PEDIATRIC PROTOCOLS

Question 1

Pediatric Pain Management - Traumatic

Answer 1

1. ABC’s, stabilize as needed
2. Pulse oximetry/cardiac monitor/ETCO2
3. O2 as needed
4. IV access (IO if critical)
5. If obvious fracture, use fracture protocol
6. For acute traumatic injury with extreme pain:
   - Fentanyl 1 mcg/kg slow IVP (if no IV, 2 mcg/kg IN or IM), repeat at .5 mcg/kg increment or 1 mcg/kg for IN/IM 5-10 min apart
   - If allergic to Fentanyl, Morphine .05-.1 mg/kg IV/IO, max initial dose of 5 mg (If no IV access, give .1 mg/kg IM), repeated one time if needed at least 5 min apart
7. Ketamine is NOT to be given to pediatrics unless physician orders it
8. Pediatric drug calculation charts to confirm drug doses
9. Transport as indicated

Question 2

Pediatric CPAP

Answer 2

Indications: moderate-severe resp distress (accessory muscle use, tripod position) from pulmonary edema, obstructive pulmonary disease, etc.)

Contraindications: resp arrest, pneumothorax/chest trauma, tracheotomy, active GI bleed/vomiting, PT unable to follow commands, not able to fit CPAP mask, overdoses, AMS

1. ABCs, spO2, ETCO2, Cardiac monitor
2. Start with pressure of 5 cm H2O (increase in increments of 1 cm H2O as tolerated
3. Maximum CPAP for PTs < 12 yrs old is 10 cmH2O
4. Explain procedure
5. Ensure adequate O2 supply
6. Begin continuous vitals monitoring
7. Place device over nose and mouth and secure with straps
8. Start 2.0 - 5.0 cm H2O and titrate up to 10 cm H2O
9. Check for leaks
10. Coach PT to keep mask on and constantly reassess

Question 3

Pediatric Refusals

Answer 3

Avoid pediatric refusals if at all possible if:

• Apparent Life Threatening Event (ALTE)
• Anaphylaxis/Allergic Reaction/ Envenomation
• Near drowning
• AMS
• Seizure
• Possible Head Injuries
• Dyspnea / Breathing Difficulty
• Medication overdose or poisoning
• Any suspected abuse or neglect

To consider refusal, confirm the following:

• PT is AAO appropriately for age
• effective work of breathing
• hemodynamically stable
• PT is left in safe environment
• PT is in care of appropriate caregiver/guardian
• Obtain vital signs when possible prior to refusal

IF Parent, Guardian, Caregiver is refusing to allow transport AMA,

• Call on-duty supervisor immediately
• Avoid conflict when possible, involve law enforcement as needed

Question 4

Family Violence/Child Abuse

Answer 4

ASSESSMENT INDICATORS:

• Fear of household member
• Reluctance to respond when questioned
• Unusual isolation, unhealthy, unsafe living environment
• Poor personal hygiene, inappropriate clothing
• Conflicting accounts of the incident
• History inconsistent with injury or illness
• Indifferent or angry household member
• Household member refusing to permit transport
• Household member prevents patient from interacting openly or privately
• Concern about minor issues but not major ones
• Household with previous violence
• Unexplained delay in seeking treatment

Ask questions when alone with patient and time available:

1. Has anyone at home ever hurt you?
2. Has anyone at home ever touched you without your consent?
3. Has anyone threatened you?
4. Are you afraid of anyone at home?

S/S:

1. injury to soft tissue areas normally protected
2. Bruise or burn in shape of an object
3. Bite marks
4. Rib fracture in absence of major trauma
5. Multiple bruising in various stages of healing

Protocol:

1. PT care is #1 priority
2. Remove PT from situation and transport whenever possible
3. Summon police assistance as needed
4. If sexual assault follow sexual assault protocol
5. Obtain information from patient and caregiver
6. Do not judge
7. Report suspected abuse to hospital and make verbal and written report.
8. Call Child Abuse Hotline

