PEDIATRIC TREATMENT OVERVIEW

Age Definitions

Unless otherwise specified, the BioTel system defines a pediatric patient for treatment and transport purposes (e.g. drug dosing and hospital destination) as a child younger than his or her 14th birthday.

There are, however, two important exceptions to this definition, as applied to Basic Life Support (CPR) and to electrical therapy for ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT).  For these specific guidelines, the system defines a pediatric patient as an infant or child younger than his/her 8th birthday.

For legal considerations, such as the right to give consent or to refuse treatment, the system defines a pediatric patient as anyone younger than his or her 18th birthday.

Approximate, Normal Pediatric Vital Signs by Age

Mean normal Systolic BP (SBP) estimate (mm Hg): 80 + (2 X age in years)

Lowest limit of SBP to define hypotension (mm Hg): SBP less than 70 + (2 X age in years) = hypotension

Weight (kg) can be estimated from pediatric length-based resuscitation tape OR (8 + (2 X age in years))
NOTE:  Some experts now suggest using (10 + (2 X age in years))

Pediatric Airway Management

Proper ventilation with a BVM is the ventilation method of choice for the pediatric patient.  Use tidal volumes sufficient only to produce visible chest rise.  Assisted ventilation with excessive rates or force may be harmful.

Endotracheal intubation may be attempted if it is impossible to ventilate or oxygenate the patient with less invasive methods AND the patient is rapidly deteriorating.

Refer to the Advanced Airway Management section in the ADULT TREATMENT Overview for guidance on the proper assessment and documentation of endotracheal intubation.  If there is ANY doubt as to the appropriate placement of an endotracheal tube, REMOVE the tube and ventilate the patient using a BVM.

Paramedics may make only one endotracheal intubation attempt per patient.  If the single attempt is unsuccessful, provide effective ventilation with a BVM.  An attempt made by a paramedic student counts as the single attempt.  The Medical Direction Team defines an endotracheal intubation attempt as the passage of an endotracheal tube past the teeth.

Pediatric Cardiac Arrest

For pediatric cardiac arrest, the following definitions apply to Basic Life Support (CPR) and electrical therapy (defibrillation):

• Infant: less than 1 year of age (before 1st birthday)

• Child: 1 to 8 years of age (between 1st birthday and 8th birthday)
• Adult: 8 years of age &  older

A child who is 8 years of age or older is considered to be an ADULT for the purposes of BASIC Life Support and CPR.  Paramedics should use adult CPR methods, adult defibrillation pads and adult shock doses during electrical therapy for VF/pVT.  However, paramedics should treat children younger than the 14th birthday as “pediatric” patients when performing ADVANCED Life Support interventions, including drug dosing.  All medication doses in pediatric cardiac arrest should be weight-based; a pediatric length-based resuscitation tape or an equivalent, weight-based reference tool may be used for rapid reference.

Metronomes: Chest compressions performed at a rate of 100-120 compressions per minute are associated with the best survival and recovery outcomes.  Use of a metronome (built-in or standalone) throughout the resuscitation is critical to maintain the optimal rate of chest compressions.

During cardiac arrest, perfusion of the heart muscle itself falls dramatically once chest compressions have stopped.  Perform compressions with minimal interruptions in order to ensure maximum myocardial perfusion.  Keep pauses in chest compression to less than 10 seconds (less than 5 seconds for shocks).  Only pause for rhythm analysis, shock delivery, and ventilations prior to advanced airway insertion (when performing standard 30:2 CPR (adults and children at least 8 years old) or 15:2 CPR (infants and children under 8 years of age)). 

Proper compression depth for infants and children under 8 years of age is at least 1/3 the chest anteroposterior (AP) chest diameter.  For infants under 1 year old, this is approximately 1½ inches (4 cm).  For children 1 to 8 years old, this is approximately 2 inches (5 cm). For both age groups, it is imperative that the chest is allowed to fully recoil between compressions (recoil/release is the phase of the compressions duty cycle that “primes the pump”).

