Taking Control of the Pediatric EMS Scene

Lou Romig MD, FAAP, FACEP Never let them see you sweat Taking Control of the Pediatric EMS Call Romig’s Rule of Vital Sign Comparisons Romig’s Rules It’s hardly ever good when the rescuer’s pulse or respiratory rate is greater than that of their pediatric patient. Goals Tell you the secrets of how many good “pedi people” control tough kid calls (even though they might not realize they’re doing it). To turn “How do they do that?” into “I can do that!” using the PREP approach The 3 P’s of Control Preparation Practice Perception The 3 P’s of Control Preparation Practice Perception P R Physiology Responses E P Equipment Protocols Using PREP, half of your scene control can be done before you even arrive. How’d you like to be caught unprepared for this? PREP before arrival: Physiology Given the available dispatch information on a pediatric call, what should you anticipate? PREP before arrival: Physiology What is the anticipated age of the child? How does their age influence: Physiology Physiologic weaknesses and strengths Yes, EMTs can do this too! PREP before arrival: Physiology What is the reported mechanism of injury (MOI) or chief complaint? What are the most likely injuries based on the age/size and MOI? What are the most common illnesses that present with this complaint? What interventions are the child most likely to need on scene/in transit? PREP before arrival: Rescuer Responses Given the age and MOI/chief complaint: What kind of emotional reactions can you expect within yourself before, during and after the call? How about in your crewmates? PREP before arrival: Rescuer Responses Identify crew strengths and weaknesses Who among the crew is most confident with children? Should usual task assignments be modified for this call? High stress/critical calls are not the time to practice weak skills PREP before arrival: Rescuer Responses The Huddle: Reinforce need for personal control if call is likely to be emotionally-charged. Reinforce ability to relax if call is not emergent. Reinforce the need to be able to change gears if the unexpected occurs. PREP before arrival: Non-rescuer Responses The Patient Assuming normal brain development for age, how is the patient likely to react to you and the situation? “I would worry if …” PREP before arrival: Non-rescuer Responses Family/caregivers Child with chronic illness? Set-up for guilt reactions? Set-up for aggression? What may be the expectations of the caregivers? PREP before arrival: Non-rescuer Responses Designate a crew member with good communications skills to be the liaison with the family/caregivers. PREP before arrival: Non-rescuer Responses Bystanders Will the emotional environment of the scene be stable and safe? Are the bystanders likely to become a distraction? What may be the expectations of the bystanders? How might they react if you don’t do what they expect? PREP before arrival: Equipment Based upon your analysis of the expected physiology: What kinds of gear are you most likely to need? What sizes? Where is the equipment? What goes with you to the patient’s side? PREP before arrival: Equipment Use your memory aids!!!! PREP before arrival: Protocols Based upon your analysis of the expected physiology: What protocols/drugs are you most likely to use? Where are your drugs? Do they need special preparation? Based on your protocols, what are your alternatives for patient disposition? Might there be consent issues? PREPare for the worst. Hope for the best. Do practice runs as drills! PREParation: After Arrival Your first clue upon arrival: The Waver PREP after arrival Scene size-up: Safety Mechanism of injury or illness “OBTWs” (Oh-by-the-ways) Completely different complaint Additional patients Emotional atmosphere Need to change the game plan? PREP after arrival: Physiology Should guide most actions during the rest of the call Rapidly determine: How sick is the child? How quickly do you need to intervene? Physiology determines Response Intense goal-oriented rapid action focusing on the patient, with tight emotional control by crew OR More relaxed family-centered approach with increased interaction between crew, patient and others on scene Physiology determines Equipment and Protocols What equipment is needed now? What might be needed later? What kinds of treatment are indicated? Where should treatment take place? Balance speed and efficiency Determine patient disposition. Initiate additional notifications and responses if needed. How sick? How quick? The Pediatric Assessment Triangle (PAT) From the AAP’s Pediatric Education for Prehospital Professionals (PEPP) course. www.PEPPsite.com The PAT Can be considered a “patient size-up” Is a pre-primary survey Can be done in seconds Often best done before getting close to the pediatric patient Results in assignment of the patient into a “physiologic cubbyhole” Can be done whenever you’re in the weeds! The PAT General Appearance Work of Breathing Circulation to the Skin General Appearance Assesses higher brain function by looking mostly at interaction with the environment Higher brain function depends on good oxygenation, ventilation and perfusion to the brain Don’t be fooled by chronic features or dramatic physical findings that don’t affect function General Appearance T Tone I Interactiveness C Consolability L Look/gaze S Speech/cry Good general appearance Normal to well-compensated physiology “Not sick” “Not quick” Poor general appearance Inadequate physiologic compensation “Sick!” “Quick!” Work of Breathing More informative in children than absolute respiratory rate Reflects resistance in small air passages, dependence on diaphragm and weakness of chest wall muscles Increased WOB (including tachypnea) is a compensatory mechanism Decreased WOB (poor effort/slow breathing) means decompensation Circulation to the Skin Decreased circulation to the skin is an early sign of compensation for a circulatory problem in kids (not always true