Question 5

Death of Child/SIDS

Answer 5

1. Scene safety
2. Scene survey to assess environmental conditions/MOI
3. Form general impression
4. Standard precautions
5. Establish responsiveness
6. Assess airway/breathing. Confirm apnea
7. Assess circulation and perfusion
8. Cardiac monitoring. Confirm absent pulse
9. Decide on resuscitation measures:
   - No lividity or rigor, resuscitate. Perform step 11 during resuscitation
   - If lividity/rigor present, do not resuscitate
10. Supportive measures for parents/siblings:
    - explain resuscitation process, transport decision, further actions to be taken by hospital personnel/medical examiner
    - Reassure parents that there was nothing they could do to prevent death
    - Allow parents to see the child and say goodbye
    - Maintain a supportive, professional attitude no matter how parents react
    - Be responsive to parental requests and sensitive to ethnic and religious needs
11. Obtain PT history in nonjudgemental way:
    - recent sickness
    - what happened?
    - Who found child? Where?
    - What actions taken after child was discovered?
    - Has the child moved?
    - When was the child last seen before this occurred and by whom?
    - How did the child seem when last seen?
    - When was last feeding provided?
12. Reassess environment. Document findings:
    - Child’s location upon arrival
    - Description of objects located near the child upon arrival
    - Unusual environmental conditions (high temp in room, abnormal odors, other significant findings)
13. If parents interfere with treatment/attempt to alter scene
    - Remain supportive, sympathetic, professional
    - Avoid arguing with parents or exhibiting anger
    - Do not restrain parents or request that they be restrained unless they are threatening scene safety
14. Document the emergency call:
    - time of arrival
    - assessment findings, basis for resuscitation decision
    - time of resuscitation decision
    - time of arrival at hospital if resuscitation and transport were initiated
    - parental support measures provided if resuscitation was not initiated
    - history obtained
    - environmental conditions
    - time law enforcement personnel arrived on scene
    - time that scene responsibility was turned over to law enforcement personnel

Question 6

Jump START Pediatric Triage

Answer 6

1. IF able to walk THEN tag as GREEN (minor) and reevaluate in secondary triage
2. IF unable to walk, THEN evaluate breathing:
3. IF not breathing, THEN reposition airway
   
   • IF breathing starts after airway repositioned, tag as RED (immediate)
   • IF no breathing after repositioning and NO pulse, tag as BLACK (deceased)
   • IF not breathing after repositioning but pulse IS present, give 5 rescue breaths. IF still apneic, tag as BLACK. IF breathing resumes, tag as RED.
4. IF breathing, check RR:
   
   • IF RR < 15 or >45, tag as RED
5. IF RR is between 15-45, check pulse
   - if no palpable pulse, tag as RED
6. IF pulse is present, check AVPU:
   - IF P (inappropriate posturing) or U, tag as RED
   - IF A, V or P (with appropriate pain response), tag as YELLOW

Question 7

Pediatric V-Fib/Pulseless V-Tach

Answer 7

1. Focus on high quality CPR:
   - compressions 100-120
   - compress 1/3 - 1/2 depth of chest wall
   - adequate chest recoil
   - minimize interruptions
2. Defibrillate at 2 Joules/KG ASAP (can use child’s weight in pounds for Joules Setting)
3. Repeat Defib every 2 minutes as needed at 4 J/KG (2 x weight in lbs)
4. Resume CPR
5. Insert OPA and ventilate with BVM with high flow O2
6. If ventilations are adequate with OPA,
   - Establish IO access and administer .01 mg/kg
   Epinephrine (1:10,000), every 3-5 minutes until ROSC
   or termination of resuscitation
   - Administer Amiodarone 5 mg/kg IV/IO bolus, repeat in 3-5 minutes if PT still in shockable rhythm
   - If PT remains apneic, intubate
7. If ventilations inadequate with OPA, intubate and use in-line ETCO2 to monitor adequacy of ventilations then continue with access and med administration noted above
8. Transport to nearest facility
9. Continue CPR with pulse checks every 2 minutes (5 cycles)
10. Consider Magnesium Sulfate 25-50 mg/kg IV/IO (max of 2 grams) over 1-2 minutes if Torsades de Pointes is suspected or if PT is malnourished
11. Consider Narcan 0.1 mg/kg IV/IO or 0.2 mg/kg IM/IN

Consider irreversible causes (H's and T's)
Hypoxia
Hypovolemia
Hypothermia
Hydrogen Ion
Hypo/Hyperkalemia

