EMS Protocol of the Week - Severe Bradycardia (Pediatric)

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Happy EMS Tuesday!

We're going to slow things down from John Su's riveting email about eye emergencies to discuss the EMS protocol for “Severe Bradycardia (Pediatric)”. These are 3 words that no one wants to hear in a sentence together, so let’s get mentally prepared in case this patient comes in!

To use this protocol, patients should have: 1) HR <60 bpm, and 2) signs of shock or AMS. Any provider taking care of this type of patient can begin chest compressions and ventilations as per AHA guidelines. If an EMT is first on scene, they should immediately request ALS assistance and transport if timing makes more sense. 

For paramedics, cardiac monitoring will be started and IV access will be obtained. Standing Order will allow them to perform the following: 

1) Epinephrine 0.01 mg/kg (0.1mL/kg) IV of 1:10,000 concentration (max 1mg) every 3-5 minutes, 

2) Atropine 0.02 mg/kg IV (min 0.1mg, max 0.5mg), 

3) intubation if unable to provide effective BVM ventilations. 

If that does not work, they will call OLMC for one of two options: 

1) administration of a 2nd dose of Atropine 0.02 mg/kg IV 

2) initiation of transcutaneous pacing. Of note, they may also for procedural sedation authorization for pediatric patients if the patient is conscious.

Check out www.nycremsco.org or the protocol binder on North Side for more.

Sincerely,

Joseph Liu, DO

Chief Resident, Emergency Medicine PGY-3

Maimonides Medical Center

EMS Protocol of the Week: Pediatric Respiratory Distress/Failure

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Hey all,

This week's EMS protocol is on pediatric respiratory distress/failure. The thought of a pediatric patient experiencing respiratory distress is enough to cause me to go into respiratory distress... but let's discuss how our pre-hospital colleagues initiate care for these patients.

Remember that respiratory distress and respiratory failure fall on a spectrum:

Respiratory distress is characterized by:

- Increased respiratory effort/WOB

- ABSENCE of central cyanosis symptoms: anxiety, nasal flaring, increased respiratory rate, accessory muscle use (ie retractions), lethargy, etc.)

Respiratory failure is characterized by:

- Presence of central cyanosis symptoms: agitation, lethargy, severe dyspnea, labored breathing, head bobbing, grunting, severe retractions, severe bradypnea, etc.

- Hypoxia and/or hypercapnia

The prehospital approach to these kiddos corresponds to a progression of care based on the level of training present. CFRs start with ABCs and monitoring vital signs. If needed, these providers can implement airway adjuncts and administer supplemental O2 at appropriate levels for either respiratory distress or failure. At this level of training, CFRs can then address potential overdose. BLS crews will pick up from here and can additionally request ALS backup and transport the patient. If the on-scene team is ALS trained, they can perform advanced airway management if unable to continually bag ventilate the patient. From here, ALS providers will start cardiac monitoring and establish IV/IO access as necessary while en route. They can even assess and treat for a tension pneumothorax (which may develop after resuscitation has begun!).

If a known cause is identified/suspected such as aspirated foreign body or anaphylaxis, treatment via those protocols will be used. If persistence of respiratory distress/failure, then providers will default back to this protocol.

There is not a lot to be aware of from an OLMC (shameless plug for our e-mailed survey 😊) standpoint other than awareness of the level of care the on-scene providers are able to provide - this will give the receiving team a better idea of what to expect when the patient is rolled in and instill the appropriate level of fear.


See the attached protocol and check out https://nycremsco.org/ for more!

Best,
Zachary Kim

PGY-2 Emergency Medicine

POTD: Umbilical Vein Catheterization

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I wanted to review a fairly rare but lifesaving EM procedure in neonates. This procedure is done fairly commonly in the NICU/L&D, but is done less frequently in the ED, especially with our excellent nurses who can literally get the most impossible venous accesses. If you went to Airway day, you might recall Dr. Sokolovsky describing her harrowing tale of providing neonatal resuscitation at Burning Man and performing an umbilical vein catheterization with an 18-gauge IV. Super wild! So for anyone who might find themselves in a similar poop-inducing situation with no pediatric support or NICU available, this is for you!


Umbilical vein catheterization is indicated in a neonate within 14 days post-birth requiring IV resuscitation. The stump must be "fresh", so it is most ideal in the newly born neonate. Here is an excellent video overviewing the following steps. https://pedemmorsels.com/wp-content/uploads/2019/08/UVC....mp4

Here's what you'll need:

  • Sterile gloves (gown and drape less non urgent)

  • chlorhexidine

  • forceps

  • scalpel

  • umbilical line (5 French is standard, 3.5 French in very premature baby)

  • three-way stopcock

  • umbilical tape of 3-0 silk/nylon

  • NS flush

In peds, we have umbilical vein catheterization trays located on the top shelf in Bay 31 that includes all of the above except the catheter. While the umbilical line is the traditional teaching, you can use any tube that can fit into the vein - that means an 18 gauge IV, pediatric central line, feeding tube, etc


Prep the umbilical stump

  1. Flush the line and place

  2. Sterilize the entire umbilical stump, including the clamp at the end of the stump, and the abdomen

  3. Tie the umbilical tape (or a silk string) around the base of the stump loosely. This helps decreased blood flow for when the clamp is eventually removed. It can also be tightened to secure the line once placed

  4. Holding the clamp, make a transverse cut off the stump to remove the distal tip. Cut should be made directly below the clamp or 2 cm from the abdomen.

Identifying umbilical vein and prep for insertion

  1. Identify the umbilical vein. The anatomy of the stump involves two smaller umbilical arteries and one umbilical vein. The arteries are typically smaller and thicker lumen, while the vein is larger and more collapsible (see below)

  2. Remove any clots from the vein and gently dilate the vein with forceps

  3. gently insert the line, when you get blood return insert 1-2 cm deeper, or approx 3-5 cm. If there is resistance, consider loosing the umbilical string.

  4. Aspirate blood and flush with NS. Secure the line by tightening the umbilical string and securing with tape or purse string suture

Complications of UVC placement are similar to CVP placement: excessive bleeding, infection, thrombosis, arterial insertion. Specifically to UVC is risk of insertion too deep into the portal venous system or right atrium, which can lead to hepatic necrosis and perforation.

Resources:

https://first10em.com/umbilical-vein-catheterization/

https://wikem.org/wiki/Umbilical_vein_catheterization

https://www.ncbi.nlm.nih.gov/books/NBK549869/