November 2022; Vol.11, Issue 11
Tia Dickson, RN, BSN
Primary Children's Hospital
One of the advantages of our own newsletter is the ability to adjust our topics based on what were are seeing in the hospital. This month we felt we needed to do just that. Primary Children's has seen record numbers of respiratory illness in the last few weeks. The predicted surge of RSV has arrived along with all our usual respiratory bugs. This is going to be a big respiratory season. Do you know how to manage the pediatric airway?
The hospitals need your help! Direct parents to seek care with their primary care doctor or at the pediatric clinics unless there is a true emergency (read below for symptoms that warn of respiratory failure).
The Doc Spot
Hilary Hewes, MD
Associate Professor, Pediatric Emergency Medicine
Principal Investigator, EMSC Data Center (NEDARC has rebranded as EDC)
University of Utah, School of Medicine, Department of Pediatrics
It is no secret that respiratory season has come early and with extra fury. Hospitals and EDs across the country are packed with sick children, and in some areas of the country, there is already a shortage of pediatric ICU beds. Our ED waiting room times are far above average. There are currently several different viruses circulating, including RSV, influenza, rhinovirus, parainfluenza, and adenovirus. All of these can cause fever, cough, congestion and trouble breathing; including bronchiolitis and croup. The strain of RSV this year seems to be fairly severe. Also, the past several years, as a result of mask wearing and social distancing during the pandemic, young children did not have usual exposure levels to these respiratory viruses. Wearing masks and social distancing decreased the normal respiratory surge we typically see from November to March. That means several years of children are potentially without immunity.
Most infants do not require hospitalization for these viruses, but they are still affected and won’t sleep or drink as well, and understandably parents worry when their child has fever, is coughing, and not sleeping well. As medical providers, we can help provide information, reassurance, and resources to parents about when to worry and what we can do for these sick children.
Most importantly, I tell parents to go to an ED if:
- They notice retractions, head bobbing, or grunting
- Their baby is feeding poorly and has gone more than 10-12 hours without a wet diaper
- The baby is inconsolable or becoming more lethargic
- They notice long pauses in breathing, which can most often happen in babies <2 months of age with RSV
Helping parents understand that otherwise they can see their outpatient doctor can help decrease ED crowding. Children with special healthcare needs obviously will be even more vulnerable and parents should seek care if they have concerns.
I warn parents that there is no medicine to make these viruses go away, and we treat children with supportive care and time. I give realistic expectations that the congestion lasts on average 10-14 days, cough 14-21 days, and days 4-5 tend to be the worst.
We all need to be prepared to treat a large volume of respiratory pediatric patients in the coming weeks, so practice your suctioning skills and use this newsletter as a resource.
Where to start? Assessment of course
- Chest and/or abdomen rise and fall
- Babies are belly breathers
- Children younger than age 5 must have a patent nose to breathe well
- From across the room for sounds like stridor or wheeze
- For chest and/or abdomen rise and fall
- What’s normal? Know normal values for variation in age. Carry a vital sign card or app with you on calls
- Wheeze (typical of asthma and lower airway constriction) vs. Stridor (upper airway restriction like croup)
- Crackles, heard in both upper and lower illness, common in bronchiolitis (RSV) and viral pneumonia
- Diminished sounds are common in pneumonia or obstructed asthma
- Reliable only if the heart rate measured on the device is similar to that of the child's on palpation or auscultation and the wave form is tracing well. (Tip: place the sat probe on the child and back away, give them time to calm for the best reading)
- The reading is considered normal above 90% in Utah
Work of breathing
Abnormal positioning indicates stress (tripod, sniffing position, not tolerating lying down). Allow the child to sit in a position of comfort, allow parental support.
Abnormal airway sounds
Stridor and wheezing are typically early signs of distress
Grunting or gasping are signs of impending respiratory failure
Retractions: use of accessory muscles
Supraclavicular, intercostal, substernal, head bobbing—the more retractions in multiple locations, the more distressed the child
Nasal flaring is a red flag for failure
Signs of respiratory failure
Nasal flaring and/or grunting
Diminished breath sounds
Decreased level of consciousness
Poor muscle tone/lethargy
Note: 80% of cardiac arrest in children results from respiratory failure
Rule out obstruction
- Head tilt/chin lift or modified jaw thrust when trauma is suspected
Obstructed airway maneuvers
- Younger than 1 year:
- 5 back blows with infant in prone position
- 5 chest thrusts with infant in supine position
- Older than 1 year:
- 5 abdominal thrusts with child supine
- If visible, remove it
- No blind finger sweeps
During respiratory season, foreign body aspiration is not the most likely cause of respiratory distress but it should always be considered and ruled out as children tend to explore their world by tasting it.