Toxins
Trauma
Tension Pneumo
Tamponade
Thrombosis

Question 8

Pediatric Asystole/PEA

Answer 8

1. Focus on high quality CPR:
   - compressions 100-120
   - compress 1/3 - 1/2 depth of chest wall
   - adequate chest recoil
   - minimize interruptions
2. Insert OPA and ventilate with BVM with high flow O2
3. If ventilations are adequate with OPA,
   - Establish IO access and administer .01 mg/kg
   Epinephrine (1:10,000), every 3-5 minutes until ROSC
   or termination of resuscitation
   - Intubate and continue ventilations
4. If ventilations inadequate with OPA, intubate and use in-line ETCO2 to monitor adequacy of ventilations then continue with access and med administration noted above
5. Transport to nearest facility
6. Continue CPR with pulse checks every 2 minutes (5 cycles)
7. Waveform Capnography < 10 mmHg may indicate poor quality CPR or suggest consultation with on-line Medical Control to terminate resuscitation
8. Persistent asystole > 20 minutes may suggest consultation with on-line Medical Control to terminate resuscitation

Consider irreversible causes (H's and T's)
Hypoxia
Hypovolemia
Hypothermia
Hydrogen Ion
Hypo/Hyperkalemia

Toxins
Trauma
Tension Pneumo
Tamponade
Thrombosis

Question 9

Pediatric Symptomatic Bradycardia

Answer 9

1. ABC’s, stabilize as needed
2. spO2, cardiac monitor, waveform capnography
3. IV access
4. if PT stable, acquire 12 lead EKG every 10 minutes during transport
5. IF PT is UNSTABLE (critical hypotension, AMS, unresponsive, ischemic chest discomfort):
   - Initiate CPR if child with HR<60, infant with HR<80
   - IV access (IV preferred to IO)
   - Administer Epinephrine 0.01 mg/kg 1:10,000 IV or IO (or .1 mg/kg via ET tube if IV/IO not available)
   - If not response to Epi and O2, give Atropine 0.02mg/kg IV (minimum dose 0.1 mg, may repeat ONCE after 3-5 min)
   - Transport emergency traffic
6. IF PT is STABLE (symptomatic but not yet critical):
   - IV access (IV preferred to IO)
   - Administer Epinephrine 0.01 mg/kg 1:10,000 IV or IO (or .1 mg/kg via ET tube if IV/IO not available)
   - If not response to Epi and O2, give Atropine 0.02mg/kg IV (minimum dose 0.1 mg, may repeat ONCE after 3-5 min)
   - Transport emergency traffic
7. If organophosphate poisoning suspected as cause of bradycardia, give 0.05 mg/kg Atropine IV (usually 1-5 mg), may repeat in 5 - 15 minutes

Question 10

Pediatric Tachycardia - Wide Complex with Pulse (V-Tach)

Answer 10

1. ABC’s, stabilize as needed
2. spO2, cardiac monitor, waveform capnography
3. IV access
4. If stable, obtain 12 lead ECG to confirm V-Tach prior to treatment
5. If PT is UNSTABLE (AMS, mottled skin/cyanosis, hypotension less than 70 + (2 x age in years), HR>220 in infant < 1 yr old, HR>180 in child > 1 yr old)
   - If conscious/responsive to stimuli, give Versed 0.1 - 0.2 mg/kg IV/IO or 0.2 mg IM
   - Proceed to cardioversion: place defibrillator in synchronized mode and shock as follows until PT converts:
   - 0.5 J/kg, 1 J/kg, 2 J/kg (max 2 J/kg)
   - Reassess and treat accordingly
   - Transport without delay to nearest facility
6. If PT is STABLE (symptomatic but not critical):
   - IV/IO access as indicated
   - Amiodarone 5 mg/kg IV, max of 150 mg, slowly over 20 minutes (see Amiodarone drip instructions in formulary)
   - Reassess and treat accordingly
   - Transport without delay to nearest facility

