September 3, 2024

This month we are doing a short review of best practices when calling medical control. We call medical control for many reasons including: 

• notifying the receiving facility of an incoming patient 

• getting assistance with high-risk non-transports 

• asking questions about the protocol 

• getting orders for treatments that are outside of what our protocol allows 

The goal of calling medical control is to efficiently relay critical info to the call taker so that our patient gets the best possible care. Calling medical control is a skill. Given that we often do this multiple times in a shift, it is worth reviewing best practices so that we are good at this highly utilized skill. 

The purpose of notifying the receiving facility of incoming patients is to make sure they are ready to take care of the patients we are bringing in. For non-critical patients, this can improve efficiency and decrease wait times. It ensures that the appropriate resources are mobilized for critical patients to continue care. When you call in your report, lead with the most critical things you need to notify them of. Examples include: 

• “This is EMS 1 calling with a trauma alert. ETA 5m. We have a…” 

• “This is EMS 1 calling with a STEMI alert. ETA 10m. EKG was just transmitted for review. We have a…” 

• “This is EMS 1 calling with a patient who likely needs intubation. Please get everything ready. ETA 10m.” 

We also call medical control when we have high-risk non-transports. Misadventures with non-transports are situations that expose EMS agencies to lawsuits more than any other thing we do. (We have a protocol that goes over all this which is worth reviewing if you haven’t seen it recently.) The key concept to understand is that for all refusals, we must determine if they have capacity. Capacity is the ability to understand what is going on (including the benefits/risks of each choice) and make a decision regarding care. Only patients with capacity can refuse treatment and/or transport. Capacity can be very nuanced, and it is strongly recommended that we involve online medical control whenever there is uncertainty since getting the patient to speak on the recorded line can be used as evidence later to defend our decision. Even when a patient has capacity, we should involve medical control for high-risk situations (such as vital sign abnormalities), since we want to do everything we can to advocate for the best care for our patients.  

Another reason to involve online medical control is when you have a question regarding patient care. There is no shame in knowing one’s limits and asking for assistance when needed. Sometimes, patients don’t fit a specific protocol and need treatment beyond what the protocol allows. It is important to know when a patient does not fit the mold of the protocol and needs online orders to get optimal care. This is true for orders for red boxed medications and for any other treatment outside the protocol within your scope of practice. When we call medical control for this reason, we want to lead with what our need is. Examples of this include: 

• “This is EMS 1 calling with a request for orders outside the protocol. We have a patient with profound hypotension who is not responding to fluids and 50mcg pushes of PDE. We would like permission to give higher doses of PDE.” 

• “This is EMS 1 calling requesting orders for a red box medication. We have a patient with AF with RVR and would like to give metoprolol. The whole story is…” 

The last thing to discuss is that many times the call taker at the receiving facility will take your report and then say, “No further orders.” It is important to understand that this statement does not mean we should do nothing; it just means there are no additional orders outside the protocol. Whenever you hear this statement, I want you to interpret it as “follow the protocol.” This will help you remember that we should always follow our protocol to provide the most comprehensive care to our prehospital patients.  

Be safe and keep up the awesome work,

Jordan Singer, MD

September 9, 2024

Good morning, everyone. Pediatric topics are back this month, starting with Brief Resolved Unexplained Event (BRUE). A BRUE is an event occurring in an infant less than one (1) year of age. The observer usually reports a sudden, brief and now-resolved episode of one or more of the following: 

1. Cyanosis 

2. Absent, decreased or irregular breathing 

3. Marked change in tone (hyper-or hypotonia) 

4. Altered level of responsiveness 

BRUEs are diagnosed after a history and physical examination fails to find an explanation for the event. It is important to note that BRUEs have replaced the term ALTE (Apparent Life-Threatening Event). ALTE was defined as a symptom rather than a diagnosis. Studies found that ALTEs gave the connotation that these events were benign and not “life-threatening.” 

