5. PEDIATRIC EMERGENCIES
5.3 PEDIATRIC BRADYDYSRHYTHMIAS
Primary heart block is rare in children. Pathologically slow heart rates usually result from hypoxemia, acidosis, hypothermia and late shock. Bradycardia may be a late finding in cases of raised intracranial pressure (ICP) due to head trauma, infection, hyperglycemia and previous neurosurgery. Rarely, an ingestion can cause bradycardia. Pre-hospital treatment is directed to the symptomatic patient only. Heart rates that are normal in older patients, may be bradycardia in children.
ASSESSMENT / TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated.
3. Administer high concentration of oxygen via non-rebreather mask.
4. Determine patient's hemodynamic stability and symptoms. Continually assess level of Consciousness, ABCs and Vital Signs including capillary refill and determine if appropriate for age. (SEE APPENDIX)
5. Obtain appropriate history related to event, including recent and Past Medical History (underlying congenital heart disease and/or surgery), Medications, Drug Allergies and Substance Abuse including possible ingestion or overdose of medications, specifically calcium channel blockers, beta-blockers, and digoxin preparations.
6. Symptomatic patients will have abnormally slow heart rates accompanied by decreased level of consciousness, weak and thready pulses, delayed capillary refill, or no palpable BLOOD PRESSURE.
TREATMENT
BASIC PROCEDURES
NOTE: Inasmuch as Basic-EMTs are unable to recognize the presence of Bradydysrhythmias, check patient for a slow and /or irregular pulse. If present, treat according to the following protocol.
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated.
3. Administer oxygen by nasal cannula or by non-rebreather mask.
4. If pulse is less than 60 in a child or is less than 80 in an infant and the patient is symptomatic start Cardiopulmonary Resuscitation (CPR).
5. Activate ALS intercept, if deemed necessary and if available.
6. Initiate transport as soon as possible with or without ALS.
7. Continue to monitor vitals signs.
8. Notify receiving hospital.
INTERMEDIATE PROCEDURES
NOTE: Inasmuch as Basic-EMTs are unable to recognize the presence of Bradydysrhythmias, check patient for a slow and /or irregular pulse. If present, treat according to the following protocol.
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated.
3. Administer oxygen by nasal cannula or by non-rebreather mask.
4. If pulse is less than 60 in a child or is less than 80 in an infant and the patient is symptomatic start Cardiopulmonary Resuscitation (CPR).
5. Activate Paramedic intercept, if deemed necessary and if available.
6. ALS STANDING ORDERS
a. Advanced Airway Management, if indicated.
b. IV Normal Saline (KVO)
7. Initiate transport as soon as possible with or without Paramedic.
8. Continue to monitor vitals signs.
9. Notify receiving hospital / Contact MEDICAL CONTROL. The following may be ordered:
- Normal Saline bolus at discretion of Medical Control (expected fluid bolus is 20 ml/kg)
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated.
3. Administer oxygen by nasal cannula or by non-rebreather mask.
4. If pulse is less than 60 in a child or is less than 80 in an infant and the patient is symptomatic start Cardiopulmonary Resuscitation (CPR).
5. ALS STANDING ORDERS
a. Advanced airway management, if indicated.
b. IV Normal Saline (KVO). If hypovolemia component is suspected, administer a fluid bolus of 20 ml/kg.
c. If patient is symptomatic as defined in Assessment Priorities:
i. Epinephrine 1:10,000, 0.01 mg/kg IV Bolus or IO (maximum single dose 0.5 mg), or
ii. Epinephrine 1:1,000, 0.1 mg/kg ET, followed by 2.0 cc sterile Normal Saline Solution. Subsequent ET dosages 0.1 to 0.2 mg/kg 1:1,000 every 3 - 5 minutes.
iii. Atropine sulfate 0.02 mg/kg IV or ET (minimum single dose 0.1 mg, maximum single dose 1.0 mg). If administered via ET, follow with 2.0 ml of sterile Normal Saline Solution.
6. Continue to monitor vital signs.
7. Initiate transport as soon as possible.
8. Contact MEDICAL CONTROL. The following may be ordered:
a. Additional fluid boluses of Normal saline (20 ml/kg)
b. Transcutaneous (pediatric) pacing if available
c. Atropine sulfate 0.02 mg/kg IV Bolus or ET (minimum single dose 0.1 mg., maximum single dose 1.0 mg.) If administered via ET, follow with 2.0 ml of sterile Normal Saline Solution.
d. Epinephrine 1:1,000 :0.1 mg/kg via ET; follow with 2.0 ml sterile Normal Saline Solution; repeat every 3 - 5 minutes
e. Epinephrine 1:10,000: 0.01-0.03 mg/kg (maximum single dose of 0.5 mg), IV or Intraosseous (IO)
f. Epinephrine Infusion: 1:1,000, 0.1-1.0 mg/kg/min.
g. Atropine 0.02 mg/kg ET, IV, IO
h. Naloxone HCL 0.1 mg/kg of a 1 mg/ml solution: IV, ET, or IO.
- If age less than 5 years: 0.1 mg/kg
- If age 5 years or greater: 2.0 mg. (NOTE: May repeat every two (2) to three (3) minutes as needed. If perfusion is adequate may give Subcutaneously (SQ) or intramuscularly (IM). If given via ET, follow with 2.0 ml sterile Normal Saline solution.)
i. Normal Saline fluid challenge 10-20 cc/kg IV or IO
j. Glucagon 0.1 mg/kg IV, IO, IM, SC to max. 1.0 mg for suspected beta blocker toxicity
k. Calcium Chloride 10% solution 0.2 ml/kg IV, IO slowly over 5 minutes for suspected calcium channel blocker toxicity
9. 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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