Question 11

Pediatric Tachycardia - Narrow with Pulse

Answer 11

1. ABC’s, stabilize as needed
2. spO2, cardiac monitor, waveform capnography
3. IV access ASAP
4. Obtain 12 lead ECG
5. IF PT is UNSTABLE (HR>150 or hypotension, AMS, acute heart failure, ischemic chest pain)
   - if PT is responsive to pain, give Versed 0.1 - 0.2 mg/kg IV/IO, or 0.2 mg/kg IM
   - proceed to electrical cardioversion: place defibrillator in synchronized mode and shock in following sequence until patient converts: 0.5 J/kg, then 1 J/kg, then 2 J/kg (max of 2 J/kg)
6. IF PT is STABLE, refer to the following considerations:
   - HR > 180 for child, HR>220 for infant
   - R-R intervals regular
   - width of QRS less than or equal to 1 mm
   (1 small block)
   - any history suggesting compensatory tachycardia requiring fluids?
7. For STABLE SVT, attempt vagal maneuvers. If ineffective, start record EKG strip and administer Adenosine 0.1 mg/kg IV (max of 6 mg) with rapid saline flush. May repeat up to one time at 0.2 mg/kg, max of 12 mg.
8. Reassess and treat appropriately.
9. Transport without delay

Question 12

Pediatric Dyspnea - Upper Airway Obstruction

Answer 12

1. Begin BLS interventions ASAP while medic prepares ALS interventions as needed (Cric)
2. Is PT able to cough/speak/breathe? If YES, continue to monitor and transport as indicate.
3. If NO, then apply BLS skills:
   - for child > 1 yr, give abdominal thrusts with 1 hand while supporting from behind
   - for infant < 1 yr, hold baby with head angled down and alternate giving 5 back slaps and 5 chest thrusts until object is removed
   - IF PT becomes unresponsive, begin high quality CPR (look in mouth before giving breaths to see if object is present, but do not do blind finger sweeps)
4. Move to Needle Cricothyrotomy protocol as needed
5. Paramedic may attempt to visualize obstruction by laryngoscopy and attempt to remove with forceps
6. Continue to monitor and transport emergency

Question 13

Pediatric Dyspnea - Upper Airway Obstruction (CROUP OR EPIGLOTTITIS)

Answer 13

IF STRIDOR IS NOTED:

1. ABC’s, stabilize as needed
2. Pulse oximetry, cardiac monitor, ETCO2 as needed
3. O2 to keep sats > 90%
4. If stridor/croup or wheezing without history of asthma (i.e. possible RSV/bronchiolitis), give humidified O2 (3-4 mL of NS @ 8 LPM via nebulizer
5. If stridor/croup or wheezing without history of asthma (i.e. possible RSV/bronchiolitis), give nebulized Epinephrine 1:1000 (1 mg mixed in 3-4 mL of NS) for ages less than 5 years of age
6. If no change in PT condition, supplement ventilations with BVM and intubate as needed
7. Transport as indicated
8. Position respiratory patients upright when possible
9. If allergy exposure possible, go to anaphylaxis protocol

Question 14

Pediatric Dyspnea - Lower Airway Obstruction (Suspected Asthma, Wheezing Noted)

Answer 14

1. Assure ABC’s are intact, stabilize as needed
2. spO2, ETCO2, cardiac monitor
3. give O2 to maintain sats > 90%, assist with BVM as needed if respiratory failure (AMS) noted
4. If PT has Hx of Asthma with wheezing or poor air movement, give Albuterol 2.5 mg in 3 mL of NS via nebulizer (may interlink with BVM as needed)
5. IF PT is Alert, may consider CPAP, initiated at 2-5 cmH2O. Use appropriate mask size
6. If in extremis or possible allergen exposure, consider 0.01 mg/kg Epi 1:1000 IM in thigh
7. Obtain IV access (may give one nebulizer treatment prior to IV access)
8. Magnesium Sulfate - 20 mg/kg (maximum of 2 grams) to be mixed in a 100-150 mL bag of Normal Saline infused over 10 minutes if severe difficulty breathing (minimum weight of 10 kg). Amount of magnesium sulfate (packaged as 5 grams/10 mL) is 1 mL per 10 kg
9. Solu-medrol 1 mg/kg IV or IM (max of 125 mg)
10. Repeat Albuterol in 10 minutes only if IV has been established
    - in absence of IV, contact Medical Control for additional Albuterol treatments
11. If no change in PT condition, assist ventilations with a BVM and intubate as needed
12. Transport as indicated
13. If allergen exposure suspected, go to anaphylaxis protocol
14. Transport respiratory PT’s upright whenever possible

