 Pediatric Assessment Triangle ...... 5 Pediatric References ...... 6 Patient Pain Assessment ...... 7 APGAR Infant / Child ...... 8 AVPU Infant / Child ...... 8 CUPS Pediatric ...... 8 Glasgow Coma Score ...... 9 Neonatal Resuscitation ...... 10

Universal Pediatric Patient Care Guideline ...... 11 AIRWAY Pediatric Airway ...... 12 Pediatric Difficult Airway ...... 13 Pediatric Rapid Sequence Intubation ...... 14 CARDIAC Pediatric Pulseless Arrest ...... 15 Pediatric Bradycardia ...... 16 Pediatric Narrow Complex Tachycardia ...... 17 Pediatric Wide Complex Tachycardia ...... 18 Pediatric Post Resuscitation Management...... 19 MEDICAL Pediatric Anaphylaxis ...... 20 Pediatric Apparent Life Threatening Event ...... 21 Pediatric Breathing Difficulty ...... 22 Pediatric Diabetic Ketoacidosis / Hyperglycemia ...... 23 Pediatric Hypoglycemia ...... 24 Pediatric Newborn Resuscitation ...... 25 Known Pediatric Toxic exposure ...... 26 Pediatric Pain Management ...... 27 Pediatric Fever ...... 28 Pediatric Shock Non-traumatic ...... 29 Pediatric Seizure ...... 30 Unknown Pediatric Toxic Exposures / Ingestion ...... 31 TRAUMA / ENVIRONMENTAL EMERGENCIES Pediatric Multi-system Trauma ...... 32 Pediatric Submersion Injury ...... 33 Pediatric Burns ...... 34 Pediatric Heat Related Emergency ...... 35 Pediatric Cold Related Emergency ...... 36 Pediatric Spinal Precautions ...... 37 Sports Concussion ...... 38 Pediatric START/jumpSTART Triage ...... 39 Suspected Child Abuse ...... 40 Pediatric Traumatic Brain Injury ...... 41 Needle Cricothyroidotomy ...... 42 References ...... 43

4 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric General Assessment

A child’s psychosocial and communication skills are constantly changing. Therefore, a child may be unable to convey key information to assist the emergency personnel in their assessment. These differences, as well as numerous others, are why emergency personnel must develop assessment skills that address the unique aspects and needs of the child. The Prehospital pediatric initial assessment teaching tool provides a systematic and comprehensive approach to the initial assessment of the child.

General Approach to a Stable Pediatric Patient

Assessment and interventions must be tailored to each child in terms of age, size, development and metabolic status. The following information may be useful in communicating with a pediatric patient:

. Smile if appropriate to the situation. . Keep voice at an even quiet tone, don’t yell. . Speak slowly; use simple age appropriate terms. . Use toys or penlights as distracters; make game of assessment. . Keep children with their caregiver(s); encourage assessment while caregiver is holding the child when appropriate. . Whenever appropriate, transport the child with the caregiver. . Kneel down to the level of the child if possible. . Make as many observations as possible before touching the child.

Initial inspections while walking up to the child, observe/inspect the following:

. General appearance . Age appropriate behavior and level of consciousness . Obvious respiratory distress or extreme pain . Position of patient . Unusual/significant odor . Muscle tone: good or limp . Movement: spontaneous, purposeful, symmetrical . Color: pink, pale, flushed, cyanotic, mottled . Obvious injuries

5 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Assessment

APPEARANCE BREATHING Tone Abnormal Sounds Interactiveness Abnormal Position A B Flaring onsolability C Retracting Look/Gaze C Speech/Cry

CIRCULATION Pallor Mottling Cyanosis

DECISION POINT

Any abnormalities above OR concerning life-threatening complaint? Consider life saving interventions Contact ALS if not enroute

Primary and Ongoing Assessment

BREATHING Rate AIRWAY Effort / Volume Clear? Sounds Maintainable? Pulse ox

CIRCULATION EXPOSURE Skin color / temp Remove clothing Heart rate / rhythm Prevent hypothermia BP Pulses / CRT End organ function

DISABILITY Alert-Voice-Pain-Unresponsive GCS Pupils

DECISION POINT

Any abnormalities above OR concerning life-threatening complaint? Consider life saving interventions Contact ALS if not enroute

6 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric References

Weight 4 kg 6 kg 8 kg 10 kg 12 kg 15 kg 19 kg 24 kg 30 kg grey pink red purple yellow white blue orange green

Newborn Age – 3 mos 6 mos 9 mos 1 yr 2 yrs 3 yrs 5 yrs 7 yrs 10 yrs

Pulse 100 100 100 90 90 80 70 70 70

Respiratory Rate 30-60 30-60 30-60 24-40 24-40 22-34 18-30 18-30 18-30

60 60 60 70 70 80 80 80 90 Blood Pressure mmHg mmHg mmHg mmHg mmHg mmHg mmHg mmHg mmHg

Endotracheal 3.0 3.5 3.5 4.0 4.5 5.0 5.5 6.0 6.5 uncuffed

Endotracheal 2.5 3.0 3.0 3.5 4.0 4.5 5.0 5.5 6.0 cuffed

Nasogastric Tube 5 Fr 5 Fr 8 Fr 8-10 Fr 10 Fr 10 Fr 12 Fr 14 Fr 16 Fr

Defibrillation 8 J 12 J 16 J 20 J 24 J 30 J 38 J 48 J 60 J

Infant Small BP cuff Infant Infant Child Child Child Child Child Child Adult

80 120 160 200 240 300 380 480 600 Fluid Challenge mL mL mL mL mL mL mL mL mL

BMV Infant Child Child Child Child Child Child Child Adult

Cardioversion 2-4 J 3-6 J 4-8 J 5-10 J 6 -12 J 8-15 J 10-20 J 12-24 J 15-30 J

Suction Catheter 6 Fr 8Fr 8Fr 10Fr 10Fr 10Fr 10Fr 10Fr 12Fr

7 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Pain Assessment

(1) Children must have appropriate control of pain and anxiety.

All children need: . Background pain control. Scheduled, not prn. . Breakthrough pain control. PCA is an option for ≥ 10 y/o. . Procedural pain control. If wound care or a procedure cannot be accomplished with meds you are comfortable prescribing, consider an anesthesia assisted procedure or booking the procedure in the OR. Use pediatric pain scales: FLACC (0-2 yrs) or Oucher (3-7 yrs)

(2) Children deserve care with respect for developmental status.

Children need basic information about their care communicated to them in a developmentally appropriate manner. Always be honest about what is happening and how it may feel. Answer questions. Respect their needs for sleep, privacy, autonomy and play.

(3) Children should receive care that is family-centered.

Families are an important part of the pediatric care team. Keep them informed and involved in decision-making. Make sure a family member can stay comfortably with the child and has his/her basic needs met. Talk to the family daily. Family members can be your best ally in working with a child – but they need to understand the plan.

(4) Children need a safe place

The child’s room and bed are a safe haven. Whenever possible, no painful or frightening procedures should happen there.

