nys doh emsc ppcc 1 medical emergencies lesson 5

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Medical Emergencies

Lesson 5

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This lesson will focus on assessment and management of non-traumatic causes of pediatric emergencies including:

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NON-TRAUMATIC Causes

• Hypoperfusion (shock)

• Cardiopulmonary failure

• Altered mental state• Seizures

• Fever• Poisoning/allergies• Diabetic

emergencies• Sudden Infant Death

Syndrome

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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.

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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.

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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.

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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.

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HeartIn 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.

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• 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.

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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.

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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.

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• 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.

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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.

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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.

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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.

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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.

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• 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.

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• 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.

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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.

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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.

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Cardiopulmonary Failure

Although children rarely die from sudden cardiac death, cardiopulmonary failure is a major cause of death in children.

Cardiopulmonary failure develops gradually.

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• 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.

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Cardiopulmonary Failure SignsObserve 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.

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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.

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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.

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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.

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CIRCULATION Check central pulse for presence and

rate.

If absent or rate less than 60/min with signs of hypoperfusion, begin chest compressions.

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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.

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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.

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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.

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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.

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Altered Mental StatusAltered 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

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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.”

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AMS Signs

Children with AMS may appear

Unusually agitated Combative Sleepy Difficult to rouse from sleep Totally unresponsive

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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

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Children can develop AMS due to:

Respiratory failure

Hypoperfusion

Head trauma

Low blood sugar

Seizures

Poisoning

Brain tumor

Infection with fever

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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

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Focused History for AMS

Findings include:• History of trauma or seizures• Poisoning• Infection with fever• Brain tumor• History of diabetes• Poor appetite

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Detailed Physical Exam - AMS

Look for:

• signs of head injury

• unequal pupils

• weakness or unequal strength in extremities

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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?

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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

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Treatment of AMS

Focus first on the airway:

• Provide positioning (tongue) and suctioning (secretions),prn

• Give high-concentration oxygen.

Provide assisted ventilation if necessary.

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Treatment of AMSHead 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.

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Treatment of AMS

• Provide oxygen and assist ventilations, if needed.

A child should respond to increased oxygenation by improved

responsiveness.

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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.

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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.

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SeizuresDuring a seizure, the child may have:

• altered mental status• behavioral changes• uncontrolled muscle movements

Loss of bowel or bladder control may occur.

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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.

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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.

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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.

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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.

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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.

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• EMTs should call for ALS backup if available.

• Provide initial interventions and rapid transport without delay.

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• If the child has uncontrolled muscle movements, support the head, maintain the airway.

• Protect from injury.

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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.

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• 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.

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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.

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Post Seizure TreatmentManage the airway:

• Provide gentle suctioning as needed.


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If the patient shows signs of respiratory

failure or arrest, begin assisted ventilation and initiate transport.

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CUPS Assessment of Pediatric Seizures

• Category

• Assessment

• Actions

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Critical

Assessment

Absent

• Airway

• Breathing

• Circulation

• AVPU= U

• Ongoing Seizure

Action

• Perform initial interventions and transport simultaneously; consider ALS backup if available.

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UnstableAssessment

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

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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

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StableAssessment

Normal• Airway• Breathing• Circulation• AVPU=A;

no history of seizure

Action• Perform initial

assessment and interventions; do focused history and detailed physical exam

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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

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• 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

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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

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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

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Head Injury and SeizuresSeizures 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.

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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.

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FeverDefinition: 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.

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Urgent Fever SignsConsider 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

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Fever and Age

More of a concern for young infants than for older children.

Any child with fever should be evaluated by a physician.

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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.

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Fever Assessment

Common findings include:

• Slightly increased respiratory rate• Slightly increased pulse rate

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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.

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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

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Heat Stroke Treatment• Remove child to cool environment.

• Assess and manage airway.

• Provide high concentration oxygen

• Assist ventilations, as needed.

• Transport immediately.

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Heat Stroke TreatmentCool 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.

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Fever TreatmentTreat 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)

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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

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Fever: To Cool or Not Too CoolFever helps the immune system fight infections.

