Pediatric PrePlans:

1. Pediatric PrePlans: Avoiding Disasters with Critical Care Kids

2. Your Hosts Gloria Dow, EMT-P FP-C Greg Winters, LP FP-C Gloria- 16 years paramedic with fire, EMS and Flight experience. Also worked as a chemistry and physics teacher for high school, so she has no fear. Past President of the IAFP and currently serves as Editor, Chairs AMTC education Committee, AMTC Standards Committee, NIMS Resource Typing Project, EMS Workforce Development project. AND she had two BIG dogs. Greg�22 years in EMS with police, fire, tactical ems background. Just finished masters in public administration and holds a bachelors in emergency management admininstration. Currently Performance Improvement/Clinical educator for AirLife and serving as president of the IAFP. STRAC education, AMPAG, Field Data.Gloria- 16 years paramedic with fire, EMS and Flight experience. Also worked as a chemistry and physics teacher for high school, so she has no fear. Past President of the IAFP and currently serves as Editor, Chairs AMTC education Committee, AMTC Standards Committee, NIMS Resource Typing Project, EMS Workforce Development project. AND she had two BIG dogs. Greg�22 years in EMS with police, fire, tactical ems background. Just finished masters in public administration and holds a bachelors in emergency management admininstration. Currently Performance Improvement/Clinical educator for AirLife and serving as president of the IAFP. STRAC education, AMPAG, Field Data.

6. �Just the Basics�� EMS was called for respiratory distress. They arrived to find a pediatric muscular dystrophy patient struggling to breath. EMS is unable to ventilate with BVM. To facilitate intubation, patient was given succinyllcholine.

7. �The Best Intentions�� And he developed respiratory failure and died. Similar things can happen with oxygen administration. ACLS medication administration. even, c-spine immobilization!

8. Objectives: By the end of this session, participants will be able to : Identify potential preplan patients. Compare and contrast fire and pediatric preplan characteristics. List potential pediatric preplan diagnoses and medical considerations.

9. Objectives: But what we really, sincerely hope is that you: Adapt preplan principles, ideas, and templates to your needs. Continuously reevaluate your patients and preplans. Take this home!

10. �Emergency Preparedness for Children with Special Health Care Needs� AAP Policy Statement (1999) �These children have very complicated histories, and without their extensive medical records available, it�s very hard (for emergency room personnel) to get a handle on what�s going on.� American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP)

11. �Emergency Preparedness for Children with Special Health Care Needs� The policy statement recommends that emergency care plans include: Use of a standardized form Method of identifying at-risk children Completion of a medical information data set Education of families, care givers and health care professionals Regular updates 24-hour access to information Maintenance of patient confidentiality

12. Emergency Medical Services for Children EMSC � �society has a special obligation to address the needs of children because they must depend on others for the protection of their health and safety�� �The assessment and management of critical illness and injury in pediatric patients requires specialized training and experience.�

13. Emergency Medical Services for Children EMSC System State and regional coordination Training, equipping, and supervising prehospital care providers Participation of emergency care facilities

14. Shawn�s Mom

15. What�s in a Name? High-Tech Kids Medically Fragile Patients Technology-Assisted Kids Children with Special Health Care Needs (CSHCN)

16. Critical Care in your Backyard Why Preplan? Identifiable population Predictable risk of emergent events Complex operational tasks Infrequently used tools Crucial outcomes

17. Critical Care in your Backyard Why now? Advances in medical knowledge and technology Psychological and developmental advantages of home care Emphasis on health care economics Medical equipment specialized for home care Discharge training for family

20. Essentials of a PrePlan

21. PrePlan Considerations Physical Location School Home Day or respite care Transport Written Orders Individualized Do Resuscitate Orders Caregivers Family Teachers Friends

22. PrePlan Considerations EMS Components Equipment Medications Transport Standing orders (protocols) Medical direction Destination Hospitals �Closest appropriate facility� is condition dependent

23. Recognition,Preparation, Education 

24. When you answer the call�

25. Apnea Monitors Meant to be mobile Timing 5-20 seconds Lights Green Blinking Red Solid Red (complete with alarm) Physiologic Parameters Respiratory Heart Rate (or others)

26. Ventilators 3 Basics Mode Respiratory rate Tidal volume Alarms If in doubt, BVM! Hypotension hint Can you transport the child�s ventilator? Size � disconnect from stand Battery life / inverter / power strip Fragile vs EMS proof