8 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

APGAR Scale 0 Points 1 Point 2 Points

A – Appearance Normal, except for Normal over entire Blue / Pale (Skin Color) extremities body P – Pulse Absent Below 100 Above 100

G – Grimace Sneeze, cough, No Response Grimace (Reflex Irritability) pulls away Arms and Legs A – Activity Absent Active Movement Flexed R – Respiration Absent Slow, irregular Good, strong cry

AVPU Infant / Child Response Infant Child Curious / Recognizes A – Alert Alert / Aware of surroundings parents V – Responds to Voice Irritable / Cries Opens eyes

P – Responds to Pain Cries in response to pain Withdraws from pain

U – Unresponsive No response No response

CUPS Pediatric Absent airway, breathing or circulation C – Critical (cardiac or respiratory arrest or severe traumatic injury)

Compromised airway, breathing or circulation U – Unstable (unresponsive, respiratory distress, active bleeding, shock, active seizure, significant injury, shock, near-drowning, etc.)

P – Potentially Normal airway, breathing & circulation but significant Unstable mechanism of injury or illness (Post-seizure, minor fractures, infant <3 months with fever, etc.)

Normal airway, breathing & circulation S – Stable No significant mechanism of injury or illness

(small lacerations or abrasions, infant >3 months with fever)

9 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Glasgow Coma Score EYE <1 y/o >1 y/o 1 None None 2 Opens to pain Opens to pain 3 Opens to shout Opens to verbal command 4 Opens spontaneously Opens spontaneously VERBAL < 2 y/o 2-5 y/o > 5 y/0 1 None None None 2 Moans to pain Moans to pain Incomprehensible sounds 3 Persistent cries to pain Persistent cries to pain Inappropriate words 4 Irritable but consoles Inappropriate words Confused 5 Coos, babbles Appropriate words Oriented MOTOR <1 y/o > 1 y/o 1 None None 2 Extension to pain Extension to pain 3 Flexion to pain Flexion to pain 4 Withdrawal to pain Withdrawal to pain 5 Withdrawal from touch Localizes to pain 6 Spontaneous movement Obeys commands

10 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Neonatal Resuscitation

Dry, Warm, Position, Tactile stimulation. Suction mouth then nose.

Administer O2 as needed.

Apnea/Gasping, HR <100 or central cyanosis

Ventilate with BVM

HR <60 after 30 sec BVM P

Chest Compressions

ALS - HR<60

Intubate

Meds

11 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Universal Pediatric Patient Care Guideline

Legend Scene Safety EMR A AEMT A P PM P Primary Assessment Pediatric Assessment M MC Order M Procedure Pg. 4

Assess ABC’s Temperature control Consider glucose assessment

PRN Oxygen

Consider Pulse Oximetry

Consider P Cardiac Monitor P 12 Lead / ECG

Appropriate Guideline

Doesn’t fit guideline? M M Contact Medical Control

Notes: • Early notification to receiving hospital when appropriate. • Required vital signs on every patient include blood pressure, pulse, respirations and saturations. • Any patient contact which does not result in an EMS transport should be documented. • Exam: Minimal exam if not noted on the specific guideline is vital signs, mental status, and location of injury or complaint. • Pulse oximetry and temperature documentation is dependent on the specific complaint. • A pediatric patient is defined by the Length based tape. If the patient does not fit on the tape, they are considered adult. • Timing of transport should be based on patient's clinical condition and the Washington State Trauma Triage Tool.

12 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Airway

History: Differential: • Onset of symptoms • Foreign body • Past Medical history • Asthma • Croup • Epiglottis • Pneumonia

Legend Assess ABC’s, Supplemental Oxygen PRN Adequate respiratory rate, EMR effort, adequacy A AEMT A P PM P Inadequate Pulse Oximetry M MC Order M

Successful removal M Contact Medical Control M

Basic Maneuvers first-- open airway; Attempt to remove obstruction Adequate Obstruction nasal/oral airway; per AHA guidelines bag-valve mask

Yes Unsuccessful?

Oxygenate, Ventilate, Deteriorating Position, Reassess Intubation Inadequate No

Stabilized Pediatric Cricothyrotomy P P procedure Pg.___ Successful Rapid Transport P Oral-tracheal Intubation P

Unsuccessful

Continuous Continue BVM Pulse Oximetry

P Capnography P

M Contact Medical Control M M Contact Medical Control M

Notes: • For this Guideline, child is defined as less than 12 years old. • EMT’s must have multi-lumen airway training to use Combitubes or LMAs • Limit intubation attempts to 3 per patient • If unable to intubate, continue BVM ventilations, transport rapidly, and notify receiving hospital early. • Capnometry, or capnography is manditory with all methods of intubation. Document results. • Maintain C-spine immobilization for patients with suspected spinal injury • Reconfirm ETT placement each time patient is moved • All choking victims need to be transported to the hospital. Children who have possibly aspirated anything may not be transported POV, but can be transported BLS if stable.

13 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Difficult Airway History: Differential: • Known difficult Airway • Physical Examination • Neck or head trauma • Small jaw or limited jaw opening • Trisomy 21 • Limited cervical spine movement; swollen tongue, • Congenital malformations oropharynx, or neck; midface hypoplasia

Legend Universal Patient Care Guideline EMR A AEMT A PRN Oxygen P PM P Advanced Airway Management M MC Order M

Basic Maneuvers; Open airway, nasal/oral airway, bag-valve mask

Pediatric Rapid Sequence P P Intubation (RSI) Pg. 14

Yes P RSI successful? P No

Maximum head extension P Airway Secured ? P No P Repeat RSI P Maximum jaw thrust C-Spine in-line

Yes P RSI successful? P

No

Patient oxygenation and Supraglottic airway P ventilation adequately with P No P P Management bag/mask ventilation?

Yes Supraglottic airway Yes P P successful?

Yes No

P Needle Cricothyriodotomy P

M Contact Medical Control M

14 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Rapid Sequence Intubation

Universal Patient Care Guideline Legend

Preoxygenate with 100% FI02 EMR A for 5 min. if possible A A AEMT A Avoid bag mask ventilation if possible P PM P A Obtain IV/IO access A M MC Order M

If Child < 1year consider premed with P P Atropine 0.02 mg/kg IV/IO

Suspected intracranial Yes Shock? No hypertension?

Etomidate 0.3 mg/kg IV/IO Consider No P P Yes Lidocaine 1 mg/kg IV/IO **If septic consider P P Etomidate 0.3 mg/kg IV/IO Fentanyl 2 mcg/kg IV/IO/IM P Etomidate 0.3 mg/kg IV/IO P OR And Midazolam P Fentanyl 2 mcg/kg IV/IO/IM P 0.1 mg/kg IV/IO/IM And Midazolam 0.1 mg/kg IV/IO/IM

Any personal family history of malignant hyperthermia, known or suspected mitochondrial disease Yes or skeletal myopathy, glaucoma, penetrating eye injury? No

Vecuronium 0.1 mg/kg IV/IO Succinylcholine 2 mg/kg IV/IO P OR P P P Rocuronium 1 mg/kg IV/IO OR Rocuronium 1 mg/kg IV/IO

Perform intubation, confirm placement, inflate cuff if necessary until resistance, continue sedation and paralysis

M Contact Medical Control M

4 kg 6 kg 8 kg 10 kg 12 kg 15 kg 19 kg 24 kg 30 kg Weight grey pink red purple yellow white blue orange green

