A.
General Principles:
1. Do not hyperextend the neck of newborns and infants.
2. Do not use a positive pressure valve on patients less than 6 years of age.
3.
If epiglottitis is a possibility, do not attempt to visualize the
throat or pharynx. However, if a patient with an airway obstruction has a
respiratory or cardiac arrest, the airway may be visualized with a laryngoscope
to rule out a foreign body airway obstruction.
B. Airway Devices:
1. Consider an oropharyngeal airway of appropriate size on all unconscious pediatric patients for initial airway maintenance.
2. Esophageal Obturator airways (EOA), Laryngeal Mask airways (LMA) and Combitubes may be used on adolescents of adult size, at least five feet in height. The decision should be based on size, not age. The EOA is to be inserted only in apneic patients unless ordered verbally by the medical control physician or if authorized by the service medical director. The EOA should be used with caution in patients with trauma causing bleeding into the pharynx.
3.
Endotracheal intubation is not a required procedure but is sanctioned by
the Willmar Ambulance Service for various categories of patients. Endotracheal
intubation is to be performed only by paramedics trained and authorized to
intubate and only for those types of patients specified by the ALS Medical
Director. Endotracheal intubation shall be performed so as to be consistent
with other protocols in this document. After endotracheal intubation, tube
position must be confirmed using both end tidal carbon dioxide detection and the
endotracheal tube locator device.
a.
An end-tidal carbon dioxide (CO2) detector should be used to
accomplish confirmation of endotracheal tube placement and is most reliable in
patients with spontaneous circulation. This device may not be able to detect CO2
in cardiac arrest patients due to extremely low blood flow to the lungs.
b. The endotracheal tube locator device utilizes anatomical differences between the trachea and the esophagus to verify proper endotracheal tube placement and is to be used in conjunction with an end-tidal CO2 detector device to confirm tube placement.
C.
Pulse oximetry: A pulse oximetermay
be used (but is not required) for any patient with suspected hypoxemia, in
respiratory distress, or whenever sedating medications are administered.
Obtaining a normal pulse oximetry reading does not negate the need for oxygen
therapy as specified in these protocols.
Pediatric oxygen therapy should be administered in accordance with the following guidelines:
Standing Orders
A. High flow O2, if agitated, use high flow blow-by O2.
B. Do not hyperextend the neck in newborns and infants.
C. Consider oral airway of appropriate size for all unconscious patients.
D. Ventilate using oxygen with pediatric mask or pocket mask when ventilation must be assisted.
E. Do not use a positive pressure valve on patients less than 6 years of age.
F. If epiglottitis is a possibility, do not attempt to visualize the throat or pharynx. However, if a patient with an airway obstruction has a respiratory or cardiac arrest, the airway may be visualized with a laryngoscope to rule out a foreign body.
G. Endotracheal intubation as per service medical director.
Pediatric intravenous therapy should be administered in accordance with the following guidelines:
A. For trauma and shockof other etiology, start IV's en route.
B. Hang IV fluid (versus saline lock) when the administration of multiple IV medications or the need for fluid volume replacement is anticipated.
C. Use IV infusion sets for non-traumatic emergencies and for trauma or hypotensive patients.
D. If IV access cannot be established at the scene in two attempts for patients with non-traumatic problems, begin transport to the hospital. There should be no delay at the scene for IV attempts on children with trauma or in shock - these IV's should be started during transport.
E. Intraosseous infusion may be considered in children under the age of seven years in critical condition when IV access is unobtainable.
A. Medications that may be administered via the tracheobronchial tree by injection into an endotracheal tube:
1. Narcan
2. Atropine
3. Epinephrine
4.
Lidocaine
B. This drug administration route should only be used in cardiac arrest whenever:
1. an endotracheal tube has been placed,
2. venous access is significantly delayed, or
3.
three attempts at venous access have failed.
C. Drugs administered via the endotracheal tube should be instilled as deeply as possible into the tracheobronchial tree using a catheter inserted beyond the distal tip of the ET tube. Drugs may be administered full strength or diluted in 1-2 ml of normal saline.
To provide relief of pain when indicated for pediatric
patients. This protocol is NOT to be used in cases where the patient:
· is hypotensive (i.e. clinical signs of poor perfusion, capillary refill >2 seconds),
· complains of abdominal pain,
· has sustained a head injury,
· has pain determined to be cardiac in origin,
·
is in active labor
Standing Orders
1. Assess pain on 0-5 scale if possible.
2. Inform patient and/or guardians that pain is an important diagnostic parameter and the goal of this protocol is to relieve suffering, not totally eliminate pain.
3. Administer MorphineSulfate x 1 at 0.1 mg/kg IV/IM/SQ (up to maximum dose of 5 mg).
Note: Refer to pediatric reference e.g., Broselow Tape, if assistance is needed with pediatric vital signs or drug dosage calculations.
4. Monitor vital signs. If respiratory depression or hypotension occurs after administration of Morphine Sulfate , ventilate patient as necessary and administer Narcan 0.01 mg/kg IV (up to a maximum dose of 0.4 mg). Notify a medical control physician.
5. Contact a medical control physician for orders if:
a. patient is hypotensive,
b. head injured,
c. complains of abdominal pain,
d. further pain medication is required.
After Obtaining Verbal Orders
6. Consider initial or additional pain medication as appropriate.