ALS MEDICAL
PROTOCOLS
FOR PEDIATRIC
PATIENTS
HENNEPIN
COUNTY EMS SYSTEM
Effective: March 1,
2000
Approved December 9,
1999
By The Hennepin
County EMS Advisory Council
PEDIATRIC PROTOCOLS
Page
Part I: GENERAL GUIDELINES
Airway
Management.............................................................. 1
Cardiac
Emergencies.............................................................. 2
Pediatric
IV’s......................................................................... 2
Childhood
Weight and Vital Signs Table................................... 3
Part II: NEWBORN EMERGENCIES................................................ 3
Part III: AIRWAY EMERGENCIES
Asthma.................................................................................. 4
Foreign body.......................................................................... 5
Croup and
Epiglottitis.............................................................. 6
Part IV. STATUS SEIZURES............................................................. 6
Part V: ANAPHYLAXIS................................................................... 7
Part VI: DRUG INGESTION/OVERDOSE......................................... 7
Part VII: UNCONSCIOUS UNKNOWN
ETIOLOGY....................... 8
Part VIII: SYMPTOMATIC KNOWN DIABETIC................................ 8
Part VIII: PEDIATRIC SHOCK
Standing
Orders for All Pediatric Shock................................... 9
Blood
Pressure Guidelines....................................................... 9
PCT
Guidelines...................................................................... 9
Part IX: CARDIAC EMERGENCIES
Bradyarrhythmias................................................................. 10
Cardiac
Arrest States............................................................ 11
ADULT
PROTOCOLS (see separate table of contents)
APPENDICES
PART I. GENERAL
GUIDELINES
1.
1.
Age limits for
pediatric and adult medical protocols must be flexible. For age less than 13 years, pediatric orders
should always apply. Between ages 13
and 18, judgment should be used, although the pediatric orders will usually
apply. It is recognized that the exact
age of a patient is not always known.
2.
2.
Patient Consent
and Refusal: Consent or refusal of
treatment/transport of minors (less than 18 years) must be given by the child's
parent or legal guardian. Although less
desirable, consent or refusal may be given by a responsible adult (over age 18)
caretaker if the parent has deliberately left the minor in the care of this
adult, and the adult is competent and capable.
If unsure whether it is appropriate to allow someone to give consent or
refuse treatment of a minor, a medical control physician should be
consulted. (Also see Adult Protocols).
3.
3.
Parents should
be allowed to stay with children during evaluation and transport, if
appropriate. The parent's lap is
usually the best place for the examination of a stable patient.
4.
4.
AIRWAY
MANAGEMENT:
A.
A.
Airway Devices
1)
1)
Do not
hyperextend the neck in newborns and infants.
2)
2)
Consider oral
airway of appropriate size for all unconscious patients.
3)
3)
Use liter flow
appropriate to the type oxygen mask being used (simple vs. partial
rebreathing).
4)
4)
For
spontaneously breathing patients in shock, high flow oxygen should be given by
partial rebreathing mask.
5)
5)
Ventilate using
oxygen with pediatric mask or pocket mask when ventilation must be assisted.
6)
6)
Do not use a
positive pressure valve on patients less than 6 years of age.
7)
7)
If epiglottitis
is a possibility, do not attempt to
visualize the throat or pharynx.
However, if a patient with an airway obstruction has a respiratory or
cardiac arrest, the airway may be visualized with a laryngoscope to rule out a
foreign body.
8)
8)
EOA or
Combitube may be used on adolescents of adult size, at least five feet in
height. The decision should be based on
size, not age. These airways are to be
inserted only in apneic patients unless ordered verbally by the medical control
physician, and should be used with caution in trauma patients.
9)
9)
Endotracheal
intubation (ETI) is not a required procedure but is sanctioned by the Hennepin
County EMS System for various categories of pediatric patients. ETI is to be performed only by paramedics
trained and authorized to intubate and only for those types of patients
specified by the ALS Medical Director.
Endotracheal intubation shall be performed in accordance with the
information and protocol contained in Appendix B and consistent with other
protocols in this document.
10)
10) Other airway interventions
not required but sanctioned by the System are rapid sequence endotracheal
intubation and transtracheal needle ventilation for patients that cannot be
ventilated by any other means. These interventions must be authorized by a
service's ALS Medical Director and shall be performed in accordance with the
information and protocols contained in Appendices C and D.
