EMS Protocol of the Week!!! - Stridor/croup/epiglottitis (Peds)

It’s that time of year! All the children have been coming in with respiratory distress. These days, most often it’s a child with bronchiolitis. But it’s also important not to forget about the kids coming in with croup, anaphylaxis, airway obstruction, and the rare but scary epiglottitis.

Management?

As always…ABC’s.

1.     Administer high flow O2 via NC or face mask

2.     Consider obstructed airway vs. anaphylaxis as causes of respiratory distress

3.     Stridor at rest? Think croup.

a.     Epi 3mg nebulized OR racemic epi nebulized

4.     Get IV access (in real life, depending on age of the child I feel like this doesn’t always happen, but it’s important for children in respiratory distress who can decompensate quickly)

5.     STEROIDS!! (ONLY if 2 years or older)

a.     Dex 0.6mg/kg to max of 12mg or methylpred 1mg/kg to max of 60mg

If EMS suspects Epiglottitis, EMS will NOT attempt advanced airway – will only ventilate with bag valve mask and transport ASAP

Last but not least, OLMC (which we are all experts on now after Vic’s great emails the other week)

-       EMS must call if kid is <2 y/o in respiratory distress and wants to give steroids

KEY POINTS:

-       Croup = stridor + retractions + barking cough

-       Epiglottitis = stridor + retractions + muffled voice + high fever (TOXIC APPEARING)

-       Unvaccinated = high risk for epiglottitis

-       Airway obstruction (foreign body, mass) = biphasic stridor

-       Don’t agitate a child already in respiratory distress

-       Dex > methylpred in kids

And if you want more... www.nycremsco.org

Jennifer Wolin, MD

Emergency Medicine PGY-2 Resident Physician

Maimonides Medical Center

EMS Protocol of the Week - Non-Traumatic Cardiac Arrest (Pediatric)

Not a ton of difference between the prehospital protocol for pediatric non-traumatic arrest when compared to its adult counterpart, at least in terms of the interventions available. The same medications and electricity can be found in the pediatric toolbox as well, albeit with more of an emphasis on age-and-weight-appropriate dosing, which is explicitly described within the protocol for your reference. Similarly to adult arrests, you may encounter OLMC calls requesting orders for calcium, sodium bicarb, or antiarrhythmics like amiodarone. 

Also worth noting is the caveat describing effective BVM use as a "reasonable alternative" to other advanced airways when needed; the point being that, given the predominance of respiratory etiologies in this population, it is likely more beneficial to focus on adequate bagging and mask seal rather than spend multiple attempts trying to intubate a difficult airway. 

Keep this protocol flagged for future use, as it's a great way to offload memorizing doses for some of these critical meds. Not that any of us would have to do that, since clearly these calls are incredibly low-stress (just...kid-ding?).

Ok bye. www.nycremsco.org for more.

Dave

EMS Protocol of the Week - Neonatal Care / Resuscitation

The prehospital protocol for neonatal resuscitation is dense, so it doesn't serve to reproduce it all within the email. Read through the attachment for details, and realize that it serves as a reference for stepwise assessment (with target heart and respiratory rates) and interventions (with target compression/ventilation rates and medication dosages) for when our EMTs and paramedics are stuck in a high stress home environment with a neonate in extremis. Not a ton to add from an OLMC perspective, but recognize that this protocol is here for your reference as well, in case a crew calls looking for assistance.

The attached appendix also includes a review of APGAR scores for your review. 

That's RESUSCITATION...BABY.

And with that, hope you all have some wonderful holidays! If you can't wait for more protocol goodness, there's always www.nycremsco.org

Dave