Evaluation of BRUE: 

Low-Risk Category 

• Infant > 60 days of age 

• Gestational age ≥ 32 weeks and post conceptual age ≥ 45 weeks 

• Event lasted < 1 minute 

• No previous BRUEs 

• No need for CPR by a trained medical provider during the event 

• No family history of sudden cardiac death 

• No concerning medical or social history 

• No concerning features that indicate an underlying etiological condition 

High-Risk Category 

• Any of the lower risk criteria not met 

• Age ≦ 60 days 

• Gestational age <32 weeks and post-conceptual age ≦ 45 weeks 

• CPR done by a trained provider 

• Event lasted ≥ 1 minute in duration 

• Second, cluster or recurrent events 

• Concerning history e.g., family history of sudden cardiac death, concern for social, feeding or respiratory problems 

• 
  

Please remember that BRUEs are a diagnosis of exclusion. With that in mind, see below a list of diagnoses categorized by systems that should be on your differential for BRUEs.  

• Upper and Lower respiratory infections 

• Bronchiolitis, pertussis, pneumonia can cause apnea 

• Hematologic  

• Sepsis 

• Neurological  

• Meningitis, Seizures, Infantile botulism 

• Gastrointestinal 

• Gastroesophageal reflux  

• Cardiac 

• Prolonged QT syndrome, dysthymia 

• Endocrine 

• Metabolic disorders, electrolyte imbalance 

• Trauma  

• Child abuse 

Obtain a complete history and physical examination when evaluating these patients. DO NOT BE FOOLED BY THE PATIENT’S WELL APPEARANCE...always perform a detailed history and physical exam.  

In the prehospital setting, we recommended obtaining vital signs, 12 lead electrocardiogram, brief pulse oximetry monitoring with serial observations, and a D-stick. Remember that a history of BRUE may be the first sign of child abuse (head and other physical trauma, suffocation, Munchausen by proxy). Have a high index of suspicion when interviewing caregivers about social history concerning child abuse.  

BRUE should be suspected when there is no explanation for a qualifying event after conducting an appropriate history and physical examination. All infants ≦ 12 months of age with possible BRUE should be transported by EMS for further medical evaluation. If the family refuses transportation, please contact Medical Command for further instructions. 

That is it for this week. We will discuss pediatric burns next week.

Have a great week and thank you for all the great work.

Regina Yaskey, MD

September 16, 2024

Good morning. This week we will be discussing Pediatric Burns. 

Burns are the fifth leading cause of unintentional injury-related death of children living in the United States and are responsible for approximately 2,500 deaths annually. Non-fatal burns are the leading cause of unintentional injury in children and there are approximately one million annual pediatric cases. Infection, respiratory failure, and sepsis increase with the percent of Body Surface Area (BSA) involved.  

Let us discuss the common burns that affect children: 

• Thermal burns are scald injuries, most common in children under 4 years old. An example is hot liquid tipping over or accidentally spilling near a child. Other examples include microwave-related burns (e.g., a child accessing microwave-heated food and removing contents). Infants are particularly at risk for bath-related scalds, too. Contact burns are seen in young children who touch hot surfaces (e.g., a hot curling iron, clothing iron, grill, hot coals).  

• Flash burns occur from accidental ignition of volatile substances (e.g., alcohol-based cleaners and liquids). They happen after brief exposure and usually cause a partial-thickness burn.  

• Flame burns can be seen in house fires. An example is the accidental ignition of clothing. Complications of these include toxic gas inhalation, carbon monoxide, and cyanide poisoning (watch out for these in house fires).  

• Child abuse should always be considered in your differential when dealing with pediatric burns. Most burns are not secondary to abuse but being familiar with burn patterns that might stem from abuse is important. Suspicious burns include burns on the palms, soles of feet or abdomen, genitals or thighs, and scalding of hands, feet, or buttocks (often involves both extremities or buttocks). Remember the pattern is a more important indicator of intentional injury than location. 

• First-degree burns involve the epidermis and sensation on the skin remains intact. There are usually no blisters involved. An example would be a mild sunburn. Treatment includes oral pain medication. These burns usually heal within a week.

• Second-degree burns, called partial-thickness burns, involve the epidermis and part of the dermis. They can cause edema blistering and weeping of the skin. These burns are very painful when exposed to air current or palpation. Examples include scald injuries. The average healing time for these is approximately 2–3 weeks. 

