2008 PEDIATRIC PREHOSPITAL PROTOCOLS

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  Pediatric Prehospital Protocols (1591K)

 
Position Statement - Pediatric Prehospital Protocols

Several key prehospital elements in local Emergency Medical Services systems facilitate the delivery of quality field care to children:

• Appropriate education of prehospital providers in the assessment and treatment of acute pediatric illness and injury.

• Standardized and appropriate equipment and medications for the delivery of care to the pediatric population.

• Uniform pediatric-specific treatment protocols.

Prehospital treatment protocols for adult patients are frequently used in EMS systems.  Within the State of Illinois there exists considerable variation in treatment protocols based upon local EMT scope of practice, availability of regional resources and differences in medical opinion regarding the delivery of Emergency Medical Responder (EMR), BLS, ILS and ALS care in the prehospital environment.  In 1997, the Emergency Medical Services and Trauma Center Code, adopted by the Illinois Department of Public Health, was revised to mandate pediatric specific treatment protocols.   

Illinois EMSC strongly endorses the concept of standardized prehospital patient care for the pediatric population at the Emergency Medical Responder (EMR), BLS, ILS, and ALS levels.  While most BLS and Emergency Medical Responder field interventions are considered relatively uncomplicated and straightforward, guidelines improve the continuity, quality and consistency of patient care.

Treatment Protocol Guidelines:

1. Within the context of all federally funded EMSC projects, the pediatric population is defined as inclusive of all patients up to the age of 21 years.  In this document, pediatric patients are defined as age 15 years and younger, consistent with the Emergency Medical Services and Trauma Center Code adopted by the Illinois Department of Public Health.  Other terms commonly applied to the pediatric population include: "newly born" (under 24 hours), "neonates" (1-28 days) and "infant" (1-12 months).

2. Emergency Medical Responder, BLS, ILS, and ALS interventions should be clearly identified within each protocol.

3. Special considerations for pediatric care should be identified within each protocol where appropriate.

4. Drug dosages should be weight-based and given per kilogram.  Inconsistencies exist within the prehospital environment secondary to the relatively low volume and exposure to pediatric patients resulting in inaccuracies and possible under- or over-treatment.  Therefore, a validated "length-based" or color coded resuscitation tool is highly recommended.  Have available precalculated drug dosing forms based on drug concentrations carried within the EMS system.  In addition, standardized weight charts should be readily available to the prehospital provider identifying age adjusted vital sign parameters and appropriate sizing of endotracheal tubes.

5. Intravenous fluids administered in the prehospital environment should be a balanced crystalloid solution.

6. A triage mechanism for the rapid and appropriate treatment and transport of "critical patients"
   (i.e., multiple trauma) to the "most" appropriate facility must be identified.

7. The Pediatric Glasgow Coma Scale should be utilized by ALS, ILS, and BLS personnel.
   

Protocol Recommendations:

Protocols for the treatment and transport of the critically ill and/or injured child should exist in a "freestanding" format isolated from adult protocols or clearly identified in a general protocol, i.e., using the EMSC teddy bear logo to highlight pediatric considerations.

The following areas have been identified as requiring specific treatment protocols:

1. PEDIATRIC INITIAL ASSESSMENT - A foundation for all pediatric patient interactions, this protocol should reinforce the need for consistent, methodical patient assessment.  The protocol should reinforce the following:

• Importance of rapid BLS interventions (i.e., CPR) specifically airway support.

• Age appropriate signs and symptoms of pediatric respiratory distress.

• Age appropriate airway interventions including the use of "blow-by" oxygen administration.

• Indicators of adequate ventilation and perfusion.

• Age appropriate immobilization of the pediatric trauma patient.

• Recognition of and monitoring for imminent life-threats.

• Unique assessment considerations and emergent care requirements of children with special health care needs (CSHCN), including those who are technologically dependent. Emphasize the appropriate inclusion of parents/primary caregivers.

2. INITIAL MEDICAL CARE/ASSESSMENT – Address the initial assessment and medical care provided to the pediatric patient, including an assessment of scene safety and ensuring body substance isolation.  Commonly referred to as "routine medical care" in adult protocols.

3. NEONATAL RESUSCITATION - Must incorporate the specific heart rate parameters and requisite interventions according to the American Heart Association recommendations.