Use of AEDs in Pediatric Patients

First responders using an automated external defibrillator (AED) should power on the device and place the special, hands-free pediatric dose-attenuating pads (if available) on the patient’s bare chest as early as possible.  (NOTE: these are not the same as and are NOT interchangeable with the pediatric defibrillation pads used with manual monitor-defibrillators.)  Do not interrupt chest compressions while applying the pads. If the infant/child is small, pads may be placed on the front and back of the left side of the chest (“sandwich”) as an alternative.

Pediatric dose-attenuating AED pads (if available) are preferable for children between the ages of the 1st birthday and up to 8 years or age.  Consult with medical direction and agency MOPs regarding the use of adult AED pads for children between the ages of the 1st birthday and up to 8 years of age.

For children who have reached their 8th birthday or older, use adult AED pads.

Do not use an AED on infants under 1 year old.  Instead, perform high-quality CPR at a 15:2 compression-to-ventilation ratio, pausing compressions for breaths, until advanced personnel arrive with a manual monitor-defibrillator and appropriate pediatric equipment (e.g. pediatric defibrillation pads).

The CARDIAC ARREST  Guidelines provide direction for determining the proper timing of defibrillation shocks.

Use of Manual Monitor-Defibrillators for Pediatric Patients

For paramedics using a manual defibrillator, power on the device and apply hands-free, pediatric defibrillation pads for all infants and children younger than the 8th birthday.  Place the device in the PADDLES lead - not in Lead II – upon initial patient contact and continue to use the PADDLES lead and MANUAL mode throughout the resuscitation attempt.  If the patient appears to be in asystole, quickly check for loose or disconnected leads, check the power, and check the gain (signal strength).  The American Heart Association and the Medical Direction Team no longer recommend interrupting CPR to check multiple leads to confirm asystole.

Cardiac arrest in pediatric patients most commonly results from hypoxia.  However, it is important to place all sick infants and children on the ECG monitor because heart rate is an indicator of distress or improvement.  Hypotension and bradycardia both indicate impending cardiac arrest.

Begin CPR, starting with effective chest compressions at a rate of 100 to 120 per minute if the pediatric patient is unresponsive and:

•          There is no palpable pulse; OR
•          The pulse rate is less than 60 per minute with signs of hypoperfusion despite 60 seconds of gentle ventilation with supplemental oxygen.

Pediatric patients rarely need transcutaneous pacing (TCP).  When necessary (e.g. bradycardia), place the pads anterior/posterior and contact BioTel for settings.

Pediatric Trauma

• Minimal on-scene time is critical for the injured pediatric patient.

• Consider the mechanism of injury, even if the child appears stable on initial assessment. Identifying the mechanism of injury is critical for triaging the pediatric trauma patient to the correct facility. Refer to the DESTINATION Policy, or contact BioTel for guidance.

• When necessary for initial pre-hospital fluid resuscitation of hypovolemic shock, paramedics may rapidly administer one bolus of Normal Saline 20 mL/kg.  Reassess vital signs and response. If necessary, repeat the 20 mL/kg rapid infusion once.  Between fluid boluses, set the IV/IO drip rate at TKO.  Do not run IV/IO fluids wide open in children.

Pediatric Fluid Therapy

• IV: Microdrip set for IV infusion for patients less than 20 Ib. (10 kg); regular set if at least 20 Ib. (10 kg).

• IO: Regular tubing set for intraosseous (IO) infusion, regardless of the patient’s age.

Pediatric Standing Orders

For the majority of treatment guidelines, standing orders for pediatric patients are the same as those for adults.  Exceptions to standing orders for pediatric patients include congestive heart failure.  Contact BioTel for assistance and guidance at any time there are questions or concerns, even when standing orders address the situation.

Pediatric Doses

• These treatment guidelines list pediatric medication doses as mL/kg and/or mg/kg.  In order to avoid potentially harmful medication errors, it is critical to pay close attention to pediatric drug dosing guidelines, especially to avoid confusing “mg/kg” and “mL/kg”.

• The maximum dose (TOTAL amount that may be given to a patient) for all drugs never exceeds the maximum (TOTAL) adult dose.  For assistance in selecting the correct dose and/or route of administration, contact BioTel, or use the length-based Pediatric Emergency Tape, or an equivalent weight-based reference tool.