• Third-degree burns are also called full-thickness burns and involve the entire epidermis and dermis. Nerve endings are damaged and there is no sensation. The skin can appear white, waxy, leathery, dark, and/or black. The surface is painless and dry. The skin does not regenerate well and may require skin grafting. 

When evaluating burn victims, the primary survey should focus on airway patency. Remember that fire victims are at an increased risk for airway edema. Carefully examine for facial burns, presence of soot, carbonaceous sputum, or singed nasal hairs. All these findings suggest impending airway edema/inhalation injury. If the patient shows signs of bronchospasm or hypoxia, it is recommended that you give humidified oxygen or high-flow oxygen. You can use pulse oximetry and end-tidal CO2 monitoring to detect clinical deterioration. 

Management includes inserting 2 large bore IVs and starting prompt fluid resuscitation. This is imperative because delays in fluid resuscitation are associated with higher incidences of renal failure, sepsis, and mortality. The formula used to determine the amount of fluid resuscitation is as follows:  

• Parkland Formula = 4mL/kg/%BSA over a 24-hour period. 

This formula is commonly applied to infants /children with burns > 10% body surface area and teenagers with burns > 15% BSA. Pediatric patients should receive maintenance IV fluids in addition to resuscitation fluids. Fluid rates should be adjusted to maintain urine output of 1 – 2ml/kg/hr for children, and 0.5 – 1ml/kg/hr for adolescents and adults.  

Pain control is important when treating burn victims. Partial–thickness burns can be extremely painful. Opioid analgesia given IV is preferred. Morphine is the most used analgesic and the dose is 0.1mg/kg IV. Intranasal fentanyl may also be used at dose 1 – 2µg/kg. Treatment also includes avoiding hypothermia. Sterile-soaked dressings may be applied to small burns but avoided in large burns due to the risk of hypothermia. 

Some burns can only be managed at burn centers with most of them having a unique multidisciplinary approach implementing the latest techniques and evidence-based practices in managing burns and wound care. Please review the Guidelines for Burn Patient Referral from the American Burn Association.

That’s it for this week. Next week we will discuss pediatric drownings.

Have a great week and keep up the amazing work. Stay safe,

Regina Yaskey, MD

September 23, 2024

Good morning, this week we will be discussing pediatric drowning.

69% of drownings in 1- to 4-year-old children occur during NON-swim times.

At the 2002 World Congress on Drowning, held in Amsterdam, a group of experts suggested a new consensus definition for drowning to decrease the confusion over the number of terms and definitions (>20) referring to this process that has appeared in the literature. The group believed that a uniform definition would allow for a more accurate analysis and comparison of studies, allow researchers to draw more meaningful conclusions from pooled data, and improve the ease of surveillance and prevention activities.

The new definition states that “drowning is a process resulting in primary respiratory impairment from submersion in a liquid medium.” Implicit to this definition is that a “liquid-air interface is present at the victim's airway.”

Drowning Risk Factors include:

ENVIRONMENTAL & INDIVIDUAL FACTORS

1. Lack of barriers to bodies of water

2. Lack of appropriate adult supervision

3. Alcohol or substance use

4. Swimming ability and lack of life jacket use

5. Male gender – increased risk of drowning

AT-RISK POPULATIONS

1. Toddlers (1-4 years are the highest risk age)

2. Adolescents (15-19 years second highest risk age)

3. Pre-existing medical conditions (Epilepsy, Arrhythmia, ASD)

4. Socio-economic disparities (African Americans)

The most important contributory factors to morbidity and mortality from near drowning are hypoxemia and a decrease in oxygen delivery to vital tissues. The pathophysiology of non-fatal drowning is intimately related to the multiorgan effects of hypoxemia. CNS damage may occur because of hypoxemia sustained during the drowning episode (primary injury) or may result from ongoing pulmonary injury, reperfusion injury, or multiorgan dysfunction (secondary injury), particularly with prolonged tissue hypoxia.