Atropine 0.8 mg 0.12 mg 0.16 mg 0.2 mg 0.24 mg 0.30 mg 0.38 mg 0.48 mg 0.60 mg

Etomidate 1.2 mg 1.8 mg 2.4 mg 3 mg 3.6 mg 4.5 mg 5.7 mg 7.2 mg 9 mg

Lidocaine 4 mg 6 mg 8 mg 10 mg 12 mg 15 mg 19 mg 24 mg 30 mg

Fentanyl 8 mcg 12 mcg 16 mcg 20 mcg 24 mcg 30 mcg 38 mcg 48 mcg 60 mcg

Midazolam 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2 mg 2 mg

Succinylcholine 8 mg 12 mg 16 mg 20 mg 24 mg 30 mg 38 mg 48 mg 60 mg

Vecuronium 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2.4 mg 3 mg

Rocuronium 4 mg 6 mg 8 mg 10 mg 12 mg 15 mg 19 mg 24 mg 30 mg

15 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Pulseless Arrest History: Differential: • Respiratory effort • Medical history • Toxins • Foreign body obstructions • Possibility of foreign body • Time of arrest • Tamponade, cardiac • Hypovolemia (dehydration) • Respiratory distress or arrest • Hypothermia • Tension pneumothorax • Hypoxia • Possible toxic or poison exposure • • Thrombosis (coronary or Non-accidental • Hydrogen ion (acidosis) • pulmonary) Congenital disease trauma • Hypo-/hyperkalemia • Trauma (hypovolemia, • Medication (maternal or infant) • SIDS • Hypoglycemia increased ICP) • Hypothermia

Universal Patient Care Guideline Legend EMR Begin CPR A AEMT A Oxygen PRN P PM P Advanced Airway Management M MC Order M A Obtain IV/IO access A

Apply AED / ECG monitor / Defibrillator Assess rhythm, shock as advised

VF / VT Yes Shockable rhythm? No Asystole / PEA

Give 1 shock · Manual: 2-4 J/kg Resume CPR Immediately

Resume CPR Immediately Epinephrine 2 minutes of CPR 100/min 1 : 10,000 0.01 mg/kg IV / IO Shockable rhythm? No P P 1 : 1,000 Yes 0.1 mg/kg ET Repeat every 3-5 min. PRN Give 1 shock · Manual: 2-4 J/kg

Resume CPR Immediately 2 minutes of CPR 100/min Epinephrine 2 minutes of CPR Assess rhyhm 1 : 10,000 100/min 0.01 mg/kg IV / IO P P 1 : 1,000 Ongoing assessment 0.1 mg/kg ET Repeat every 3-5 min. PRN Return Of Spontaneous Circulation Yes (ROSC)?

Post Resuscitation No Guideline Pg. 19 M Contact Medical Control M

4 kg 6 kg 8 kg 10 kg 12 kg 15 kg 19 kg 24 kg 30 kg Weight grey pink red purple yellow white blue orange green Epinephrine 1 : 10,000 0.04 mg 0.06 mg 0.08 mg 0.1 mg 0.12 mg 0.15 mg 0.19 mg 0.24 mg 0.3 mg 0.01 mg/kg IV / IO Epinephrine 1 : 1,000 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2.4 mg 3 mg 0.1 mg/kg ET

Defibrillation 8 J 12 J 16 J 20 J 24 J 30 J 38 J 48 J 60 J

16 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Bradycardia

History: Differential: • Respiratory failure • Medical history • Toxins • Foreign body obstructions • Possibility of foreign body • Tamponade, cardiac • Hypovolemia (dehydration) • Respiratory distress or arrest • Tension pneumothorax • Hypoxia • Possible toxic or poison exposure • Thrombosis (coronary or • Hydrogen ion (acidosis) • pulmonary) Congenital disease • Hypo-/hyperkalemia • Trauma (hypovolemia, • Medication (maternal or infant) • Hypoglycemia increased ICP) • Airway / Respiratory is most common cause • Hypothermia

Universal Patient Care Guideline Legend EMR Oxygen A AEMT A Advanced Airway Management P PM P M MC Order M P 12 lead / ECG P

Perform CPR if despite oxygenation and ventilation HR<60/min with poor perfusion

PRN Fluid bolus 20 ml/kg IV/IO A Obtain IV/IO access A A May repeat up to 60 ml/kg A for signs of shock

Epinephrine 1 : 10,000 0.01 mg/kg IV / IO Support ABC’s; Persistent symptomatic OR give oxygen if needed No Yes P P bradycardia? Epinephrine Observe 1 : 1,000 0.1 mg/kg ET Repeat every 3-5 min.PRN

If vagal tone or primary AV block consider P P Atropine 0.02 mg/kg IV/IO

P Consider pacing P

M Contact Medical Control M

4 kg 6 kg 8 kg 10 kg 12 kg 15 kg 19 kg 24 kg 30 kg Weight grey pink red purple yellow white blue orange green Epinephrine 1 : 10,000 0.04 mg 0.06 mg 0.08 mg 0.1 mg 0.12 mg 0.15 mg 0.19 mg 0.24 mg 0.3 mg 0.01 mg/kg IV / IO Epinephrine 1 : 1,000 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2.4 mg 3 mg 0.1 mg/kg ET

Atropine 0.1 mg 0.12 mg 0.16 mg 0.2 mg 0.24 mg 0.3 mg 0.38 mg 0.48 mg 0.6 mg

17 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Narrow Complex Tachycardia

History: Differential: • Medications or toxins Sinus Tachycardia vs. SVT • Congenital heart disease • Heart disease (congenital) • Respiratory distress • Electrolyte imbalance • Syncope • Hypotension • Volume loss (diarrhea / vomiting) • Fever / infection / sepsis • Trauma? • Medication / toxin / drugs • Pulmonary Embolism • Tension pneumothorax

Legend Universal Patient Care Guideline EMR A AEMT A Oxygen PRN Advanced Airway Management P PM P M MC Order M PRN A Obtain IV/IO access A

Adequately perfused? P 12 lead / ECG PRN P Poorly perfused?

Probable Sedation should not delay Borderline ? Sinus Probable SVT cardioversion Tacycardia Infant rate Infant rate ≥ 220 bpm < 220 bpm Children Attempt Valsalva maneuver Lorazepam Children ≥ 180 bpm 0.1mg/kg IV / IO <180 bpm P Or P Midazolam 0.1 mg/kg IV / IO Consider Vagal Search and Maneuvers if treat causes uncompensated (no delays) Adenosine 0.1 mg/kg IV/IO Synchronized P P PRN Repeat dose X 2 P Cardioversion P 0.5-1 joules/kg 0.2 mg/kg IV/IO

M Contact Medical Control M

4 kg 6 kg 8 kg 10 kg 12 kg 15 kg 19 kg 24 kg 30 kg Weight grey pink red purple yellow white blue orange green

Adenosine 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2.4 mg 3 mg 0.1 mg/kg – 1st dose Adenosine 0.8 mg 1.2 mg 1.6 mg 2 mg 2.4 mg 3 mg 3.8 mg 4.8 mg 6 mg 0.2 mg/kg – 2nd dose

Lorazepam 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2 mg 2 mg

Midazolam 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2 mg 2 mg

18 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Wide Complex Tachycardia History: Differential: • Medications or toxins • Heart disease (congenital) • Congenital heart disease • Hypovolemia (dehydration) or anemia • Respiratory distress • Electrolyte imbalance • Syncope • Anxiety • Drugs (cocaine) • Hypotension • Medication / toxin / drugs

Legend Universal Patient Care Guideline EMR

PRN A A Oxygen AEMT Advanced Airway Management P PM P M MC Order M P 12 lead / ECG PRN P

A Obtain IV/IO access A

Regular Irregular Is rhythm regular?