27. Tracheostomies Airway D isconnect O xygenate P hlegm E quipment BLS - BVM Special considerations: Suction Irrigate Suction Remove cannula Suction Remove trach tube Suction Replace New trach tube ETT (exchanger)

28. Central Lines Catheters placed in large veins shortest internal = distal lumen 16 g or 17g blood administration, viscous fluids medium internal = medial lumen 18g or 20g Parenteral nutrition longest internal = proximal lumen 18g or 20g Blood sampling, medication administration

29. Central Lines Broviac - soft Groshong � valve Hickman Single lumen Double lumen Triple lumen Dialysis PICC lines Port-a-cath Flushing chamber Huber needle access Bandage in place

30. Central Lines Line is dislodged Direct pressure Physician reinsertion - 2 hours Infection control Clean access site Close clamps Caps intact and in place Flush Heparin � 3 ml Normal saline � 5 ml Between medication administrations Lack of blood return

31. IV Pumps Chamber or syringe 3 �C�s of Alarms Connections Clamps Chambers KISS Silence OFF Take it with you! Disconnect from stand Extra tubing

32. Insulin Pumps CSII Continuous subcutaneous insulin infusion Delivers short acting insulin Basal rates Bolus Correction or supplemental doses Hints Water resistant Disconnect port Check for catheter dislodgment

33. Insulin Delivery Watch for: Computerized glucometers/CSII�s Inhalers Patches

34. Gastric Tubes Nasogastric Tubes Aspirate Flush Rotate Provider replacement Only emergent to get stuff out! Carefully assess patient for aspiration!

35. Gastric Tubes G-Tubes and J-Tubes Care Flush q 4 hours Flush after medication Don�t clamp tubing! Check skin and tube Redness Bleeding/discharge Temperature changes Don�t run through pumps

36. CFS Shunts Hydrocephalus Imbalance of CSF production and removal Fluid accumulation in brain ventricles Increased ICP Generally congenital Spina bifida May accompany Head trauma, meningitis, tumor

37. CSF Shunts Types VP - peritoneal VA - atrium VP �pleural space Assess Malfunction Infection (greatest risk 1-2 mos. post placement Care Supportive Pump shunt once Tap shunt (CSF evacuation)

38. Sample PrePlan Diagnosis

39. Primary Pulmonary Hypertension Idiopathic Pulmonary Artery Hypertension (IPAH) Acute or chronic right heart failure Syncope Infection Control (fevers) Therapies Oxygen � pulmonary vasodilator Coumadin � bleeding Digoxin � narrow therapeutic range Prostacyclin � continuous Inhaled nitric oxide Nifedapine

40. Cerebral Palsy Actually a group of different disorders Spastic: stiffness Athetoid: writhing Atonic: weakness Mixed Monoplegia Hemiplegia Paraplegia Diplegia Quadraplegia

41. Cerebral Palsy Difficulty with motor movement preexisting sedation Plus, Epilepsy Scoliosis Difficulty breathing Feeding and swallowing problems Dental problems Joint deformities Physical deformities do NOT predict intellectual capabilities!

42. Hemolytic Uremic Syndrome Characteristic triad Microangiopathic hemolytic anemia Thrombocytopenia Acute renal failure (hypertension) Most common cause of acute renal failure in children 10 �15% fatal Recurrences � mortality of 30% Common Precipitating Factors Diarrhea E. coli,Shigella Upper respiratory infection

43. Congenital Heart Defects Stabilization of CHD patients Airway Breathing O2 saturation at 75-85% O2 vasodilates Circulation Treat aggressively for Shock Respiratory failure � avoid benzo�s Initiate PGE-1 0.05 � 0.01 mcg/kg/min

44. Prader Willi Syndrome Breathing concerns Breathing problems and lung infections Sleep apnea No vomiting Vomiting is the sign of a serious illness Large or bloated abdomen is a medical emergency Not able to feel pain Any change in behavior or condition Medications People with PWS may not be able to handle normal dosages Body temperature problems Hyperphagia/uncontrolled appetite Uncontrolled appetite can lead to a life-threatening weight gain Supervised 24 hours per day

45. In Summary�

46. Additional  Resources International Association of Flight Paramedics flightparamedic.org Greg Winters greg.winters@txairlife.com Gloria Dow gtdow@flightmedicmail.com www.aap.org www.acep.org EMSC State of Ohio EMSC

49. Thank you!