During respiratory season the more likely cause of airway obstruction is secretions.
Suctioning—Yes, it is within your scope of practice!
- BBG suction (similar to the Nose Frida or Neilmed nasal aspirator) is becoming the standard of care. These allow for more frequent clearing and cause less inflammation in the nasal tissue as compared with deep nasopharyngeal suctioning.
Used in hospital and attached to suction. It is a noninvasive method to clean out the nose
A popular oral suction device available in retail markets
Neilmed Naspira Aspirator
PCH gives these to parents in the ER for home use
- 8fr suction catheters work well for most ages
- Use saline to lubricate (1-2 drops per nare), insert the distance of the nare to the patient’s ear lobe
- Insert tube perpendicularly to the body lying down and medially to the septum of the nose
- Insert to measured length, remove as you apply suction, no longer than 10 seconds per nare
Skills Refresher—Nasopharyngeal suction
- Respiratory or cardiac arrest
- Inability to maintain patent airway with good BVM
- Long transport time
- Good response to BVM ventilation
- Anatomical abnormalities
Before you jump to intubation consider, can I maintain this airway with a basic airway technique?
PALS Basic Airway Tips
What will you see
Asthma, croup, and bronchiolitis are the most common respiratory culprits to result in 911 calls and trips to the ER. Here are a few reminders on their differences and similarities.
Asthma is a disease of small airway inflammation
Clinical signs and symptoms:
- Wheezing or decreased breath sounds
- Tachypnea, tachycardia
- Positioning—tripod, neck extension
- Albuterol nebulized
- Oxygen support
- Most common in ages 3 mos-3 yrs but we have been seeing "COVID croup" in children as old as age 12
- Caused by a viral infection
- Onset usually follows a cold
- Signs and symptoms
- Hoarse voice or cry
- Barking cough
- Allow the child to remain in a position of comfort
- If hypoxic, use a high-concentration oxygen
- Cool and humidify if possible
- You may try cool nebulized saline
- Monitor for total airway obstruction
- Stridor at rest with signs of distress or obvious severe distress, consider nebulized racemic epinephrine < 5 kg = 0.25 mL (mixed in 3ml NS) > 5 kg = 0.5 mL (mixed in 3ml NS) OR epinephrine 2 cc of 1:1000 in 3cc of saline and give as nebulizer treatment
- Lots of secretions
- Signs of dehydration because those secretions make it hard to eat/drink
- Lethargy because those secretions make it hard to sleep
- Suction, suction, suction
- Inhaled beta agonists (albuterol) are no longer recommended, even as a trial
Past PETOS on the topic
12/14/2020—Pediatric Respiratory Emergencies, Mike Miescier, MD
3/9/2020—Little Airways by Sarah Becker, MD
- 6/10/2019—Pediatric Respiratory Emergencies by Zachary Drapkin, MD https://mediaspace.utah.edu/media/t/0_2sfxjo0b
Tips from the field
Tips for parents—baby nose suctioning
Protocols in Practice—Respiratory Distress
Current Events—RSV Outbreak
Sharing these important AAP media messages on RSV.
“RSV is spreading rapidly and much earlier than normal this year. That combined with flu season and the continued spread of COVID makes for a scary time for many parents of young children. Pediatrician and parent of young kids, Dr. Parga-Belinkie, offers reassurance and practical guidance for parents in this new video, including signs it's time to #CallYourPediatrician.”
News From National
Cases are expected to continue to rise as the result of a so-called “tripledemic” of influenza, enterovirus/rhinovirus and COVID-19. The inpatient bed shortage was covered in an October 11 New York Times article, “As Hospitals Close Children’s Units, Where Does That Leave Lachlan?” The article featured Kate Remick, MD, FAAP, co-director of the EMSC Innovation and Improvement Center, who spoke about pediatric readiness and the importance of being prepared to care for children in crises and every day.
That story led to additional coverage, including a PBS News Hour segment. While the segment focused primarily on inpatient care, it closed by highlighting a statistic from a 2018 EMSC paper on pediatric readiness.
