5. PEDIATRIC EMERGENCIES
5.2 PEDIATRIC ANAPHYLAXIS
Anaphylaxis is an acute, generalized and violent antigen-antibody reaction that can be rapidly fatal. An anaphylactic reaction may present as a mild to severe response: management is based upon severity. Anaphylaxis in children is unusual. As in adults, there are multiple causes of anaphylaxis: injected substances or drugs such as penicillin, cephalosporin, sulfa; other causes include food sensitivities, vaccines, insect stings, virtually any chemical or other environmental allergens.
Hypotension in children is usually due to other causes such as shock from sepsis or dehydration. Wheezing, another feature of anaphylaxis, is most often due to reactive airway disease, infection or foreign body. Drooling, hoarseness and stridor signal upper airway compromise, which is usually due to infection in children. If these symptoms are present, follow the Pediatric Upper Airway Obstruction Protocol.
Most reactions occur within thirty (30) minutes following allergen exposure, although the onset of symptoms can vary from several seconds to hours. As a rule, the earlier the onset of symptoms following antigenic exposure, the more severe will be the subsequent reaction. Virtually all body systems are affected in an anaphylactic reaction.
ASSESSMENT / TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions.
2. Determine presence of upper airway involvement (stridor) or lower airway symptoms (wheezing). These may coexist. Maintain an open airway, remove secretions, vomitus and assist ventilations as needed.
3. Administer high concentration oxygen by non-rebreather mask.
4. Determine patient's hemodynamic stability and symptoms. Continually assess Level of consciousness, ABCs and Vital Signs. Determine if blood pressure is appropriate for age (See Appendix M).
5. Obtain appropriate history related to event, including Past Medical History (prior allergies and/or anaphylaxis), current medications, or recent antigen exposure.
6. Determine if patient is in mild or severe distress:
a. Mild Distress: itching, isolated urticaria, nausea, no respiratory distress.
b. Severe Distress: poor air entry, flaring, grunting, cyanosis, stridor, bronchospasm, abdominal cramps, respiratory distress, tachycardia, shock, edema of lips, tongue or face and generalized urticaria.
TREATMENT
BASIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Determine presence of upper airway involvement (stridor) or lower airway symptoms (wheezing). These may coexist. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning, or use of airway adjuncts (oropharyngeal airway) as indicated.
3. Administer high concentration of oxygen by non-rebreather mask.
4. Activate ALS intercept, if deemed necessary and if available.
5. *SPECIAL CONSIDERATION: Use of Auto-Injector Epi-pen Jr. (for pediatric patient with a body weight less than 30 kg/66 lbs) NOTE: Patients under age 5 require contact with Medical Control prior to administration of epinephrine.
a. If patient presents in Severe Distress, as defined in Assessment Priorities, prior to or after contact with Medical Control: administer epinephrine by Epi-pen Jr. A second injection in 5 minutes may be necessary.
b. Monitor vital signs every 5 minutes and keep patient warm.
6. Initiate transport as soon as possible with or without ALS.
7. Notify receiving hospital.
* NOTE: Only EMTs with Auto-Injector Epi-Pen training and Regional credentials may administer Epi-Pen emergency treatment.
INTERMEDIATE PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Determine presence of upper airway involvement (stridor) or lower airway symptoms (wheezing). These may coexist. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning, or use of airway adjuncts (oropharyngeal airway) as indicated.
3. Administer high concentration of oxygen by non-rebreather mask.
4. Activate Paramedic intercept, if deemed necessary and available.
5. *SPECIAL CONSIDERATION: Use of Auto-Injector Epi-pen Jr. (for pediatric patient with a body weight less than 30 kg/66 lbs) NOTE: Patients under age 5 require contact with Medical Control prior to administration of epinephrine.
a. If patient presents in Severe Distress, as defined in Assessment Priorities, prior to or after contact with Medical Control: administer epinephrine by Epi-pen Jr. A second injection in 5 minutes may be necessary.
b. Monitor vital signs every 5 minutes and keep patient warm.
6. ALS STANDING ORDERS:
a. Provide advanced airway management, if indicated.
b. Initiate IV Normal Saline KVO or rate determined by medical control.
7. Initiate transport as soon as possible with or without Paramedics.
8. Contact MEDICAL CONTROL. The following may be ordered:
a. Administration of fluid bolus(es) (expected fluid bolus will be at intervals of 20 ml/kg).
9. Notify receiving hospital.
* NOTE: Only EMTs with Auto-Injector Epi-Pen training and Regional credentials may administer Epi-Pen emergency treatment.
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Determine presence of upper airway involvement (stridor) or lower airway symptoms (wheezing). These may coexist. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning, or use of airway adjuncts (oropharyngeal airway) as indicated.
3. Administer high concentration of oxygen by non-rebreather mask.
4. ALS STANDING ORDERS
a. Provide advanced airway management (if indicated).
b. Initiate IV Normal Saline KVO titrated to appropriate BP for age.
c. Severe Distress:
- Epinephrine (1:1,000), 0.01 mg/kg subcutaneously up to maximum single dose 0.3 mg.
- Large Bore IV normal saline, titrate to appropriate BP for age.
- Diphenhydramine HCL (Benadryl) 1.0 mg/kg up to maximum single dose of 50 mg via deep intramuscular injection (IM) or IV push.
5. Initiate Transport as soon as possible.
6. Contact MEDICAL CONTROL. The following may be ordered:
a. Epinephrine 1:1,000; administer 0.01 mg/kg subcutaneously up to maximum single dose 0.3 mg.
b. Epinephrine 1:1,000; administer 0.1 mg/kg via ET followed by 2.0 cc sterile Normal Saline solution.
c. Epinephrine infusion 1:1,000 (1 mg/ml) administer 0.1 to 1.0 m g/kg/min.
d. Albuterol Sulfate 0.5% (via nebulizer):
- If age less than 2 years, 0.25 ml diluted with 2.5 ml sterile Normal Saline solution.
- If age 2 years or greater, 0.5 ml diluted with 2.5 ml sterile Normal Saline solution.
e. 20 ml/kg fluid bolus of Normal Saline.
f. Epinephrine 1:10,000; administer 0.01 mg/kg IV Bolus up to maximum single dose 0.3 mg.
g. Diphenhydramine HCL (Benadryl) 1.0 mg/kg up to maximum single dose of 50 mg via deep intramuscular injection (IM) or IV push. For mild distress, 2 mg - 5 mg Benadryl IV push or IM may be administered.
h. Pediatric PASG
7. Notify receiving hospital.
MoonDragon's EMS Index Page
HELPFUL PRODUCTS & FURTHER EDUCATION
-- by Phyllis A. Balch, James F. Balch - 2nd Edition
-- by Phyllis A. Balch, James F. Balch - 4th Edition
-- by Phyllis A. Balch
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