Question 15

Pediatric Shock (All Types)

Answer 15

1. Assess CAB’s
2. spO2, O2 via NRB, cardiac monitor
3. Position supine as tolerated
4. IV access
5. 20 mL/kg LR bolus:
   -may repeat PRN
   
   • check lung sounds after each bolus
   • Liver engorgement (RUQ swelling) may indicate too much fluid too fast
   • Use 10 gtt tubing for any bolus infusions
6. Attempt to determine etiology of shock with history and exam:
   Hypovolemic/Hemorrhagic: Continue IV fluid bolus, titrate to effect to maintain perfusion based on patient condition, maintain permissive hypotension
   Anaphylactic: Continue IV fluid bolus and go to anaphylaxis protocol
   Cardiogenic: Go to appropriate protocol based on rate and rhythm. If patient still in shock after rhythm/rate normalized, give Epi drip 0.1 - 1 mcg/kg/min, carefully titrated to effect
   Spinal/Neurogenic: IF possible multisystem trauma, withhold vasopressors and consult on-line physician. Begin Epi drip 0.1 mcg/kg/min, carefully titrated to effect
   Septic: Initiate fluids at 30 mL/kg bolus. If no effect, move to vasopressors - begin Epinephrine drip 0.1 mcg/kg/min, carefully titrated to effect, not to exceed 1 mcg/kg/min without Physician’s orders. Notify receiving facility of Sepsis Alert.
7. Transport Emergency

Question 16

Pediatric Anaphylaxis/Allergic Reaction

Answer 16

1. Assure ABC’s, stabilize as needed
2. spO2, O2 via NRB, cardiac monitor
3. Administer Epinephrine 1:1000 at 0.01 mg/kg IM (in thigh preferred), max dose of .3 mg. May repeat once after 15 minutes
4. Give Albuterol 2.5 mg in 3 mL of NS nebulized if wheezing/dyspnea present (use waveform capnography to assess for shark-fin waveform)
5. IV access
6. If hypotensive/inadequate tissue perfusion, administer NS bolus 20 mL/kg
7. Give antihistamines:
   - H1 Blocker: Benadryl (Diphenhydramine) 1 mg/kg, max dose of 25 mg IV/IM
   - H2 Blocker: Pepcid (Famotidine) 1 mg/kg, max dose of 20 mg
8. Administer Solumedrol, 1 mg/kg IV or IM
9. If patient still in extreme anaphylaxis (profound hypotension, dyspnea, stridor/wheezing) after all above treatments, consider Epinephrine drip 0.1 - 1 mcg/kg/min, titrate to effect OR consult online MD for repeat Epi IM doses.
10. Transport as indicated

Question 17

BRUE (Brief Resolved Unexplained Event)

Answer 17

Presentation:
An episode of a child < 2 or infant that is frightening to an observer characterized by one or more of the following:
- Apnea (central or obstructive)
- Skin color change: cyanosis, erythema, pallor, plethora (fluid overload)
- Marked change in muscle tone
- Choking or gagging not associated with feeding
- Witnessed foreign body obstruction

MOST PATIENTS WILL APPEAR STABLE AND WILL EXHIBIT A NORMAL PHYSICAL EXAM UPON ASSESSMENT BY RESPONDING FIELD PERSONNEL. HOWEVER, THE EVENT MAY BE A SIGN OF A SERIOUS UNDERLYING INJURY OR ILLNESS.

FURTHER EVALUATION BY MEDICAL PERSONNEL IS NEEDED AND IT IS ESSENTIAL TO TRANSPORT ALL PT’s WHO HAVE HAD AN APPARENT LIFE THREATENING EVENT (ALTE).