Due to relatively lower body strength, younger children cannot pull their faces out of the water to breathe. Contrary to the media portrayal of drowning, children typically drown quickly and quietly. They may slip into the water without a splash or recognition by adults. There is the “instinctive drowning response” phenomenon which is the autonomic nervous system's response to actual or perceived suffocation in water. The victim is incapable of waving or yelling for help because instinct gives breathing priority. The arms instinctively extend to the sides to lift their body and bring their mouth above water to breathe.

Due to their relatively lower body strength, younger children cannot pull their face out of the water to breathe. After approximately one minute, they will fatigue and succumb to submersion.

Primary CNS injury is the major determinant of survival & long-term morbidity in non-fatal drowning. It is associated with tissue hypoxia and ischemia. Submersion duration directly impacts the severity of hypoxic-ischemic injury to the brain, potential cerebral edema, and subsequent neurologic outcome. If the drowning process is interrupted by rescue, CNS injury may be limited due to brief hypoxia.

Hypoxia can be triggered by laryngospasm and/or bronchospasm. Fluid aspiration as little as 1-3 mL/kg can result in significantly impaired gas exchange, primarily secondary to altered surfactant function. Pulmonary hypertension may occur secondary to inflammatory mediator release due to aspiration during or shortly after the submersion event.

Acute respiratory distress syndrome (ARDS) from altered surfactant function and neurogenic pulmonary edema is a common complication in survivors of submersion injury. Although cardiovascular effects may be severe, they are usually transient, unlike severe CNS injury.

The clinical course may be complicated by multi-organ system failure resulting from prolonged hypoxia, acidosis, rhabdomyolysis, acute tubular necrosis, or infection, or the treatment modalities. Disseminated intravascular coagulation (DIC), hepatic and renal insufficiency, metabolic acidosis, and gastrointestinal injuries must be considered and appropriately managed.

Success or failure of initial basic life support provided at the scene of the accident is the most important determinant of outcome. Attention should be given to cervical spine stabilization if the scenario suggests spinal trauma. Remove the patient from the water as soon as possible. Initiate rescue breathing immediately, even while the patient is still in the water, if necessary and feasible. The Heimlich maneuver or abdominal thrusts have not been shown to be effective in clearing aspirated water.

 Higher pressures may be required for ventilation because of the poor compliance, resulting from pulmonary edema. The patient may need suctioning and remember to place them on their side in the recovery position due to vomiting

A focused history should be taken and include the following:

• Time of submersion

• Type of body of water involved

• Length of submersion

• Was the swimming supervised? Was it witnessed?

• Events surrounding the submersion

• Bystander or EMS resuscitation?

• Symptoms following the submersion

• Pre-hospital treatment

Patients with lethargy, hypoxia, cough, or respiratory distress may require further testing depending on their clinical severity. Associated injuries must be considered, just as in any other accidental injury. Consider potential spinal injuries, especially in diving accidents. The most critical role in management is a prompt correction of hypoxemia and acidosis. Intravascular volume depletion is common, secondary to pulmonary edema and intra-compartmental fluid shifts. Rapid volume expansion may be indicated using isotonic crystalloid (20 mL/kg) or colloid. Most acidosis is restored after correction of volume depletion and oxygenation. Sodium bicarbonate may be administered in cases of severe acidosis that do not correct themselves using the above measures, but only administered after adequate ventilation has been established.

Asymptomatic Management

Some patients may only require a thorough exam (attention to neurologic and respiratory findings) and pulse oximetry monitoring. There is currently no evidence-based standard to identify children at low risk of morbidity or recommended length of ED observation. It is generally recommended to observe in the ED for 4 to 8 hours. Closely monitor for development of hypoxia, cough/respiratory distress, abnormal lung auscultation, abnormal pulse or blood pressure, and altered mentation/lethargy. Literature suggests if patients remain asymptomatic with normal respiratory status, GCS, and vital signs, they may be discharged after ED observation between 4 and 8 hours.

Much like our ABC approach to the critical patients, we use an ABCD approach to water safety counseling (as recommended by the Texas Drowning Prevention Alliance or TXDPA). This is a strategy which can help to quickly organize the key drowning prevention points during anticipatory guidance.