“The surge crisis is a reminder that we, as a health care system, have to do more to prioritize children’s needs,” says Remick.
Is your hospital experiencing a surge? Access resources.
November 1-31, 2022
The Great American Smokeout | American Cancer Society November 18, 2022
National Injury Prevention Day | Injury Free Coalition for Kids November 18, 2022
News from Utah EMSC
Our EMSC Family Representative (FAN)
The EMSC Program created the Family Advisory Network (FAN) to facilitate the inclusion of family representatives in state EMSC programs. FAN members contribute to their state program activities in numerous ways, including, but not limited to: serving as members, chairs, and, co-chairs of their state EMSC advisory committee; coordinating special community outreach projects; assisting with the development and implementation of EMSC policy objectives; and helping to plan, present, and promote educational offerings within their state.
We are excited to welcome our new family representative
Heather is currently a sign aid for the special needs students of the Alpine School District. Heather loves to sign and loves to teach everyone she can. Due to John's special needs, we have been able to help many learn sign language so they can communicate with John. Heather lost her father due to an ruptured aneurysm more than 15 years ago. She strives to represent her dad in every day of her life. Jerry Love was a Gold Cross supervisor and she was willing to date me because of that connection with her dad, since I currently work for Gold Cross. Heather's other love is cooking. Her favorite TV channel is the food channel, and she works hard to mimic the best meals.
My name is Jeff Wilson. I have many loves in life. I love to help others. I started with the Boy Scouts of America and was an archery director at Steiner Scout Camp. I then served a mission for the Church of Jesus Christ of Latter Day Saints in Cincinnati, Ohio. This is started my love for medicine. Our assignment in Cincinnati was to give blessings in the many hospitals in the area. I witnessed modern medical miracles. As my love to help others grew, I wanted to see more miracles. I came home and found that I wanted to be an EMT and paramedic. I worked hard at it and now have been at Gold Cross Ambulance for 15 years. I have been a paramedic for 5 years.
In the past 2 years, as I learn how to help John with his challenges, I have learned that not enough people are aware of autism. Our family has dived in as autism advocates. Jerry and Logan are incredible and have told their friends who John is and how unique he is. I am so proud of their love for their brother. Heather and I want to make a difference as well. We want all first responders and other medical personnel to understand and become autism advocates.
All PECCs, please join us for our first PECC quarterly meeting on zoom, see the invite below.
Our first open house hours was held on November 1, 2022. Here's a recap:
Some of you are not getting our communications, There are 3 main ways we reach out to you
- EMSC Connects newsletter (monthly digital, sent out on the second Monday of the month). Each has a PECC development section just for you. Go to our latest issue and click the Pac-man ghost icon to follow us.
- Our official PECC email mailing list. If you did not get an email from me last night about the open hours, then you are not on the list. Please be sure EMSC (Jaredwright@utah.gov) has your correct email information if you are a hospital or agency PECC.
- Annette Newman is sending out monthly emails titled "PECC—Hot topics and updates." Be sure she is in your "safe senders list" firstname.lastname@example.org
Great questions discussed:
Where do I start in this role?
- Develop the role
Define the PECC role within your agency or hospital
Work out sustainability for the role
Ensure communication between yourself and EMSC/UPTN/PPN. We encourage information exchange in both directions
- Assess. Find your pediatric gaps in training, equipment, or in general. Define barriers and buy-ins and set goals, or send these things to the EMSC staff and let us help you.
What should this role look like?
This role is an initiative for every EMS agency and hospital in the nation but we are at the forefront of its development. Right now, you get decide what it looks like for your organization. Do you want it to be a yearly checkmark, an occasional pediatric focused activity, or a fully developed peds program? It's up to you. EMSC wants to help you with resources for whatever you decide.
- The new EMSC grant will be funded at a higher rate than it has been in several years. We'd love to hear from our PECCs on how to spend that money to improve pediatric care.
- Designating a PECC is now part of EMS agency licensure and will be required going forward.
PECC open office hours will be on the first Tuesday of each month and are a casual time to come and network, discuss issues, and find resources.
Our first PECC quarterly meeting will be held November 15, 2022. Watch your email for more information.