1. ABC’s, stabilize as needed
2. spO2, ETCO2 as indicated
3. Cardiac monitor is required
4. Assess CO levels if exposure is suspected
5. Perform initial assessment utilizing Pediatric Assessment Triangle
6. Obtain description of event (nature, duration, severity)
7. Obtain Medical History: chronic diseases, GERD, evidence of seizure activity, current/recent infections, recent trauma, medications (current or recent)
8. O2 and airway maintenance as needed
9. Be prepared to assist ventilations if this event is repeated during transport
10. Assess environment for possible abuse
11. IV/IO access as indicated, ONLY if fluids or meds required
12. Transport without delay
13. If parent/guardian refuses care or transport, contact supervisor and medical control and get Law Enforcement involved as needed

Question 18

Pediatric Burns

Answer 18

1. STOP THE BURNING:
   - Remove burning/smoldering clothing
   - Cool with cool (not cold) moist sterile towels if available
   - Burns > 10% body surface area should be covered with a dry sterile dressing/burn sheet to prevent heat loss
   - Remove dry chemicals by brushing off, liquid chemicals by flushing with large amounts of water unless contraindicated in ERG handbook
2. Assess ABC’s and stabilize as needed
3. O2 via NRB and control airway as indicated
4. Cardiac monitor as indicated
5. Obtain vascular access
6. Is PT hypotensive? (SBP<70 + age in years)
   - YES: LR bolus of 20 ml/kg
   - NO: See Pain management protocols
7. Continue to Pain management protocols, but use caution if PT hypotensive
8. Transport as indicated:
   - Critical burns requiring Vanderbilt:
   
   • Burns > 10% BSA partial thickness or worse
   • any burns involving airway or thoracic region
   • Burns affecting the genitalia or hands
9. Keep PT warm, use dry sterile dressing to prevent hypothermia and infection

Question 19

Pediatric Diabetic Emergency/Hypoglycemia

Answer 19

1. ABC’s, vital signs, spO2
2. O2 as indicated
3. Cardiac monitor
4. Glucose check
5. IF Glucose > 70;
   - transport as indicated
6. IF Glucose < 70:
   - IV access
   - Administer Dextrose as follows:
   
   • D50% 1-2 ml/kg 1 yr - 8 yr
   • D25% 2-4 ml/kg 6 months - 1 yr
   • D10% 2-4 ml/kg 0 - 6 months
     - max rate of infusion is 2 ml/kg/min
7. May repeat Dextrose once in 5-10 minutes if no change in mental status
8. if D10 or D25 not available, use D50:
   - D25: expel half of D50 syringe and draw up saline
   - D10: Expel 40 mL of D50 syringe and draw up 10 mL saline
9. May use IO after 2 failed IV attempts or after 90 seconds
10. If PT is awake, alert, cooperative and Glucose > 50, may use a 15 gram tube of oral glucose (may apply small amount to a pacifier)
11. Paramedics must be the attending provider with all Peds receiving medications.
12. If unable to give Dextrose and mental status is abnormal, transport emergency

Question 20

Pediatric Overdose (General/Medications)

Answer 20

1. ABC’s, stabilize as needed
2. spO2/Cardiac Monitor/Capnography as indicated
3. Suction as needed
4. O2 via NRB
5. Aggressive airway management with ventilation as needed
6. Intubate as needed
7. IV access, if hypotensive give 20 ml/kg bolus of LR or NS
8. Check blood glucose, if <70 or >400, go to hypo/hyperglycemia protocols
9. If PT seizing, go to seizure protocol
10. Obtain history:
    - Type and amount of poison
    - If possible, bring container with PT
    - Route of intake
    - Time of intake
    - History of drug or alcohol use
11. If PT agitated and possible stimulant overdose suspected, consider Versed 0.05 mg/kg IV/IO or 0.2 mg/kg IM. May repeat dose in 10 minutes and titrate to effect
12. IF narcotic overdose suspected (constricted pupils, hypotension, decreased respirations): Give Narcan 0.1 mg/kg IV/IO
13. IF beta blocker overdose suspected and PT is hypotensive and/or bradycardic: give Glucagon 0.5 mg if <25kg, 1 mg if >25 kg.
14. If tricyclic overdose suspected AND PT is unstable, (hypotensive, unresponsive), give Sodium Bicarb 1 meq/kg, using 4.2%
15. If calcium channel blocker overdose suspected, and PT is hypotensive and/or bradycardic: give Calcium Chloride 20 mg/kg mixed in 100 ml bag of NS and give over 10 minutes
16. When in doubt call Poison Control: 1-800-222-1222
17. Transport as indicated

