EMSC Connects

April 2022; Vol.11, Issue 4

Big picture

Pedi Points

Tia Dickson, RN, BSN

Primary Children's Hospital


Seizures are the most common pediatric neurologic emergency and account for around 15% of all pediatric EMS calls which rarely come wrapped nicely as a "seizure" complaint. More often the call will be made for a child choking, altered, or unresponsive. In our last PETOS presentation, Dr. Chris Ryba took us through one of these calls which is summarized here.

The Doc Spot

Chris Ryba MD, EMS Fellow, University of Utah

Excerpts from March 14, 2022 PETOSInteresting Prehospital Pediatric Cases


Chris Ryba completed his EM residency at University of Wisconsin where he served as a flight physician. He also has prior experience working as a paramedic in Chicago, IL.

PCR: 2-year old with concern for choking

On arrival: Patient was lying on his right side with his eyes closed. He was crying. He did not interact with providers and allowed vitals to be obtained without fuss.

Assessment: HR 138, RR 26, O2 89% RA, BG 135, GCS 10, Temp 100.4. Lungs clear, oxygen started, and restored saturations to 100%.

History: Grandpa saw child walking by with a cup and cookie. The child suddenly dropped to his knees with his body shaking then became stiff. His eyes rolled back and he became blue. Grandpa believed the boy was choking, called dispatch, and was instructed to begin chest compressions. After about a minute the child began to cry. No family history of seizures.

PCR concerns for airway: think about the differences in adult and pediatric airways

Big picture

Response to a true choking event

Typical presentation: No vocalization, surprise/worried facial expression, or unresponsive.

Actions for full obstruction:

  • Make one attempt to clear any obvious obstruction
  • For choking infants, apply a sequence of 5 back blows and 5 chest thrusts until the item becomes dislodged or the patient becomes unresponsive.
  • For children, use the abdominal thrust maneuver and continue until the obstruction resolves or the patient becomes unresponsive.
  • Once unresponsive. begin CPR.


Begin CPR, starting with chest compressions. Do not check for a pulse. Each time you open the airway to give breaths, open the victims mouth. Look for the object.

  • If you see an object that looks easy to remove, remove it with your fingers.
  • If you do not see an object, continue CPR.


Actions for partial or resolved obstruction:
  • Avoid agitation
  • Allow family member presence and position of comfort
  • Provide supportive measures as needed

Back to our case

En route: Patient was transported to PCH and became more alert but did have a repeat temperature of 101.4. The crew felt the presentation was more likely a febrile seizure than a choking event.

EMS Response for a febrile seizure

Actions for simple febrile seizure:
  • Generally supportive care
  • Provide reassurance to the family
  • Evaluate for source of fever (most often a virus or upper respiratory infection)
  • May not need to transport but family will often prefer it
Actions for complex febrile seizure:
  • Follow the seizure treatment pathway

Case #2―7 year old male at school, concern for seizure

On arrival: Patient found supine with eyes open with limited response. He stated his name and could follow simple commands but was otherwise nonverbal.

Assessment: HR 126, RR 22, BP 136/86, O2 84% RA BG 135, Temp 36.8. Lungs clear. The rest of the exam was unremarkable.

History: Bystander reported patient was in class when he began to stare off into space which was recognized as his seizure start. While walking to the med room, he became unresponsive then had tonic-clonic activity.

Patients medical history: Known history of epilepsy, 28wk premature and very low birth weight, autism, and an unknown genetic disorder.

Treatment on scene: 10 mg IN diazepam (rescue med) was administered by school staff. IV and 400 cc of fluids started by EMS as well as 4L of O2 with good response. Weight of 25 kg (determined by Handtevy app).

Big picture

Back to our case

En route: Patient had an additional 60 second seizure witnessed but resolved before administering 2 mg of IV Versed. The patient's eyes were open spontaneously, he localized to pain, and moaned following the event but there was no intelligible verbal response. A second seizure occurred and an additional 2 mg of IV Versed was given. ETCO2 was noted to be 80-84 and thus respirations were assisted by BVM for shallow irregular respirations. Transported to PCH.

Suspicion of Status Epilepticus

In this case the patient was treated appropriately in the field with medication dosing per their protocol. The hospital was suspicious that this patient was in status. Across the board, medical providers tend to under treat seizures and more particularly status epilepticus.

From adult research: "Prehospital midazolam use and outcomes among patients with out-of-hospital status epilipticus" by Gluterman, Et Al. in 2020 in the journal, Neurology.