ABCDs of water safety

• A is for Adult Supervision

• B is for Barriers for your pool

• C is for Classes (Swim lessons and CPR)

• D is for Devices (Flotation, emergency equipment, cell phone for 911)

• Multiple “layers of protection” are needed to prevent drowning

Multilayered protection plan against drowning:

• Prioritize evidence-based strategies: Barriers - Supervision - Swim lessons - Life jackets – CPR

• 4-sided isolation fencing of residential pools is the most proven way to prevent drownings (>50% swimming pool drownings in young children)

• Major change - Swim lessons for children older than 1 year of age (remember that swimming does not ‘drown-proof’ a child)

• Swim at sites with lifeguards, especially for open water recreation but remember that they are not a substitute for parental supervision

That is all for this week. Thank you for all your hard work. Have a great week and be safe out there!

Regina Yaskey, MD.

September 30, 2024

Fall is upon us, which means the weather is changing and you know what that means. It’s “Viral Respiratory Season” in the pediatric world, so we’ll focus on the evaluation and management of the child presenting in respiratory distress. 

When faced with a child in respiratory distress, ask yourself, is it an upper or lower airway obstruction?  

We will first start with lower airway involvement because you will encounter these most frequently during the respiratory season.  

Respiratory illnesses of the lower airway are obstructive, parenchymal, or alveolar diseases. The clinical hallmarks include dyspnea, tachypnea, and cough. Common causes include asthma, bronchiolitis, congenital abnormalities (tracheal webs, cysts, vascular rings, and lobar emphysema), cystic fibrosis, inhalation injury, pneumonia, and pulmonary edema. 

Asthma accounts for 15% of all emergency department visits. It is a chronic inflammatory lung disease with symptoms that include paroxysmal cough, wheezing, dyspnea, and chest tightness. It is caused by airway inflammation and narrowing that is partially or completely reversible. Precipitating factors include infection, allergens, irritant exposure (tobacco smoke, air pollution), exercise, cold exposure, beta-blockers, and emotional stress. When presented with a patient with asthma, your goal is to rapidly determine the severity of the acute exacerbation and examine their overall appearance (color and level of consciousness). Their respiratory mechanics are important. Look for tachypnea, retractions, nasal flaring, grunting, abdominal breathing, and prolonged expiratory phase. When auscultating, listen for their degree of air exchange (Are they wheezing? Are they not moving air at all? Do they have symmetry of their breath sounds?). Monitor their hydration status. In severe exacerbations, the child may be breathless, have difficulty speaking in complete sentences and may have a change in mental status (remember that hypoxia can cause agitation, and hypercapnia causes drowsiness or coma). Treatment for acute asthma exacerbations includes oxygen and duonebulizer treatments (Albuterol and Ipratroprium). These treatments can be repeated en route if the work of breathing persists. In severe exacerbations, insert an IV or IO, administer fluids for hydration, and add Solumedrol (2mg/kg; Max Dose: 60mg for children). Transport the patient to an appropriate facility and remember to consult Medical Control when indicated.  

Bronchiolitis is a viral lower respiratory tract infection of the bronchioles (small airways). It usually presents in the winter-spring months and is seen in children less than 24 months old. Respiratory syncytial virus (RSV) is the most common cause. Clinical signs are similar to a viral respiratory infection. These children usually start with a prodrome of nasal congestion, rhinorrhea, fever, cough, wheezing, and mild respiratory distress. Additional signs and symptoms include apnea, decreased oral intake, moderate to severe respiratory distress (tachypnea, nasal flaring, retractions, grunting), cyanosis, restlessness, and lethargy. Risk factors for severe disease include children less than 12 weeks old, with histories of prematurity (less than 37 weeks), congenital heart disease, chronic lung disease, and immunodeficiency. The course of bronchiolitis is variable and dynamic, ranging from transient events, such as apnea or mucous plugging, to progressive respiratory distress from lower airway obstruction. Symptoms usually worsen on days 3–5 of illness. Determining the degree of airway obstruction is the most important consideration when assessing children with bronchiolitis. Examine their general appearance, their degree of respiratory distress, cyanosis or pallor, and their level of oxygen saturation. When dealing with these patients en route, give them supplemental oxygen if the oxygen saturation is consistently below 92%. Insert an IV and administer fluids if they appear to be dehydrated. If wheezing is present, a trial of a bronchodilator (Albuterol) is an option. Please auscultate before and after the albuterol administration to determine if it made a difference in the patient’s air exchange or work of breathing.  