Question 21

Poisoning/Chemical Exposure/HAZ-MAT/Nerve Agents

Answer 21

1. Personnel Safety Is the Highest Priority: Do not handle PT until they are decontaminated. All treatment should occur in the support zone after PT decon.
2. Suction as needed
3. O2 via NRB
4. Aggressive Airway Management with Ventilation as Needed
5. Intubate as needed
6. Obtain IV access: if any hypotension, give 20 ml/kg fluid bolus of NS
7. Check blood glucose, if <70 or >400, go to hypo/hyperglycemia protocols
8. If PT seizing, go to seizure protocol
9. Obtain history:
   - Type and amount of poison
   - If possible, bring container with PT
   - Route of intake
   - Time of intake
   - History of drug or alcohol use
10. If PT agitated and possible stimulant overdose suspected, consider Versed 0.05 mg/kg IV/IO or 0.2 mg/kg IM. May repeat dose in 10 minutes and titrate to effect
11. If inhaled poison, remove PT from source using appropriate PPA/SCBA preferred. Assess CO (Carbon Monoxide) Levels - Consult with / use Haz-Mat personnel when appropriate
12. If the chemical is a dry substance, brush off the chemical before irrigating
13. Irrigate with copious amounts of water and reassess for hypothermia
14. Transport as indicated.
15. When in doubt call Poison Control: 1-800-222-1222
16. For organophosphate/nerve agent poisoning: Administer Atropine 0.02 mg/kg IVP ever 5-15 min as needed to dry secretions.
17. Depending on Signs and Symptoms, administer Nerve Agent Antidote Kit:
    Mild - (Increased secretions, pinpoint pupils, general weakness): Decontamination, supportive care
    Moderate - (Mild secretions and respiratory distress): 1 Nerve agent antidote kit, may be repeated in 5 min, PRN
    Severe - (unconscious, convulsions, apnea): 3 Nerve agent antidote kits

Question 22

Treating Children from Homes with Meth Labs

Answer 22

1. Two main concerns: medical evaluation and decontamination
2. Determine whether child is Symptomatic or Asymptomatic:
   - Asymptomatic: No need for child to be evaluated at ER, unless medical evaluation is required for the child to be placed in an appropriate social setting, in which case only physical exam and history will be required at the ER
   - Symptomatic: Medical evaluation at ER should occur ASAP including physical exam and history
3. Decontamination: Change child’s clothes if they have residue on them, or have them sit on a disposable chuck, diaper or sheet. Children should shower at some point following removal regardless of symptom status, but decontamination not necessarily required on scene
4. Take the least traumatic approach possible
5. Do not take toys or other objects from the house with you
6. Poisons commonly found at meth labs: Solvents, ephedrine, acids, iodine, lye, phosphorous
7. Dangers of living in a home with a meth lab include:
   - injury or death from explosions/fire
   - chemical burn
   - poisoning from ingestions or absorption of chemicals
   - upper respiratory problems, headaches, rash from exposure to chemicals in the environment
   - long term effects (asthma, neurological problems)
   - malnutrition
   - emotional/physical neglect

Question 23

Seizures

Answer 23

Primary Assessment:

1. ABC’s
2. Protect PT from injury
3. Suction as needed
4. NPA as needed
5. Give O2 and assist ventilations PRN

Secondary Assessment:

1. Assess vital signs ASAP
2. Cardiac monitor as indicated
3. Pulse oximetry
4. Capnography (required if giving Versed)
5. Assess temperature as indicated

Is PT actively seizing?:
YES:
1. If IV established, immediately give Versed 0.1 mg/kg IV
2. If no IV, immediately give Versed 0.2 mg/kg IM
3. Then check glucose, and if < 70, follow hypoglycemia protocol
4. If seizures continue, may give Versed as follows:
IV: May repeat IVP Versed 2 times after initial dose, 2-3 minutes apart, 0.1 mg/kg IV/IO
IM: May repeat IM Versed 1 time after initial dose, 5 minutes after initial dose, 0.2 mg/kg IM
5. Transport as indicated

NO:

1. check glucose, and if < 70, follow hypoglycemia protocol
2. Transport as indicated

NOTE: Make sure PT is ventilating adequately and monitor ETCO2 for hypercapnia indicating hypoventilation (ETCO2>45). If hypoventilation suspected, ventilate with BVM.