  • Found that underdosing of benzos in status/seizures often occurs due to provider concern for causing respiratory depression.
  • Found that higher doses of midazolam did not increase risk of respiratory side effects but limited the risk of need for further rescue therapy.
Big picture

What if he had gone into respiratory failure?

Patients with lengthy respiratory insufficiency (a long, unbroken seizure) who are given these drugs are at a higher risk for acute respiratory decompensation (they stop breathing). Early intervention can decrease the chance of respiratory failure but if it happens, it couldn't happen in better hands. Prehospital providers know how to bag and are capable of maintaining the airway during transport.

Protocols in Practice

Big picture
Big picture

Pediatric Skills Refresher - Pediatric Seizure Control - Stop the BS

Pediatric Seizure Control - Stop the BS!

Pediatric Skills Refresher - Post-ictal aggression and how to help someone after a seizure

Derrick Kay - Post-ictal Aggression and How to Help Someone After a Seizure

News from National

MEMORANDUM

TO: NASEMSO Members

FROM: NASEMSO Pediatric Emergency Care Council

SUBJECT: Defibrillator Pad Incompatibility

DATE: January 25, 2022


This information was brought to the Board of Directors who supported its distribution to members in the interest of protecting the public.

Situation:

The NASEMSO Pediatric Emergency Care (PEC) Council recently learned of several issues regarding automatic external defibrillator (AED) pad incompatibility, with multi-function defibrillator and AED pads not being used in accordance with manufacturer’s recommendations, particularly in pediatric applications.

Background:

In recent inspections, it was identified that some EMS services and/or their personnel are utilizing incorrect pediatric defibrillator pads with various manual monitor/defibrillators and AEDs. This results in an inability to deliver therapy across all age and weight ranges. On November 29, 2021, the Massachusetts Office of EMS issued a statewide memorandum regarding this issue and shared it with the NASEMSO PEC Council. Subsequently, this has been found to be occurring in several other states as well.

Assessment:

Examples include:


  • Zoll Pedi-padz: These defibrillator pads, although manufactured by Zoll, are not compatible with the Zoll AED Plus units and will not plug into the unit. The pediatric pads required for the Zoll AED Plus units are the Pedi-padz II. The Zoll AED Plus Administrators Guide, page 30, states to use “ZOLL Stat-padz II, CPR-D-padz or Pedi-padz II” and to “Only use electrodes labeled “Infant/Child” on children less than 8 years old or weighing less than 55 lbs. (25 kg). Use CPR-D-padz® if patient is older than 8 years or weighs more than 55 lbs. (25 kg).”
  • Physio-Control Lifepak-15: Use of non-manufacturer recommended pads for LP-15 units, with the intent of using them for pediatric patients. These pads have therapy limitations for both age and weight ranges for infants and children in both the manual and AED mode on the LP-15. The pads’ packaging states that in manual defibrillator mode, these pads cannot be used for patients who weigh less than 22 pounds, and in AED mode, are not to be used for patients younger than age 8. As a reminder, providers cannot use an LP15 in the AED mode for pediatrics, regardless of pad type. The LP15 operator’s manual, in section 5 pages 5-7, under “Automated External Defibrillation (AED)” states, “In AED mode, the LIFEPAK 15 monitor/defibrillator is not intended for use on pediatric patients less than 8 years old.”
  • General: Some AEDs have been identified that were accompanied by pediatric pads with packaging that had red writing and a circle with a line through it around an AED symbol that stated, “not for AED use.”


Recommendation:

Although pediatric defibrillation is an uncommon event, ensuring that properly compatible equipment is available is one of the keys to this life-saving intervention. We recommend state and regional EMS leadership share this information and remind all EMS, fire, and other public safety agencies to double-check all monitors and AED units to ensure they have the correct manufacturer recommended pads stocked in all units. For questions, please refer to the manufacturer instructions for the device, contact the manufacturer, and/or contact state or regional EMS leadership.


References

1. Lifepak-15 Operators Manual https://www.physio

control.com/uploadedFiles/Physio85/Contents/Emergency_Medical_Care/Products/Operating_Instr uctions/LIFEPAK15_OperatingInstructions_3306222-002.pdf

2. Zoll AED Plus Administrator’s Guide https://www.zoll.com/-/media/product-manuals/aed-plus/01- english/9650-0301-01-sf_yd.ashx

3. Massachusetts Office of EMS Memorandum


https://www.cmemsc.org/images/Announcements/Memorandum_Ensuring_Defibrillator_Pad_Com patibility_to_Provide_Effectivepdf.pdf

News from Utah EMSC

The 2022 EMS For Children Survey is complete!