Wide Complex Adequate Amiodarone P P Tachycardia Perfusion 5 mg/kg IV/IO Atrial Fibrillation

Unable to convert or P P unstable? No No Lorazepam 0.1mg/kg IV / IO P Or P Midazolam 0.1 mg/kg IV / IO Inadequate Yes perfusion Synchronized Monitor patient and P Cardioversion P transport. (Atrial 0.5-1 joules/kg Fibrillation very rare) Go to Narrow Complex tachycardia Guideline Pg. 17

M Contact Medical Control M

4 kg 6 kg 8 kg 10 kg 12 kg 15 kg 19 kg 24 kg 30 kg Weight grey pink red purple yellow white blue orange green

Amiodarone 20 mg 30 mg 40 mg 50 mg 60 mg 75 mg 95 mg 120 mg 150 mg

Lorazepam 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2 mg 2 mg

Midazolam 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2 mg 2 mg

19 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Post Resuscitation Management History: Differential: • Past Medical History • Hypovolemia (dehydration) • Toxins • Event / complaints • Hypoxia • Tamponade, cardiac • Hydrogen ion (acidosis) • Tension pneumothorax • Hypo-hyperkalemia • Thrombosis (coronary • Hypoglycemia or pulmonary) • Hypothermia • Trauma (hypovolemia, increased ICP)

Legend Universal Patient Care Guideline EMR A AEMT A Oxygen PRN Advanced Airway Management P PM P M MC Order M A Obtain IV/IO access A

Fluid bolus 20 ml/kg IV/IOPRN A A May repeat up to 60 ml/kg

P 12 lead / ECG PRN P

PRN Monitor ECG / P P ETCO2 if available

P Sedation Post Intubation P

Consider Pain Management Guideline Pg. 27

Midazolam PRN 0.1mg/kg IV / IO P Or P Lorazepam 0.1 mg/kg IV / IO

Treat other associated signs and symptoms per guideline Consider temperature control (avoid Hypothermia)

M Contact Medical Control M

4 kg 6 kg 8 kg 10 kg 12 kg 15 kg 19 kg 24 kg 30 kg Weight grey pink red purple yellow white blue orange green

Midazolam 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2 mg 2 mg

Lorazepam 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2 mg 2 mg

20 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Anaphylaxis History: Differential: • • • Asthma Allergies • Last oral ingestion Acute respiratory failure • • • Drug reaction Medications • Event preceding Anxiety • Past Medical history • Aspiration • Shock

Universal Patient Care Guideline Legend EMR Evidence of impending Respiratory Yes No distress or shock? A AEMT A Epinephrine P PM P PRN 1:1,000 0.1 mg/kg IM Oxygen M MC Order M May repeat Q 5 minutes Advanced Airway Management max 0.3 mg P ECG/ Consider 12 lead P

A Obtain IV/IO access A Fluid Bolus NS PRN A 20 mg/kg IV/IO A May repeat up to 60 ml/kg Hives/ Rash only No respiratory PRN Albuterol component P 5 mg Nebulized P single dose Diphenhydramine Diphenhydramine P P P P 1mg/kg PO 1mg/kg IV/IO Decadron Solumedrol P P P P 0.6 mg/kg PO 2 mg/kg IV/IO Epinephrine Drip P P Yes Continued Hypotension? Reassess patient 0.1-1.5 mcg/kg/min IV/IO No

M Contact Medical Control M

4 kg 6 kg 8 kg 10 kg 12 kg 15 kg 19 kg 24 kg 30 kg Weight grey pink red purple yellow white blue orange green

Fluid Bolus 80 mg 120 mg 160 mg 200 mg 240 mg 300 mg 380 mg 480 mg 600 mg

Diphenhydramine 4 mg 6 mg 8 mg 10 mg 12 mg 15 mg 19 mg 24 mg 30 mg

Solumedrol 8 mg 12 mg 16 mg 20 mg 24 mg 30 mg 38 mg 48 mg 60 mg

Decadron 2 mg 4 mg 6 mg 6 mg 8 mg 10 mg 12 mg 14 mg 16 mg

Nebulizer Albuterol 2.5 mg Albuterol 5 mg

Epinephrine 0.04 mg 0.06 mg 0.08 mg 0.1 mg 0.12 mg 0.15 mg 0.19 mg 0.24 mg 0.3 mg

Epineprine Drip 1 mg Epinephrine 1:1,000 in 250 ml = 4 mcg/ml Use 60 gtt tubing Mcg/min 2 4 6 8 10 Administer 30 gtts/min 60 gtts/min 90 gtts/min 120 gtts/min 150 gtts/min Run gtts/sec 1 every 2 seconds 1 every second 1.5 every second 2 every second 2.5 every second 21 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Apparent Life Threatening Event (ALTE) History: Differential: • Altered Mental Status • Hypovolemia (dehydration) • Toxins • Cardiac • Hypoxia • Tamponade, cardiac • • Respiratory Failure • Hydrogen ion (acidosis) Tension pneumothorax • • Thrombosis (coronary or • Seizures Hypo-hyperkalemai • Hypoglycemia pulmonary) • Syncope • Hypothermia • Trauma (hypovolemia, • Cyanosis increased ICP) • Change in tone

Universal Patient Care Guideline Legend EMR Oxygen PRN A AEMT A Advanced Airway Management P PM P M MC Order M P 12 lead / ECG PRN P

PRN A Obtain IV/IO access A

Glucose check

PRN Fluid bolus 20 ml/kg IV/IO A A May repeat up to 60 ml/kg

Consider other treatment guidelines as necessary Obtain full history and features of event Explore medication ingestion/toxin risk

Complete thorough history

• Specifically assess for history of apnea No? (>15 seconds?), increased or decreased tone?, change of color?, pallor or cyanosis?

Yes to any?

Meets criteria for an ALTE

Patient must be transported for evaluation even if well appearing Consider contacting medical control if caregiver refusing transport

M Contact Medical Control M

22 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Breathing Difficulty History: Differential: • Possibility of foreign body • Asthma • Epiglottitis (Rare) • Cardiac/Respiratory history • Aspiration • Congenital heart disease • Respiratory infection • Foreign body • Medication or Toxin • Pneumonia (aspiration) • Trauma • Croup

Legend Universal Patient Care Guideline EMR A AEMT A High flow Oxygen Airway Management P PM P M MC Order M Pediatric Advanced Severe Distress Respiratory Yes Airway Management Failure No

Transport in position of minimal agitation

Lower Airway Upper Airway

Wheeze? Stridor and/or Retractions?