What sound do you hear from kids with an upper airway obstruction? Think about it. It is stridor, a high-pitched, crowing noise typically heard on inspiration. It indicates the presence of a large airway obstruction above the thoracic inlet. 

Croup is a common upper airway respiratory illness. It is an acute viral infection that causes inflammation of the subglottic airway, producing upper airway obstruction. Its hallmarks are stridor, barky cough (baby seal sound), and hoarseness. Some children present with fevers while others do not. When evaluating and treating these patients, it is important to keep them calm and not agitate them (remember, they have edema of their upper airway). Keep them in their position of comfort. Do not lay them down or perform a digital airway exam. Check a pulse oximetry and place them on the cardiac monitor. If they are in mild distress without stridor, give them nebulized normal saline while in transport. If they have stridor at rest with a barky cough, give them nebulized racemic epinephrine. If they are in moderate/severe distress with stridor and a barky cough, give racemic epinephrine plus IV Solumedrol (2mg/kg; Max Dose = 60mg in children). Of note, if racemic epinephrine is unavailable, you can administer aerosolized epinephrine 1mg/ml. Please note: (1) If your patient is wheezing, it is not croup. Wheezing in the breathing patient with respiratory distress indicates lower airway disease, not upper. (2) With croup, you should be able to note some improvement after a dose or two of racemic epinephrine (whether it is improvement in stridor or work of breathing). If you do not note any improvement, consider an Upper Airway Foreign Body Obstruction at the top of your differential.  

Upper airway foreign body obstruction is the leading cause of accidental death in toddlers. The history is that of a crawling infant or toddler presenting with an abrupt onset of choking or gagging. The parents will usually tell you that the patient has not been ill with any respiratory symptoms before this event. During auscultation, there is typically minimal or no air exchange despite effort from the child. Cyanosis can be present in a complete obstruction. Crawling infants and toddlers love to put things in their mouth hence the saying “everything is edible” to them, therefore, please keep your index of suspicion HIGH in a toddler-aged child. In coughing and conscious infants (0-12 months), administer oxygen (10-15L) via infant mask as tolerated. If the infant is conscious but there is concern for a complete obstruction (no breath sounds on auscultation, cyanosis), give 5 back blows followed by 5 chest thrusts. If the child is a toddler or older, perform abdominal thrusts instead. In the case of an unconscious patient with complete obstruction, immediately begin chest compressions/CPR. Have your partner open the airway to see if they can see the foreign body. If they can and it is retrievable, they can remove it with their fingers or consider using the laryngoscope and Magill forceps to retrieve and remove it. If unable to remove the foreign body, ventilate the patient via a bag valve mask and transport to an appropriate facility. DO NOT PERFORM A BLIND FINGER SWEEP. This may lodge the foreign body even further down the airway. Remember to contact Medical Control where indicated and provide appropriate transfer of care.  

Acute epiglottis is a life-threatening bacterial infection of the epiglottis and surrounding structures. Nowadays, it is very rare due to the administration of the Haemophilus Influenzae type B vaccine (also known as Hib vaccine). These patients are toxic-appearing and present with a very abrupt onset of fever, stridor, sore throat, and drooling. Do not agitate them and allow the child to maintain their position of comfort. Ensure adequate ventilation via BVM as soon as possible. DO NOT ATTEMPT invasive airway procedures on the conscious patient who is suspected of having epiglottitis, unless they are in respiratory arrest. Call medical command early and transport to an appropriate facility. 

Thank you for having me this month. I look forward to delivering more pediatric-focused messages in the future. Thank you for all your hard work. Stay safe out there.  

Regina Yaskey, MD.