4. PEDIATRIC AED – Treatment must be in accordance with the Department approved Pediatric AED protocol and in accordance with American Heart Association guidelines.  AED’s can be used in children age 1-8 years.  Use of pediatric pads and cables are preferable; however adult pads can be used in an anterior/posterior application.

5. PEDIATRIC ALLERGIC REACTION/ANAPHYLAXIS – Pay special attention to the differentiation between local reaction (hives), respiratory distress and cardio-respiratory compromise. 

6. PEDIATRIC ALTERED LEVEL OF CONSCIOUSNESS - Emphasize the importance of recognizing etiology, aggressive airway maintenance, glucose monitoring and naloxone administration.

7. PEDIATRIC BRADYCARDIA - Treatment in accordance with the current American Heart Association recommendations.

8. PEDIATRIC BURNS - Special emphasis on the pediatric "rule of nines" for burn size estimation, aggressive airway management and triage to the appropriate facility.  Differentiation should be made between thermal, chemical and electrical injuries.

9. PEDIATRIC ENVIRONMENTAL HYPERTHERMIA – Emphasize appropriate assessment, cooling techniques and fluid replacement considerations of children presenting with environmental hyperthermia.

10. PEDIATRIC HYPOTHERMIA - Emphasize the pediatric population at high risk for hypothermia: neonates and infants.  Address aggressive airway management, warming techniques and recognition of frostbite injury.  Interventions for arrhythmias in accordance with the American Heart Association recommendations.

11. PEDIATRIC NEAR DROWNING - Emphasize aggressive airway management and the potential for associated cervical spine injury and hypothermia.

12. PEDIATRIC NERVE AGENT ANTIDOTE GUIDELINE – Define specific antidote dosing based on mild, moderate or severe exposure and patient age/weight.

13. PEDIATRIC PULSELESS ARREST – Treatment modalities/algorithms should be consistent with the current guidelines set forth by the current American Heart Association “Pediatric Advanced Life Support” algorithms.  The use of intraosseous access should be taught to all ALS providers.

14. PEDIATRIC RESPIRATORY ARREST - Treatment must be in accordance with the current American Heart Association "Pediatric Advanced Life Support" guidelines.

15. PEDIATRIC RESPIRATORY DISTRESS - Differentiation should be made between "upper airway obstruction" (i.e., croup, epiglottitis and foreign body) and lower airway disease (i.e., asthma, bronchiolitis, pneumonia).  The potential for invasive airway interventions must also be identified.

16. PEDIATRIC RESPIRATORY DISTRESS WITH A TRACHEOSTOMY TUBE – Differentiate between an obstructed and patent tracheostomy tube.  Identify appropriate assessment and management of the child presenting with respiratory distress with a tracheostomy tube. 

17. PEDIATRIC RESPIRATORY DISTRESS WITH A VENTILATOR – Address steps in managing a pediatric patient that requires ventilator support.  Emphasize to utilize the parents, caregivers and home health nurses as medical resources, and arrange to bring the ventilator to the hospital.

18. PEDIATRIC SEIZURES - Must include the identification of rapid blood glucose monitoring in the field, considerations for febrile seizures and administration of rectal benzodiazepines.

19. PEDIATRIC SHOCK - Differentiation should be made between "hypovolemic" (dehydration, hemorrhagic), cardiogenic and "distributive" (sepsis).

20. PEDIATRIC TACHYCARDIA - Interventions for both wide and narrow complex tachycardias must be in accordance with the American Heart Association recommendations.

21. PEDIATRIC TOXIC EXPOSURES/INGESTIONS - Incorporate accidental /environmental toxic exposure or ingestion events commonly encountered in the pediatric population.

22. PEDIATRIC TRAUMA - Emphasis should be made on mechanism of injury, limited on-scene time, aggressive airway maintenance, field triage to the appropriate facility and addressing the unique needs of the head-injured child.  Additional information or an addendum specific to initial assessment and management of head trauma should also be included.

23. SUSPECTED CHILD ABUSE AND NEGLECT - Special emphasis should be made on careful documentation of physical findings, discrepancy between history of injury and physical findings, interaction between child and parent/caregiver, and characteristics of the environment.  Discuss the prehospital provider's responsibility as a mandated reporter, and to report suspicions to the emergency room staff.  Include directions for responding to parent/caregiver refusal to allow transport.