Yes Yes Epinephrine P Albuterol Nebulized P 3 mL P P 1:1,000 nebulized Albuterol No saline needed P 5 mg Nebulized P Single dose Transport greater than 30 mins? Age > 1 year P P Consider Decadron 0.6 mg/kg PO or IM Crush tabs

Repeat appropriate nebulizer P Treatment as indicated for P continued symptoms

M Contact Medical Control M

4 kg 6 kg 8 kg 10 kg 12 kg 15 kg 19 kg 24 kg 30 kg Weight grey pink red purple yellow white blue orange green Epinephrine 3 mL nebulized 1 : 1,000

Atrovent 0.5 mg nebulized

Nebulizer Albuterol 2.5 mg Albuterol 5 mg

Decadron 2 mg 4 mg 6 mg 6 mg 8 mg 10 mg 12 mg 14 mg 16 mg

23 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Diabetic Ketoacidosis / Hyperglycemia

History: Clinical Signs: • Polyuria • Dehydration • Polydipsia • Kussmaul respirations • Vomiting • Smell of ketones • Weakness • Change in mental status • Confusion

Legend Universal Patient Care Guideline EMR A AEMT A P PM P PRN Oxygen M MC Order M Advanced Airway Management

Check Glucose

P 12 Lead / ECG P

A Obtain IV/IO access A

Clinical Signs of Intracranial Yes Hypertension?

Consider Rapid Sequence Intubation P P for GCS <8 No Pg. 13

Clinical Signs of Dehydration Elevate head of bed to 45° or Hyperglycemia > 250?

Ventilate patient to P maintain 30-35 mm/Hg P ETCO2

Slow Fluid bolus A 10 ml/kg IV/IO A No repeat unless shock

M Contact Medical Control M

24 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Hypoglycemia

History: Differential: • Known diabetic, medic alert tag • Head trauma • Past medical history • CNS (stroke, tumor, seizure, infection) • Medications • Infection • History of trauma • Thyroid (hyper / hypo) • Ingestion • Diabetes (hyper / hypoglycemia) • Syncope • Toxicologic • Acidosis / Alkalosis • Electrolyte abnormatility

Legend Universal Patient Care Procedure EMR A AEMT A P PM P Blood Glucose check M MC Order M

< 60 mg/dL

Administer Oral Glucose Yes Alert and stable airway?

No

A Obtain IV/IO access A

Blood Glucose < 60 A D 25 W A 2 mL/kg OR P Glucagon P 0.1 mg/kg IM to 1 mg max

PRN P 12 lead / ECG P

M Contact Medical Control M

4 kg 6 kg 8 kg 10 kg 12 kg 15 kg 19 kg 24 kg 30 kg Weight grey pink red purple yellow white blue orange green

D 25 W 8 mL 12 mL 16 mL 20 mL 24 mL 30 mL 38 mL 48 mL 60 mL

Glucagon 0.4 mg 0.6 mg 0.8 mg 1 mg 1 mg 1 mg 1 mg 1 mg 1 mg

25 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Newborn Resuscitation

History: Differential: • Prenatal care and history • Airway obstruction • Due date/LMP • Respiratory effort • Expected multiple births • Infection • Meconium • Hypovolemia • Congenital disease • Hypoglycemia • Medications • Congenital heart disease • Maternal risk factors • Hypothermia

Legend Universal Patient Care Guideline EMR Dry infant and keep warm A AEMT A P PM P Suction with bulb syringe PRN Mouth then nose M MC Order M

Oxygen Blow-by PRN

Assess breathing and heart rate Heart rate < 60? Heart rate > 100? Or inadequate respirations

Assist ventilations BVM Intubation PRN

No improvement after 30 seconds? begin chest compressions Continue ongoing assessment A Obtain IV/IO acess A

Fluid bolus A 20 ml/kg IV/IO/NS A May repeat up to 60 ml/kg

P 12 Lead / ECG P

Epinephrine 1 : 10,000 0.01 mg/kg IV / IO OR P P M Contact Medical Control M Epinephrine 1 : 1,000 0.1 mg/kg ET Repeat every 3-5 min.PRN

2 kg 3 kg 4 kg 5 kg Weight grey grey grey red Epinephrine 1 : 10,000 0.02 mg 0.03 mg 0.04 mg 0.05 mg 0.01 mg/kg IV / IO Epinephrine 1 : 1,000 0.2 mg 0.3 mg 0.4 mg 0.5 mg 0.1 mg/kg ET 26 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Known Pediatric Toxic Exposure History: Differential: • Ingestion or suspected ingestion of a potentially toxic substance • Tricyclic antidepressants (TCAs) • Cardiac medications • Substance ingested, route, quantity • Acetaminophen (tylenol) • Solvents, Alcohols, • Time of ingestion • Depressants Cleaning agents • Reason (suicidal, accidental, criminal) • Stimulants • Insecticides • Available medications in home • Anticholinergic (organophosphates) Poison Control 800-222-1222

Universal Patient Care Guideline Legend EMR Oxygen PRN Advanced Airway Management A AEMT A P PM P M Contact Medical Control M Yes BLS Provider? with nature of toxic exposure M M No MC Order Consider Activated Charcoal 1 gm/kg PO Fluid bolus A Obtain IV access A A 20 ml/kg IV/IO A May repeat up to 60 ml/kg Respiratory depression, Opiate O.D. A A Naloxone PRN 0.1 mg/kg (max 2 mg) IV/IO/IM

Tricyclics Calcium Channel Blockers Beta Blockers Organophosphates CNS stimulants

Calcium Chloride Excess Lorazapam Sodium Bicarbonate P P P P 20 mg/kg IV/IO Airway Secretions? 0.1 mg/kg IV/IO 1 – 2 mEq/kg IV/IO P P Atropine P Or P Consider 0.02 mg/kg IV/IO Midazolam P Transcutaneous P 0.1 mg/kg IV/IO Pacing

Epinephrine PRN P See Pediatric Shock P Non-Traumatic Pg. 28

Glucagon P 0.1 mg/kg IM P (max does 1 mg)

M Contact Medical Control M

4 kg 6 kg 8 kg 10 kg 12 kg 15 kg 19 kg 24 kg 30 kg Weight grey pink red purple yellow white blue orange green

Activated Charcoal 4 gm 6 gm 8 gm 10 gm 12 gm 15 gm 19 gm 24 gm 30 gm

Naloxone 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2 mg 2 mg

Sodium Bicarbonate 4 mEq 6 mEq 8 mEq 10 mEq 12 mEq 15 mEq 19 mEq 24 mEq 30 mEq Calcium Chloride 80 mg 120 mg 160 mg 200 mg 240 mg 300 mg 380 mg 480 mg 600 mg

Glucagon 0.4 mg 0.6 mg 0.8 mg 1 mg 1 mg 1 mg 1 mg 1 mg 1 mg

Atropine 0.1 mg 0.12 mg 0.16 mg 0.2 mg 0.24 mg 0.3 mg 0.38 mg 0.48 mg 0.6 mg

Lorazapam 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2 mg 2 mg

Midazolam 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2 mg 2 mg

27 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Pain Management

History: Differential: • Age • Musculoskeletal • Location • Visceral (abdominal) • Duration • Cardiac • Severity (1 - 10) • Pleural / Respiratory • Past medical history • Neurogenic • Medications – especially pain med • Renal (colic) • Drug allergies • Sickle cell • Aggravating factors • Alleviating factors

Universal Patient Care Guideline Legend EMR est PRN R A AEMT A Ice/Immobilize Compression P PM P Elevation M MC Order M A Obtain IV/IO access A

P 12 lead / ECG PRN P

Nitrous Oxide PRN Moderate to High pain level? P P Yes if available Burns?