HRSA highlight—CYSHCN blueprint for change
If you are working to improve care for children and youth with special healthcare needs (CYSHCN), we hope you will take a look at a new report from the National Academies of Sciences, Engineering, and Medicine. They conducted a 2-day workshop to examine the impact of the COVID-19 pandemic on children with disabilities and their families. The report, Supporting Children with Disabilities: Lessons from the Pandemic, can help inform the work in the CYSHCN Blueprint for Change. Let's create a nation where all children enjoy a full life and thrive in their communities from childhood through adulthood.
EMSC Monthly Office Hours
Tuesday, Dec. 6th, 9-10am
This is an online event.
BEMSP is inviting you to a scheduled Zoom meeting.
Join Zoom meeting
Meeting ID: 870 0564 5259
Monthly from 9 a.m. to 10 a.m. on the first Tuesday from Tuesday, November 1 to Tuesday, February 7, 2023 (Mountain Time—Denver)
Virtual quarterly PECC meeting—save the date
Tuesday, Nov. 15th, 10-11am
This is an online event.
Kids and Covid
Utahns who are eligible to receive a bivalent booster dose right now include:
- Individuals 6 years of age and older are eligible for the updated Moderna booster if it has been at least 2 months since they completed their primary vaccination series or received a booster dose.
- Individuals 5 years of age and older are eligible for the updated Pfizer-BioNTech booster if it has been at least 2 months since they completed their primary vaccination series or received a booster dose.
The pandemic lead to many missed well-child checks and some children missed childhood vaccinations. Check to see if you’re up-to-date on all immunizations, whether for yourself or your children, as well as health screenings and well-child checks:
Birth transfers? We need your feedback for QI
Pediatric Education from Utah EMSC
Pediatric Education and Trauma Outreach Series (Petos)
Monday, Nov. 14th, 2-4pm
This is an online event.
Utah EMS for Children (EMSC), Primary Children's Hospital (PCH), and Utah Telehealth Network (UTN) offer the pediatric emergency and trauma outreach series (PETOS) to EMS providers.
This course provides one free CME from the Utah Department of Health and Human Services Office of Emergency Medical Services for EMTs and paramedics. The lectures are presented by physicians and pediatric experts from Primary Children’s Hospital. The format is informal; inviting questions and discussion.
Join us on Zoom each second Monday at 02:00 PM Mountain Time (US and Canada) Click the pic below!
Archived presentations can be viewed and also qualify for CME. Access at https://intermountainhealthcare.org/primary-childrens/classes-events/petos
To obtain a completion certificate
- For "live" (virtual) participants: To receive a certificate of completion for attendance be sure to include your email address when the host requests it in the chat during the live presentation. Certificates are e-mailed out after verification of attendance and processing.
- For archived viewing: After viewing archived presentations (link above) e-mail email@example.com with the date and title of presentation viewed. You will receive a three question quiz to verify participation. Once the quiz is returned, certificates are e-mailed out.
We try to have certificates out within a week but will occasionally have delays.
Looking for a PEPP class?
Pediatric Education for the Prehospital Provider
Register online at www.peppsite.com. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($21.95). Return to peppsite.org to register for the class and follow the prompts.
If you have any questions, please email Erik Andersen at firstname.lastname@example.org or text/call 435-597-7098. Continue to watch the website for additional classes.
Other Pediatric Education
45th Annual Current Concepts in Neonatal and Pediatric Transport Conference
Tuesday, Feb. 21st 2023 at 8am to Friday, Feb. 24th 2023 at 5pm
215 West South Temple
Salt Lake City, UT
University of Utah's EMS Grand Rounds (Offered every 2nd Wednesday of even months)
Wednesday, Nov. 9th, 2pm
This is an online event.
Click here to join
Virtual-Zoom Meeting Meeting
ID: 938 0162 7994 Passcode: 561313
Primary Children's Pediatric Grand Rounds (offered every Thursday, Sept-May)
Thursday, Nov. 17th, 8am
This is an online event.
The Pediatric Grand Rounds weekly lecture series covers cutting-edge research and practical clinical applications, for hospital and community-based pediatricians, registered nurses, and other physicians and practitioners who care for children of any age.
The series is held every Thursday, 8 to 9 am from September through May in the 3rd Floor Auditorium at Primary Children's Hospital. The lectures are also broadcast live to locations throughout Utah and nationwide.
Emergency Medical Services for Children, Utah Office of EMS and Preparedness
The Emergency Medical Services for Children (EMSC) Program aims to ensure emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, regardless of where they live, attend school, or travel.