THANK YOU!


We are excited to announce Utah's EMSC has a NEW PROGRAM MANAGER!

Jared Wright


The majority of my EMS career was spent in Tooele County for Mountain West Ambulance where I worked as a paramedic & training officer. For approximately six years, I've been instructing EMT/AEMT, AHA, and NAEMT courses. I am a Weber State University paramedic graduate. I started at BEMSP as an Educator Specialist last year. I'm excited to join the EMSC team!

PECC Planning

The EMSC Innovation and Improvement Center has compiled a list of currently available state EMSC pages with PECC information as a resource for all PECCs. These are located here: https://emscimprovement.center/collaboratives/pecclc/resources/program-managers/―the links are located under the “EMSC Program Resources  Webpages.

Highlighting our most recent PEPP class in Gunnison, Do you need a PEPP class? See below

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 erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

Attention EMS providers, your feedback is needed!

Have you attended a home birth transfer of an infant or a mother to a hospital and saw ways the process could be improved? Have you seen midwives who have really great systems and communication and wish they all did? Help us learn how to improve the collaboration and communication about birth transfers by giving feedback to the Utah Women's and Newborns Quality Collaborative!


Find out more about our work and the improvement tools we have created here: https://mihp.utah.gov/uwnqc/out-of-hospital-births

Interested in follow up or case review on patients taken to Primary Children's Hospital?

Ask Our Doc

Do you have a question for our EMSC Medical Director, Hilary Hewes, MD, PCH, ER Attending Physician about this newsletter topic or anything related to pediatrics? Shoot an email to the following address tdickson@utah.gov.

Pediatric Education and Trauma Outreach Series (Petos)

Monday, May 9th, 2-4pm

This is an online event.

Utah EMS for Children (EMSC), Primary Children's Hospital (PCH) and Utah Telehealth Network (UTN) have partnered to offer the Pediatric Emergency and Trauma Outreach Series (PETOS) to EMS providers.

This course provides one free CME from the Utah Department of Health Bureau of EMS and Preparedness 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 2nd 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 utah.petos@gmail.com with the date and title of presentation viewed. You will receive a three question quiz to verify participation and once the quiz is returned, certificates are e-mailed out.


We try to have certificates out within a week but will occasionally have delays.

Other upcoming pediatric education

Project ECHO, Tribal Programs and Resources

Wednesday, April 20th, 12pm

This is an online event.

Series on the diagnosis and treatment of specialty pediatric disorders. CME and CEU credit available to those who attend.


Connection information:

Click here to register on Zoom

Project Echo, Brachial Plexus Injuries

Wednesday, May 4th, 12pm

This is an online event.

Series on the diagnosis and treatment of specialty pediatric disorders. CME and CEU credit available to those who attend.


Connection information:

Click here to register on Zoom

Big picture

The 1st Annual “LIFE” Event

Friday, April 29th, 9pm to Sunday, May 1st, 12pm

National Ability Center, Park City, UT, USA

Park City, UT

Project Overwatch and the Utah Women in Law Enforcement non-profits have partnered to create a women’s first responder peer network in the state of Utah. The first annual “LIFE” event will be hosted Friday April 29-May 1, 2022. This event will be open to women who are military veterans, police officers, and/or firefighters. This event will include the following:


● Individual trauma assessment ● Trauma resources ● Resiliency ● Teambuilding ● Mindfulness ● Meditation ● Yoga ●Leadership ● Archery ● Indoor rock climbing ● Networking ● Mentoring


Every aspect of this event focuses on the mental wellbeing of our women military veterans, women police officers, and women firefighters. This will be the first of many retreats for female first responders hosted at the National Ability Center in Park City and the Utah Valley University Wasatch Campus in Heber. Deadline for applications is past.


Contact Dr. Marcy Hehnly at mhehnly@project-overwatch.org or marcy.hehnly@uvu.edu. With questions


Dr. Marcy Hehnly Retired Cobb County Police Department,

GA Project Overwatch Vice-President

www.project-overwatch.org

678.524.0103

University of Utah's EMS Grand Rounds (Offered every 2nd Wednesday of even months)

Wednesday, June 8th, 2pm

This is an online event.

Click here to join

Virtual-Zoom Meeting Meeting

ID: 938 0162 7994 Passcode: 561313

EMS Focused Education

Big picture

Emergency Medical Services for Children, Utah Bureau of EMS and Preparedness

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that 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, no matter where they live, attend school, or travel.