Risks of cooling include hypothermia inadvertent production of additional

body heat by inducing shivering

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CUPS Assessment of Pediatric Fever

• Category

• Assessment

• Actions

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Critical

Assessment

Absent

• Airway

• Breathing

• Circulation

• AVPU=P or U

Actions• Perform initial

interventions and transport simultaneously; consider ALS backup if available

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Unstable

Assessment Compromised

• Airway• Breathing• Circulation• AVPU=V or P

Actions• Perform rapid initial

assessment and interventions; transport promptly; consider ALS backup if available

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Assessment Normal

• Airway• Breathing• Circulation• AVPU=A with

unusual agitation; history of fever with other risk factors


assessment and interventions; begin focused history and physical exam; initiate transport promptly if risk factors are found

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StableAssessment

Normal• Airway• Breathing• Circulation• AVPU=A

history of fever without other risk factors


assessment and interventions; complete focused history and detailed physical examination; transport

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PoisoningAccidental 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.

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Common Sources of Poisons

The most common substances involved in accidental poisonings are those found at home: cleaning agentsplants cosmeticsmedications

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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).

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Fatal PoisoningsSupplemental 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.

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Poisonings in Young Children

Most frequently curious toddlers swallow poison at home.

Unlocked cabinets invite exploration.

– Liquids that resemble juice

– Pills that resemble candies

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Adolescent PoisoningsAdolescents 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.

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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.

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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.

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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).

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The Substance 411As 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.

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Poison Control Center

If protocols allow, contact a PCC.

The PCC can quickly offer precise instructions on effective management of identified poisons.

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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

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Urgent First Impression

First Impression findings that indicate an urgent condition due to poisoning:• decreased responsiveness• sweating• drooling• increased breathing effort

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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

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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)

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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.

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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.

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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.

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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

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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.

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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.

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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.

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Treatment

• Treat based on assessment findings.

• Support ABC’s.

• Contact PCC, if allowed.

• Transport without delay.

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Assessment Findings for Swallowed Poisons Poison

Airway

Breathing

Circulation

Mental Status

Other Findings

Stimulant(cocaine, PCP, cold meds)sympathetic pattern

Normal

Fast

Fast pulse; high BP

Agitated, alert

Sweating; enlarged pupils

Narcotic(methadone, heroin)

Normal or closed

Slow, shallow

Slow pulse; low BP

Altered (V, P, or U)

Poor muscle tone; small pupils

Heart medication(digoxin, beta or calcium channel blocker)

Normal

Wheezing in asthmatics (beta blockers)

Slow pulse; low BP

Normal unless severe shock, then V, P, or U

Iron supplement

Normal

Normal

Fast pulse; poor perfusion; low BP

Normal unless severe shock, then V, P, or U

Vomiting; abdominal pain; abdominal tenderness

Hydrocarbon(kerosene, pine oil, gasoline)

Normal unless severe altered mental status

Respiratory distress if substance was aspirated

Normal

Altered (V, P, or U)

Vomiting

Pesticidecholinergic pattern

Respiratory distress; wheezing

Normal or poor perfusion

Normal or altered (V, P, or U)

Small pupils; vomiting; drooling; diarrhea; sweating; increased urination; seizures

Caustic substance

Normal

Respiratory distress; stridor

Normal

Normal

Drooling; mouth burns; vomiting; abdominal pain

Antidepressant

Normal

Normal

Possible shock

Altered(V, P, or U)

Seizures

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CUPS Assessment of Pediatric Poisonings

• Category

• Assessment

• Actions

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Critical

Assessment

Absent

• Airway

• Breathing

• Circulation

• Perform initial assessment; begin interventions and transport simultaneously; call for ALS backup if available

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Unstable

Assessment

Compromised

• Airway

• Breathing

• Circulation

• AVPU=V, P, or U

• Perform initial assessment and interventions; begin transport; call for ALS backup if available

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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

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StableAssessment

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

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Poison in Eyes - Treatment

• If poisoning involves eyes

– Flush with water for at least 20 minutes.