Morphine PRN 0.1 mg/kg IV/IO/IM No P Or P Fentanyl PRN 1 mcg/kg IV/IO/IM Midazolam 0.1 mg/kg IV/IO/IM Extremely anxious? Yes P Or P Lorazepam 0.1 mg/kg IV/IO No Ondansetron PRN IV/IM P Or P Yes Nausea? 4 mg PO if patient weight > 10kg No

M Contact Medical Control M

4 kg 6 kg 8 kg 10 kg 12 kg 15 kg 19 kg 24 kg 30 kg Weight grey pink red purple yellow white blue orange green

Morphine 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2.4 mg 3 mg

Fentanyl 4 mcg 6 mcg 8 mcg 10 mcg 12 mcg 15 mcg 19 mcg 24 mcg 30 mcg

Lorazapem .04 mg .06 mg .8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2 mg 2 mg

Midazolam 0.4 mg 0.6 mg 00..88 mgmg 1 mg 1.2 mg 1.5 mg 1.9 mg 2 mg 2 mg

Ondansetron IV/IM 0.6 mg 0 11.5 mg mg 11.8 mg mg 2.125 mg mg 2.285 mg mg 32.6 mg mg 43 mg

Ondansetron PO 0 4 mg ODT

28 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Fever History: Differential: • Fever not associated with heat injury • Infections/Sepsis • Does not require rapid temperature reduction • Medication or drug reaction • Fever less than 107° is not dangerous

Legend Universal Patient Care Guideline EMR A AEMT A P PM P M MC Order M

No Temp ≥ 101° or ≥ 38 Celsius ?

Yes

Keep patient comfortable Otherwise well? Yes Do Not undress Do Not apply cool compress

No

See appropriate Associated with needing treatment? Yes See appropriate guideline guideline

No

No vomiting, no acetaminophen in 4° And Transport > 10 mins Consider P Acetaminophen P 15 mg/kg PO/PR

M Contact Medical Control M

4 kg 6 kg 8 kg 10 kg 12 kg 15 kg 19 kg 24 kg 30 kg Weight grey pink red purple yellow white blue orange green

Acetaminophen 60 mg 90 mg 120 mg 150 mg 180 mg 225 mg 285 mg 360 mg 450 mg

29 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Shock Non-traumatic History: Differential: • • Respiratory effort Medical history • • Hypovolemia (dehydration) Toxins • Respiratory distress or arrest • • Hypoxia Tamponade, cardiac • Possible toxic or poison exposure • ension pneumothorax • Hydrogen ion (acidosis) T • Congenital disease • hrombosis (coronary or • Hypo-hyperkalemia T • pulmonary) Medication (maternal or infant) • Hypoglycemia • Non accidental trauma • Hypothermia

Legend Universal Patient Care Guideline EMR A AEMT A Oxygen PRN Advanced Airway Management P PM P M MC Order M

P 12 lead / ECG PRN P

A Obtain IV/IO access A

PRN Fluid bolus 20 ml/kg IV/IO A A May repeat up to 60 ml/kg

Improved?

No

Epinephrine Bolus 0.01 mg/kg IV/IO P P Epinephrine Drip Yes 0.1-1.5 mcg/kg/min IV/IO

Ongoing assessment

Consider other treatment Guideline as necessary

M Contact Medical Control M

Epineprine Drip 1 mg Epinephrine 1:1,000 in 250 ml = 4 mcg/ml Use 60 gtt tubing Mcg/min 2 4 6 8 10 Administer 30 gtts/min 60 gtts/min 90 gtts/min 120 gtts/min 150 gtts/min Run gtts/sec 1 every 2 seconds 1 every second 1.5 every second 2 every second 2.5 every second

Epinephrine 0.04 mg 0.06 mg 0.08 mg 0.1 mg 0.12 mg 0.15 mg 0.19 mg 0.24 mg 0.3 mg

30 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Seizure

History: Differential: • Prior history of seizures • Medication or Toxin • Seizure medications • Hypoxia or Respiratory failure • History of VP Shunt • Hypoglycemia • Fever • Head Trauma

Legend Universal Patient Care Guideline EMR A AEMT A P P See Fever Guideline PM Yes Febrile? Page 28 M MC Order M No

Oxygen Advanced Airway Management

PRN A Obtain IV/IO access A

Blood Glucose < 60 A A D 25 W 2 mL/kg OR P Glucagon P 0.1 mg/kg IM to 1 mg max

Diastat ™ Active Seizure ≥ 5 minutes? Yes (Patients own RX) Lorazepam 0.1 mg/kg IV/IO Or P Midazolam P No 0.1 mg/kg IV/IO/IM Can repeat after 5 minutes if still seizing

M Contact Medical Control M Yes

4 kg 6 kg 8 kg 10 kg 12 kg 15 kg 19 kg 24 kg 30 kg Weight grey pink red purple yellow white blue orange green

D 25 W 8 mL 12 mL 16 mL 20 mL 24 mL 30 mL 38 mL 48 mL 60 mL

Glucagon 0.4 mg 0.6 mg 0.8 mg 1 mg 1 mg 1 mg 1 mg 1 mg 1 mg

Lorazepam 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2 mg 2 mg

Midazolam 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2 mg 2 mg

31 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Unknown Pediatric Toxic Exposure / Ingestion Guideline Smells: Potential exposures: • Almond = Cyanide • Burning overstuffed furniture = cyanide • Fruit = Alcohol • Old burning buildings = Lead fumes and Carbon • Garlic = Arsenic, parathion, DMSO monoxide • Mothballs = Camphor • Pepto-Bismol™ like products = Aspirin • Natural gas = Carbon monoxide • Pesticides = Organophosphates and Carbamates • Rotten eggs = Hydrogen sulfide • Common Plants = Treat symptoms and bring plant/flower • Silver polish = Cyanide to ED • Wintergreen = Methyl salicylate

Universal Patient Care Guideline Legend EMR Assess scene safety as Indicated: A AEMT A • Appropriate body substance isolation P PM P • Refer to System/Department Haz/Mat Protocol M M • Stop exposure MC Order

Oxygen Advanced Airway Management

A Obtain IV/IO NS/LR access A

Contact Medical Control Initial interventions per M Medical Control indicated for M identified exposure

Naloxone For Altered Level of Consciousness P 0.1 mg/kg (max 2 mg) P IV/IO/IM

• Support ABC’s • Keep Warm • Bring Container(s) of drug or substance to the ED

Special Considerations: • Intubate for GCS<8 • Do not induce vomiting, especially in cases where caustic substance ingestion is suspected • Poison Center Phone # 800-222-1222

M Contact Medical Control M

4 kg 6 kg 8 kg 10 kg 12 kg 15 kg 19 kg 24 kg 30 kg Weight grey pink red purple yellow white blue orange green

Naloxone 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2 mg 2 mg

32 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Multi-System Trauma

History: Differential: • Time and Mechanism of injury • Abnormal neurological exam • Hypovolemia • Damage to structure or vehicle • Tamponade, cardiac • Hypoxia • Others injured or death • Tension pneumothorax • Hydrogen ion (acidosis) • Restraints / protective equipment • Intracranial Hypertension • Hypo-hyperkalemia • Ejection • Toxins • Hypoglycemia • Speed and details of MVC • Tamponade (cardiac) • Hypothermia • Tension pneumothorax • Thrombosis (Pulmonary, Coronary) • Trauma