B.
B.
Adjunctive
Airway Equipment:
1)
1)
End-tidal CO2
monitoring: An end-tidal carbon dioxide
(CO2) detector may be used (but is not required) to accomplish
confirmation of endotracheal tube placement and is most reliable in patients
with spontaneous circulation. This
device often is not able to detect CO2 in cardiac arrest patients
due to extremely low blood flow to the lungs.
2)
2)
Pulse
oximetry: A pulse oximeter may be used
(but is not required) for any patient with suspected hypoxemia, in respiratory
distress, or whenever sedating medications are administered. Obtaining a normal pulse oximetry reading
does not negate the need for oxygen therapy as specified in these protocols.
C.
C.
Drug
Administration By Inhalation or Via the Airway:
1)
1)
The use of the drug Nitronox for pain relief is not required but is
sanctioned by the System. This
intervention must be authorized by a service's ALS Medical Director and
administered in accordance with the information and protocol contained in
Appendix E.
2)
2)
Drugs
administered via the endotracheal tube should be instilled as deeply as
possible into the tracheobronchial tree using a catheter inserted beyond the
distal tip of the ET tube. Drugs may be
administered full strength or diluted in 1-2 ml of normal saline.
5.
5.
CARDIAC EMERGENCIES:
A.
A.
Most critical
cardiac states in children are not due to primary cardiac problems but are
secondary to respiratory, airway, metabolic, or infectious disorders.
B.
B.
Most standing
orders for cardiac arrest states follow the adult orders. However,
contact the medical control physician early to have the appropriate drug doses
calculated.
C.
C.
Contact the
medical control physician early when there is a question about the nature of a
presumed cardiac emergency in children.
6.
6.
PEDIATRIC IV'S:
A.
A.
For trauma and shock of other etiology, start IV's en route.
B.
B.
Hang IV fluid
(versus saline lock) when the administration of multiple IV medications or the
need for fluid volume replacement is anticipated.
C.
C.
Use minidrip IV
infusion sets for non-traumatic emergencies and macrodrip sets for trauma or
hypotensive patients.
D.
D.
If IV access cannot be established at the scene in two attempts for
patients with non-traumatic problems, begin transport to the hospital. There should be no delay at the scene for IV
attempts on children with trauma or in shock - these IV's should be started
during transport.
E.
E.
Intraosseous infusion is a procedure which is not required, but is
sanctioned by the Hennepin County EMS System for use in children under the age
of seven years in critical condition when IV access is unobtainable. This procedure must be authorized by a
service's ALS Medical Director and performed in accordance with the information
and protocol contained in Appendix I.
7.
7.
CHILDHOOD
WEIGHTS AND VITAL SIGNS:
|
|
|
|
Heart Rate |
Heart Rate |
Systolic
BP |
|
Age |
Kg |
Lbs |
Upper limit |
Lower limit |
Lower limit |
|
Newborn |
3 |
7 |
180 |
80 |
40 |
|
6 months |
7 |
15 |
180 |
80 |
70 |
|
1 year |
10 |
22 |
180 |
80 |
70 |
|
2 years |
12 |
26 |
180 |
80 |
80 |
|
4 years |
16 |
35 |
150 |
75 |
80 |
|
6 years |
20 |
44 |
150 |
70 |
80 |
|
8 years |
25 |
55 |
125 |
60 |
85 |
|
10 years |
34 |
75 |
125 |
60 |
90 |
|
12 years |
45 |
99 |
125 |
60 |
90 |
|
14 years |
50 |
110 |
125 |
60 |
90 |
PART II. NEWBORN EMERGENCIES
1.
1.
In all
situations, minimize heat loss:
A.
A.
Dry the newborn
well.
B.
B.
Increase
environmental temperature.
C.
C.
Fill two
sterile gloves with above-body-temperature (100-104o) water and
place next to newborn.
D.
D.
Use bunting,
swaddler or similar device if patient is stable.
2.
2.
Suction infant:
A.
A.
During
delivery, suction mouth and oropharynx first, then nose on perineum, before
delivery of shoulders.
B.