– Begin prior to transport and continue through transport.

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Poison on Skin -TreatmentIf 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.

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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.

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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.

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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.

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Activated Charcoal Contraindications

Contraindications include: A non-alert child. An uncooperative child. A swallowed hydrocarbon. Hydrocarbons including kerosene,

gasoline, and pine oil.

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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.

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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.

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Activated Charcoal Treatment Not Effective

Does not absorb:

• cyanide

• alcohols

• iron

• lithium

• most solvents

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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.

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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.

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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.

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Concerns of Ipecac TreatmentOnset 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.

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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.

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Concerns of Ipecac Treatment

• If the patient does not vomit, ipecac itself is a toxin.

• Always contact a PCC before using Ipecac.

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Ipecac DosageFor 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)

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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.

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Hypoglycemia means abnormally low blood

sugar• Characteristics

– Rapid onset

– Signs of hypoperfusion possible

– Altered mental status

• irritable

• agitated

• decreased responsiveness

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Low Blood Sugar Assessment

• First impression findings:• Irritability or agitation

• Trembling, weakness

• Pale skin, sweating

• Behavioral changes

• Decreased responsiveness

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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?

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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.

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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

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CUPS Assessment of Diabetic Emergencies

Category

Assessment

Actions

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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

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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

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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.

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Stable

Assessment• Normal initial

assessment with no signs of high or low blood sugar

Action

• Complete focused history and physical exam; transport.

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Assessment Findings in Diabetic Emergencies

Assessment

Low Blood Sugar

High Blood Sugar

First impression

Normal or decreased responsivenessNormal or pale skin; sweatingNormal or agitated mental status

Normal or decreased responsivenessFlushed, reddish skin

Breathing

Normal or shallow, rapid breathing

Normal or deep, rapid breathing, like sighingBreath odor fruity or like nail polish remover

Circulation

Fast pulse rateStrong peripheral pulsesNormal or slow capillary refill timeNormal or cold, pale, clammy skin

Normal or fast pulse rate Normal or weak peripheral pulsesNormal or slow capillary refill time; Warm or hot, flushed skin

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Focused history

Rapid onsetTook too much insulinAte less than usualIncreased exerciseHeadacheDizzinessSeizuresSweatingNausea

Slow onsetDid not take insulinAte more than usualRecent illness or infectionFrequent urinationThirsty, drinking a lotTirednessWeight loss

Vomiting

Physical exam

Shaky, jittery hand and arm movements

Abdominal painSigns of dehydration

Actions Give high-concentration oxygen. Give oral glucose IF patient can swallow normally; if not, call for ALS backup; transport for further evaluation

Give high-concentration oxygen; transport promptly; call for ALS backup if child has poor perfusion and altered mental status

Assessment Findings in Diabetic Emergencies

Assessment

Low Blood Sugar

High Blood Sugar

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Low Blood Sugar TreatmentIf 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.

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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.

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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.

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When In Doubt, Give GlucoseWhen 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.

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Assessment and Managementof 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.

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High Blood Sugar Assessment

First impression findings:

• decreased responsiveness

• slow speech

• flushed skin

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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

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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

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Look for signs of dehydration:

• sunken eyes

• lack of tears

• skin that remains "tented" after EMTs gently pinch a fold

• abdominal pain

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Special Considerations

High Blood Sugar Critical patient has:

• signs of high blood sugar and• altered mental status and • hypoperfusion

and needs• Immediate transport

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High Blood Sugar Treatment

For a non-urgent patient:


• Treat for signs of hypoperfusion.

• Assess for dehydration when transport is underway.

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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.

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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.

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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.

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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.

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SIDS AssessmentRapid First Impression findings:

• absence of movement• no chest rise• pale or bluish-grey skin color

Initial assessment findings confirm:• unresponsiveness• apnea• pulselessness

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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

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Detailed Physical ExamOther 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.

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Controversies in Resuscitating SIDS

VictimsArguments 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.

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Controversies in Resuscitating SIDS

VictimsArguments 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.

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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.

nys doh emsc ppcc 1 medical emergencies lesson 5

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