Legend Universal Patient Care Guideline EMR A AEMT A Pediatric Spinal Precautions P PM P M MC Order M

PRN Oxygen Advanced Airway Management

A Obtain IV/IO access A

PRN Fluid bolus 20 ml/kg IV/IO A A May repeat up to 60 ml/kg

Ongoing assessment

Consider other treatment Guideline as necessary

M Contact Medical Control M

33 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Submersion Injury

History: Differential: • Submersion in water regardless of depth • Trauma • Possible history of trauma • Pre-existing medical problems • Duration of submersion • Barotrauma • Temperature of water • Decompression Sickness

Legend Universal Patient Care Guideline EMR A AEMT A P PM P Pediatric Spinal Precautions M MC Order M Pg. 37

Oxygen Advanced Airway Management

If no pulse or Symptomatic Bradycardia begin CPR See Appropriate Guideline

Remove wet clothing Cover with dry (warm) blankets Warming Measures

A Obtain IV/IO access A

P 12 Lead / ECG P

Consider other treatment Guidelines as necessary

M Contact Medical Control M

Notes: • Patients may have delayed respiratory symptoms. Transfer all patients for evaluation.

34 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Burns History: Differential: • Type of exposure • Superficial (1°) red and painful • Inhalation injury • Partial thickness (2°) blistering • Time of injury • Full thickness (3°) charred or leathery skin • Mechanism of Injury • Chemical • Non-accidental trauma • Thermal • Electrical

Legend Universal Patient Care Guideline EMR A AEMT A Oxygen PRN Advanced Airway Management P PM P M MC Order M Stop the burning process: Remove jewelry and clothing that may be burned, covered in chemicals or restricting. Thermal / Electrical Chemical

Cover burn with a dry clean Brush off any excess sheet or dressing chemical or powder

Keep warm Flush area with water or Normal Saline (except materials that react with H2O) Keep warm

Eye involvement? Use Rule of 9's to calculate BSA Saline flush in the affected eye

>15% BSA then

Obtain IV/ IO access PRN If Hypotensive fluid bolus LR 20ml / kg A A (if LR unavailable use NS) If not Hypotensive Maintenance fluid

Pain Management Guideline Pg. 27

M Contact Medical Control M

35 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Heat Related Emergency

History: Differential: • Age • Infection • Exposure to increase temperature and/or humidity • Dehydration • Delirium tremors • Extreme exertion • Medications • CNS lesions or tumors • Time and length of exposure • Thyroid storm • DKA • Fatigue and/or muscle cramping • Predisposing factors • Heat related emergency ≠ fever response to illness

Universal Patient Care Guideline Legend EMR Oxygen PRN A AEMT A Advanced Airway Management P PM P Remove from heat source M MC Order M Remove clothing

P 12 Lead / ECG P

Yes Alert and oriented, no nausea No

Cool Fluid intake PO A Obtain IV/IO access A Cool Fluid bolus A A 20 ml/kg IV/IO Check Glucose < 60 mg/dl See Hypoglycemia Guideline Pg. 24

Continue cooling to 39° C (103° F)

Yes Shivering or seizures? No Lorazepam Continue Care 0.1 mg/kg IV/IO P Or P Midazolam 0.1 mg/kg IV/IO/IM

M Contact Medical Control M

4 kg 6 kg 8 kg 10 kg 12 kg 15 kg 19 kg 24 kg 30 kg Weight grey pink red purple yellow white blue orange green

Lorazepam 0.04 mg 0.06 mg 0.08 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2.4 mg 3 mg

Midazolam 0.04 mg 0.06 mg 0.08 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2.4 mg 3 mg

Notes: • Succinycholine not recommended for Hyperthermic patients • Document patient’s rectal temperature • Rapid cooling to 39° C (103° F) to avoid overshooting and shivering. • Apply room temperature water to skin and increase airflow around patient if possible. • Ice packs to axillae and groin

36 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Cold Related Emergency

History: Differential: • Age • Medications • Exposure to decreased • CNS dysfunction temperatures and / or humidity • Environmental exposure • Past medical history / medications • Poisoning/overdose • Time and length of exposure • Hypothermia = core tem < 35º C

Legend Universal Patient Care Guideline Handle patient gently EMR A AEMT A Oxygen P P Advanced Airway Management PM M MC Order M

PRN P 12 Lead / ECG P

A Obtain IV/IO access A

Warm Fluid bolus A 20 ml/kg IV/IO A May repeat up to 60 ml/kg

No Pulse / Breathing? Yes

Begin CPR Support ABC’s Monitor Defibrillate VF/VT Once Treat other associated sypmtoms Consider Differentials

Core temperature? < 28° C > 28° C

Continue CPR Continue CPR Hold IV Meds Give IV Medication per appropriate Guideline Repeat Defibrillation as core temperature rises if V-Tac or V-Fib Begin active external warming

M Contact Medical Control M

37 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Spinal Precautions

Recommended high-energy guidelines: • Any accident involving motorized recreational vehicles • High-speed motor vehicle collision • Diving accident • Rollover motor vehicle accident • Fall from height > 5 ft or > 5 stairs • Occupant ejected from motor vehicle • Any other high-energy mechanism with rapid acceleration and • Pedestrian/bicyclist struck by motor vehicle deceleration • High contact sports injuries

Legend Universal Patient Care Protocol EMR A AEMT A P PM P Patient with mechanism or exam concerning for potential spinal M MC Order M injury

Maintain manual cervical spine stabilization

Apply properly sized pediatric cervical collar

1. Place padding under shoulders to maintain neutral spinal alignment 2. Place child on backboard/papoose or stabilize child in car seat 3. Properly place restraint straps 4. Place tape across forehead

Maintain continuous monitoring throughout transport

M Contact Medical Control M

38 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Sports Concussion Signs observed by Others: Symptoms Report by Athlete: • Appears dazed or stunned • Headache • Confusion • Nausea or vomiting • Forgetfulness • Balance problems or dizziness • Unsure • Double or blurry vision • Moves Clumsily • Sensitivity to light • Answers Questions slowly • Sensitivity to noise • Loses consciousness – not needed to have concussion • Numbness or weakness in extremities • Behavior or personality Changes • Feeling sluggish, hazy, foggy, or groggy • Can’t recall events prior to hit / fall • Concentration or memory problems • Apparent weakness • Confusion • DOES NOT “FEEL RIGHT”

Universal Patient Care Guideline Legend EMR PRN Oxygen A AEMT A Advanced Airway Management P PM P PRN M MC Order M Pediatric Spinal Precautions Pg. 37

A Obtain IV/IO access A

A Fluid bolus 20 ml/kg IV/IO A

P 12 Lead / ECG P

Evidence of increased intracranial Yes pressure or a GSC < 8 ?