in adults) Cap refill is a good measure in kids, especially when done in serial fashion in a normothermic environment Putting the PAT together Respiratory A Good B C Physiologic Sick? Cubbyhole Respiratory Distress Poor Respiratory Failure Circulatory A Good B C Physiologic Cubbyhole Nonspecific Peripheral Vasoconstriction Sick? Poor Shock Central Nervous System A Poor B C Physiologic Cubbyhole Sick? CNS Good Good Dysfunction Seizure/Postictal Intoxication/Drug effect Metabolic Head injury Meningitis/Encephalitis Chronic disability The Last Chance A B C Physiologic Cubbyhole Cardiopulmonary Failure! Sick? PREP after Arrival: Physiology PAT = How sick? How quick? Primary Survey (Initial Assessment) = More detailed assessment of physiologic disruption Secondary Survey (Focused Assessment = More detailed assessment of anatomic disruption PREP after Arrival: Responses PAT = Quick/patient focused or Relaxed/Family focused Use the PAT to show the family that the patient is doing well PREP after Arrival: Equipment/Protocols Major or “minor” but “sick” trauma patients Minimal stabilization on scene Rapid disposition decisions PREP after Arrival: Equipment/Protocols Medical patients who are “not sick” Initial assessment and management on scene (unless unsafe) No rush to separate child and family PREP after Arrival: Equipment/Protocols “Sick” medical patients Consider what is the most favorable environment in which to provide initial assessment and intervention. Rapid disposition decision. Emergency Departments rarely have anything more to offer a sick child in the first minutes than a well-equipped and well-trained ALS EMS crew! And sometimes they have less… Applying the PREP Approach PREP A mislabeled prescription has caused a mother to give her 4 month old daughter five times the normal dose of a cold medicine – three times! The mother tells the dispatcher that the baby’s heart feels like it’s racing and the child is acting “nervous”. Before Arrival Physiology: Cold meds usually stimulate the sympathetic system Kids tolerate sympathetic stimulation well Seizures can occur with marked toxicity Has mom called Poison Control yet? Before Arrival Responses: Mom’s liable to be frantic and feeling very guilty. Crew members who are not comfortable with infants will not be very comfortable with this patient. Before Arrival Equipment: Be ready to monitor basic vital signs. Take in suction. Mom may have been instructed to make child vomit. Seizures are a possibility so anticipate them. Before Arrival Protocols Contact Poison Control? Administer charcoal? Seizure management Upon Arrival Mom is anxious but controlled Rx was mislabeled. Mom gave three doses of an antihistamine/decongestant over 18 hrs, each one 5 times the usual dose. Child has been “hyperactive” and unable to sleep. This is what you see … PREP on scene Physiology Good general appearance No increased WOB Good skin circulation PAT says NOT SICK HR 170’s, RR 30’s, BP 114/73 Exam normal except the baby is a little cranky on and off and moves around a lot PREP on scene Responses Crew can relax and take their time Try to reassure mom Keep child with mom as much as possible. PREP on scene Equipment Basic monitoring during transport Remain prepared for seizure PREP on scene Protocols Consider calling Poison Control on scene Consider charcoal IV probably not needed Calculate anticonvulsant dose in case it’s needed. Be prepared to give rectally Transport to pediatric-capable facility with mother (ALS) You respond to a 6 month old with vomiting and diarrhea for a week. The child doesn’t want to drink. Mom states “He looks at me but he doesn’t seem to see me!” Before Arrival Physiology: Child’s been sick for a while Dehydration most likely cause of any serious problems. Worst case is shock. Consider low blood glucose. “Not seeing me” doesn’t sound good. Before Arrival Responses: Mom’s liable to be alarmed or hysterical as well as exhausted. This may be a really sick kid who needs vascular access and fluids badly. Before Arrival Equipment: Be ready to monitor vital signs manually or electronically. Be prepared to keep infant warm. IV equipment (including IO), glucometer, oxygen, pulse ox Stretcher Before Arrival Protocols Vascular access Shock Hypoglycemia May need critical care facility Where to start interventions? This is what you see and hear… PREP on scene Physiology POOR general appearance Retracting but good effort, RR 60 HR 200, CR 4 sec, skin pale and cool in distal extremities PAT says this child is SICK and you need to move QUICKLY! This is early cardiopulmonary failure. PREP on scene Physiology Further exam confirms clinical impression of shock. BP 78/58. Oxygen saturation not obtainable on fingers/toes Rapid blood sugar is 83 PREP on scene Responses This is the time to focus energies and defer emotions. Most capable team member goes for IV access. Don’t let the rest of the call get lost in the search for an IV. Stay calm to keep mom calm. PREP on scene Equipment You need all the stuff you thought you might need and were prepared with. PREP on scene Protocols Shock. Probably will need rapid, repeated boluses. Monitor HR, skin signs and general appearance as indicators of improvement. Sugar is OK for now PREP on scene Protocols The house may be the best place to secure vascular access and begin fluid replacement. If BLS, need fastest possible access to ALS by call-in, intercept or transport to closest pediatric capable facility. Needs pediatric critical care facility. The 3 P’s of Control Preparation Practice Perception P R Physiology Responses E P Equipment Protocols Summary Use dispatch information to PREPare before you make patient contact. Use the PREP approach to analyze and control the scene once you get there. Summary The PAT is the anchor tool for the PREP approach The Boy Scouts have it right… “Always be PREPared!” Questions or Comments? Lou Romig Louromig@bellsouth.net JEMS, May 2001 www.jumpstarttriage.com Thank you!