EMS Protocol of the Week: Pediatric Respiratory Distress/Failure

Hey all,

This week's EMS protocol is on pediatric respiratory distress/failure. The thought of a pediatric patient experiencing respiratory distress is enough to cause me to go into respiratory distress... but let's discuss how our pre-hospital colleagues initiate care for these patients.

Remember that respiratory distress and respiratory failure fall on a spectrum:

Respiratory distress is characterized by:

- Increased respiratory effort/WOB

- ABSENCE of central cyanosis symptoms: anxiety, nasal flaring, increased respiratory rate, accessory muscle use (ie retractions), lethargy, etc.)

Respiratory failure is characterized by:

- Presence of central cyanosis symptoms: agitation, lethargy, severe dyspnea, labored breathing, head bobbing, grunting, severe retractions, severe bradypnea, etc.

- Hypoxia and/or hypercapnia

The prehospital approach to these kiddos corresponds to a progression of care based on the level of training present. CFRs start with ABCs and monitoring vital signs. If needed, these providers can implement airway adjuncts and administer supplemental O2 at appropriate levels for either respiratory distress or failure. At this level of training, CFRs can then address potential overdose. BLS crews will pick up from here and can additionally request ALS backup and transport the patient. If the on-scene team is ALS trained, they can perform advanced airway management if unable to continually bag ventilate the patient. From here, ALS providers will start cardiac monitoring and establish IV/IO access as necessary while en route. They can even assess and treat for a tension pneumothorax (which may develop after resuscitation has begun!).

If a known cause is identified/suspected such as aspirated foreign body or anaphylaxis, treatment via those protocols will be used. If persistence of respiratory distress/failure, then providers will default back to this protocol.

There is not a lot to be aware of from an OLMC (shameless plug for our e-mailed survey 😊) standpoint other than awareness of the level of care the on-scene providers are able to provide - this will give the receiving team a better idea of what to expect when the patient is rolled in and instill the appropriate level of fear.

See the attached protocol and check out https://nycremsco.org/ for more!

Best,
Zachary Kim

PGY-2 Emergency Medicine

EMS Protocol of the Week - Dysrhythmia (Pediatric)



Calling this week's protocol the one for pediatric dysrhythmias is a bit of a misnomer, as severe bradycardia in kids is managed elsewhere. When it comes to tachydysrhythmias, however, this protocol has you covered! If BLS is on scene with one of these kids, they’ll request ALS backup, but they are instructed not to allow this to delay transport. So don’t be surprised if EMTs arrive with a tachycardic kid with minimal interventions; just realize that our ED may have been closer than the closest paramedics. If ALS is on scene, it’s all about recognition and identification of the dysrhythmia. Stable SVT are treated with vagal maneuvers, with adenosine available as a Medical Control Option as backup after calling OLMC. Cases of unstable SVT and VT with a pulse will always come through OLMC, at which point you and the paramedics can discuss synchronized cardioversion. Remember to utilize weight-based energy settings, and consider sedation options for your conscious patients.

It may come as a…shock…to you all, but there are some subtle differences here between this protocol and its adult counterpart, so be sure to…slow down…and read through it, carefully? Idk, I’m writing less of these now, I’m rusty.

www.nycremsco.org and the protocol binder for more.

Dave

EMS Protocol of the WEEK!! CO poisoning

Keeping the theme of last weeks cyanide poisoning/smoke inhalation injuries… the EMS protocol of the week is on carbon monoxide poisoning!

What is CO?

A colorless, odorless, tasteless gas produced by burning gasoline, wood, propane, charcoal, or fuels.

Common causes of CO poisoning?

Appliances such as furnaces, heaters, or stoves burning in an enclosed space, as well as smoke inhalation during a fire.

Symptoms?

Headache, dizziness, nausea/vomiting, AMS, weakness.

Initial management is the same as cyanide poisoning (and tbh most other things)... ABCs, supplemental O2, cardiac/vital sign monitoring, IV access.

Treatment

Transport to hyperbaric center if:

-      SpCO > 25% and asymptomatic

-      High index of suspicion of CO poisoning AND headache, AMS, or syncope

-    Pregnant and SpCO > 15%

Key points:

-      Also consider cyanide poisoning if exposed to smoke

-      SpO2 from pulse ox is not accurate and can be falsely elevated

-    Continue giving high concentration O2 even if signs/symptoms have resolved 

See attached protocol; check out https://nycremsco.org/ for more!

Jennifer Wolin, MD

Emergency Medicine PGY-2 Resident Physician

Maimonides Medical Center