No Go to Traumatic Brain Injury Guideline Pg. 41

Consider other treatment Guideline as necessary

Continuous reassessment of vital signs of mental status

M Contact Medical Control M

Notes: • Uneven gait Signs of possible sports related concussion include: • Nausea • Trauma / Head Injury • Blurred vision • Headaches • Amnesia • Dizziness • Confusion • Fatigue • Neurological deterioration over time

39 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric START/JumpSTART Triage Legend EMR A AEMT A P PM P M MC Order M

Refer to appropriate Able to walk? Yes Minor Guideline

No

Breathing? No Position upper airway Breaths IMMEDIATE

Apenec

Pediatric Adult

Pulse No No Pulse DECEASED

5 Rescue Breaths Apnec

Breathing IMMEDIATE

> 30 Adult Respiratory Rate < 15 or > 45 Pediatric IMMEDIATE

< 30 Adult 15 - 45 Pediatric

CRT > 3 sec (Adult) Perfusion No Palpable Pulse (Pediatric) IMMEDIATE

Doesn't obey commands (Adult) Mental Status “P” Inappropriate posturing or “U” (Pediatric) IMMEDIATE

Obeys Commands (Adult) “A”, “V” or “P” Appropriate (Pediatric) DELAYED

AVPU Infant / Child Response Infant Child A - Alert Curious / Recognizes parents Alert / Aware of surroundings V – Responds to Voice IrritableEMT / Cries- A Opens eyes P – Responds to Pain Cries in responseEMT- toP pain WithdrawalsWithdraws from from Pain pain U - Unresponsive No ResponseMC Order OpensNo resonse eyes

40 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Suspected Child Abuse

Physical findings: Behavioral: • Unexplained bruises • History of minor incident inconsistent with major injury • Numerous/mulitple bruises • MOI inconsistent with developmental age • Burns: • Inappropriate fear of parent Cigarette, Immersion, Rope, Infected, patterned • Inconsistent explanation for injury • Torn, stained, bloody underclothes • Nervous disorders (rash, hives, stomachaches) • Bleeding, irritation or pain of the genitals • Age-inappropriate behaviors (bedwetting) • Poor hygiene/malnourished • Lack of adult supervision • Child with repeated injuries/multiple calls to the same • Delay in seeking medical care address • Caregiver who refuses treatment or transport • Flat/bald spots on head (infants) Contact LE/CPS should caretaker not allow • Unexplained wet clothing/body transport to hospital

Legend Universal Patient Care Guideline EMR A AEMT A Oxygen PRN Advanced Airway Management P PM P M MC Order M PRN P 12 lead / ECG P

PRN A Obtain IV/IO access A

PRN Fluid bolus 20 ml/kg IV/IO A A May repeat up to 60 ml/kg

Consider other treatment Guideline as necessary Have a high index of suspicion for traumatic brain injury

Documentation: • Carefully document caretakers description of event • Note environment including temperature • Note clothing, stains, and conditions

M Contact Medical Control M

Sexual abuse: • May be present without apparent signs of physical abuse • Discourage patient from going to the bathroom • Don’t allow patient to change clothes or wash • Bring clothing to hospital

41 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Pediatric Traumatic Brain Injury

Legend Universal Patient Care Guideline EMR A AEMT A Mechanism or Signs / Symptoms of P PM P Head Injury M MC Order M

Pediatric Spinal Precautions Pg. 37

Advanced Airway Management or Focal neurologic abnormalities, or GCS < 8

Yes No

Consider RSI Pg. 14 Support ABC’s Monitor Treat other associated symptoms Consider Differentials Hypotension? Yes A Obtain IV/IO access A Including Concussion Fluid bolus 20 ml/kg IV/IO A A May repeat up to 60 ml/kg No

Consider Rapid Sequence Signs of Intracranial Yes P Intubation for GCS <8 P Hypertension? Pg. 14

No Elevate head of bed to 30°

Ventilate patient to maintain P P 30-35 mm/Hg ETCO2

Lorazepam 0.1 mg/kg IV/IO Clinical signs of seizure? Yes P Or P Midazolam 0.1 mg/kg IV/IO/IM

No M Contact Medical Control M

4 kg 6 kg 8 kg 10 kg 12 kg 15 kg 19 kg 24 kg 30 kg Weight grey pink red purple yellow white blue orange green

Lorazepam 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2 mg 2 mg

Midazolam 0.4 mg 0.6 mg 0.8 mg 1 mg 1.2 mg 1.5 mg 1.9 mg 2 mg 2 mg

42 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

Needle Cricothyroidotomy

Note: This is an emergency rescue airway procedure, it should not be attempted in a patient that can be ventilated by other means.

Equipment:

Sterile gloves Universal precautions Povidone iodine Sterile drape 10 mL syringe half-filled with sterile saline 16-18 gauge angiocatheter (12-16 g angiocatheter for large adolescent) 3.0 ETT connector

Procedure:

1. Lay patient supine with neck extended, preoxygenate

2. Prep anterior neck with povidone iodine

3. Consider 1% Lidocaine at injection site if patient is conscious

4. Hold trachea with thumb and third finger, palpate cricothyroid membrane

5. Connect 10 mL syringe to angiocatheter, insert midline to inferior margin of cricothyroid membrane at 30-45 degree angle directed caudally

6. Maintain negative pressure on syringe as you advance until you have air bubbles

7. Advance catheter until hub is against skin

8. Remove needle

9. Attach 3.0 ETT connector to BVM

43 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011

REFERENCES

Park MK Pediatric Cardiology for Practitioners, Mosby, 2002, 4th Edition

Pediatric Advanced Life Support: American Heart Association, 2002 Pediatric Advanced Life Support: American Heart Association, 2006

Rosen’s Emergency Medicine: Concepts and Clinical Practice, 2006

John A Marx, Robert S. Hockberger, Ron M Walls, Mosby, 6th edition

Heatstroke: Robert S. Helmen, MD; Rania Habal, MD, eMedicine.medscape.com, September 18, 2009

NHLBI Guidelines for the Diagnosis and Management of Asthma (EPR-3), and updates nhlbi.nih.gov/guidelines/asthma eMedicine.medscape.com ; Brian E Benson, MD; Soly Baredes, MD; Robert A Schwartz, MD eMedicine.medscape.com ; Antionio Muniz, MD; Rona E. Molodow, MD JD; Germaine L Defendi, MD

Medications: Harriet Lane Handbook, Lexicomp Pediatrics

Jamie Alison Edelstein, MD, James Li, MD, Mark Silverberg, MD, Wyatt Decker, MD; Update October 2009

American Burn Association; ameriburn.org

Advanced Trauma Life Support for Doctors; American College of Surgeons Committee on Trauma, 8th Edition, 2008

Cervical Spine Clearance Algorithm; Columbus Ohio Division of Fire, February 2004

Kwon BK, Vaccaro AR, Grauer JN, Fisher CG, Dvorak MF; Subaxial Cervical Spine Trauma, J American Academy Orthopaedic Surgeons, 2006; 14: 78-89

Yates D, Breen K, Brennan P. Head Injury: triage, assessment, investigation and early management, National Guideline Clearinghouse, June 2003

Luhs.org/depts./emsc/Prehospital

Markenson D, tunkik M, Cooper A, et al. A national assessment of knowledge, attitudes and confidence of prehospital providers in the assessment and management of child maltreatment, Pediatrics 119(1):e103-8, Jan. 2007

Ndhealth.gov/EMS/BLS.htm

Emsoffice.com/protocols

Emsresponder.com/print/EMS-Magazine/EMS-and-Child-Abuse/1$4682

Cob.org/cob/policies.nsf/0/10311735FCE4882574D40064E0A2

44 Washington State Department of Health - Office of Community Health Systems DOH 530-137 December 2011