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).

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:

1. They notice retractions, head bobbing, or grunting
2. Their baby is feeding poorly and has gone more than 10-12 hours without a wet diaper
3. The baby is inconsolable or becoming more lethargic
4. 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.

• Nasal flaring and/or grunting

• Diminished breath sounds
  

• Cyanosis

• Decreased level of consciousness

• Poor muscle tone/lethargy

Note: 80% of cardiac arrest in children results from respiratory failure

• Head tilt/chin lift or modified jaw thrust when trauma is suspected
  

• 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.

• 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.
  

• 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

• 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?

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.

On topic:

• 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.
  

Seasonal prevention

• Native American Heritage Month | Department of the Interior

  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

• Association of Online Risk Factors with Subsequent Youth Suicide-Related Behaviors in the US | Pediatrics

• Evaluating the Signs of Suicide Program: Middle School Students at Risk and Staff Acceptability | School Psychology Review

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

1. 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.
2. 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.
3. Annette Newman is sending out monthly emails titled "PECC—Hot topics and updates." Be sure she is in your "safe senders list" annettenewman2020@gmail.com

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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.

1. 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.
2. Designating a PECC is now part of EMS agency licensure and will be required going forward.

Reminders

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.