RESPIRATORY DISTRESS – PEDIATRIC

Inclusion Criteria:  Patients complaining of shortness of breath or those who have labored respirations, dyspnea, wheezing, or rales. Respiratory distress can be caused by a number of conditions, including asthma, croup, airway obstruction, and volume overload (as in congestive heart failure (CHF) and end stage renal disease).  Treat patients with respiratory distress caused by trauma using the TRAUMA Guidelines and patients experiencing an allergic reaction using the ALLERGIC REACTION Guidelines.

Special Note:  If fever is present with any respiratory signs or symptoms, or if the patient is coughing, sneezing, or generating airborne droplets, EMS personnel should wear a HEPA mask to reduce transmission of infection. A HEPA mask may be placed on the patient (if tolerated), or a 100% NRB mask may be used, if tolerated, to reduce transmission of infection.

Basic Level

1. Assess and support ABCs. Suction the nose with a bulb syringe or mechanical suction, if excessive secretions are present.
2. Place the patient in a position of comfort.
3. Administer oxygen, as needed, by nasal cannula or non-rebreather mask (NRBM) to maintain a SpO2 of at least 94%.
4. Assess breath sounds:

1. If the patient is wheezing, administer albuterol 2.5 mg via nebulizer.
2. If the patient has a barky cough or if stridor is present, do NOT administer albuterol. Proceed to the “Croup” section of these Guidelines (7c below), as soon as possible.

Advanced Level

5. All patients treated under this guideline must have continuous ECG and ETCO2 monitoring.  If a dysrhythmia develops, treat it according to its specific guideline.  Anticipate the need for a possible advanced airway (ETT or SGA) via PHARMACOLOGICALLY-ASSISTED INTUBATION (PAI) (BioTel authorization required).
6. Consider establishing IV/IO access at a TKO rate, or use a saline lock.
7. Assess breath sounds:
   1. Signs of volume overload (rales, JVD, peripheral edema or hepatomegaly):
      

      Pediatric Under 2 Years Old and Pediatric at Least 2 Years Old

   • Contact BioTel.
   • Prepare to obtain a 12-Lead ECG.
   • Monitor closely and transport.
     
     
   2. Wheezing, pediatric patients of all ages:
      • Mild to moderate wheezing, administer nebulized albuterol 2.5 mg

   If no significant improvement following nebulizer therapy:
   
   Pediatric Under 2 Years Old AND NO Asthma History

   • Repeat nebulized albuterol 2.5 mg dose.
   • If the child improves somewhat, but is still in distress, repeat albuterol 2.5 mg once.

     
     Pediatric At Least 2 Years Old AND/OR Asthma History

   • Administer 2.5 mg albuterol combined with 0.5 mg ipratropium via nebulizer.
   • If the child improves somewhat, repeat with both albuterol and ipratropium.
     • Albuterol: contact BioTel for authorization if more than 3 doses are needed.
     • Ipratropium: maximum total of 3 doses.

   If no significant improvement following 3 nebulizer treatments, add the following:

   Pediatric Under 2 Years Old AND NO Asthma History

   • Administer 1:1,000 epinephrine 2 mg (2 mL) via nebulizer.
   • If the child improves somewhat, consider repeating the nebulized epinephrine once.
     
     
     Pediatric At Least 2 Years Old AND/OR Asthma History
     
     
   • If SpO2 is still less than 94% & child is not improving, obtain IV/IO access at TKO rate.
   • Administer methylprednisolone IV/IO, if available (optional medication) – Reconstitute 125 mg in 2 mL (as supplied), then dilute with 8 mL Normal Saline to a final volume of 10 mL (12.5 mg/mL); Administer IVP/IO:
     • Age less than 1 yr: 12.5 mg (1 mL)
     • Age 1 to 3 yr: 25 mg (2 mL)
     • Age 3 to 5 yr: 37.5 mg (3 mL)
     • Age 5 to 9 yr: 50 mg (4 mL)
     • Age 9 to 13 yr: 62.5 mg (5 mL)
   • Consult BioTel for dosing confirmation if IM administration is required because of lack of vascular access:
     • Reconstitute, but do NOT dilute
     • Dose: 2 mg/kg (0.032 mL/kg) IM

   If no response to albuterol or epinephrine nebulizers, with status asthmaticus or impending respiratory failure (altered mental status, severe difficulty ventilating), administer:
   

   Pediatric Under 2 Years Old AND NO Asthma History

   • Normal Saline 20 mL/kg IV/IO.
   • Contact BioTel.

   Pediatric At Least 2 Years Old AND/OR Asthma History

   • Dilute 2 g magnesium sulfate in 250 mL Normal Saline & contact BioTel for dose confirmation; then,
   • Administer 40 mg/kg (5 mL/kg) IV/IO over 30 minutes (Maximum dose: 2 g); AND ALSO ADMINISTER
   • 1:1,000 epinephrine 0.01 mg/kg IM (0.01 mL/kg) (Maximum dose: 0.3 mg).
3. For respiratory distress with a history of a barking cough and/or stridor, assume Croup:
   • If stridor is present at rest, administer 1:1000 epinephrine 5 mg (5 mL) via nebulizer.
   • Consider vascular access at a TKO rate or a saline lock, if not already done.
   • Administer a Normal Saline 20 mL/kg IV/IO bolus for the patient with impending respiratory failure.
   • Contact BioTel.

8. For additional patient care considerations not covered under standing orders, consult BioTel.