In contrast to adult patients, pediatric patients do not follow simple rules and as such, there is no one “magic number” to use as a predictor for patient condition, such as SBP in adults. In contrast, the best predictor for pediatric patients is getting the whole picture. No one vital sign trumps, the other instead they all build on one another to provide a better picture of what is happening. The most important part of a pediatric call is knowing recognizing that they are sick and knowing which tools can be used to help them.

Jonathan Lee

Jonathan Lee is a Critical Care Paramedic with ORNGE in Toronto, Canada with clinical experience in 911, critical care, aeromedical and paediatric critical care transport. In addition to his clinical practice, he is also Adjunct Faculty in the Paramedic Program at Georgian College. Jonathan’s teaching experience includes classroom, clinical and field education, as well as curriculum development and design across a number of health professions. He is currently pursuing a Master of Science in Critical Care from Cardiff University. His interests surround paediatrics, especially the confidence and competence of prehospital providers caring for acutely ill children.

Notes Written by: Katrina Cantera

Jon Lee, a critical care paramedic with ORNGE and pediatric specialist who founded the kinder medic program, joins us to explain the signs of critical pediatric patients that you do not want to miss. The KinderMedic program focuses on 3 key components of prehospital pediatrics assessment and management: IV’s, airway management and neonatal resuscitation to help shift the educational paradigm and teach vital hands-on skills paramedics need to know to be a good pediatric medic.

One of the biggest misconceptions around pediatric patients is that they get very sick very quickly. Pediatric patients do not get sicker more quickly, but instead they show signs differently. One very common comprehensive tool that is vital in pediatric prehospital medicine is the use of the Pediatric Assessment Triangle (PAT), which is the foundation for any thorough pediatric assessment. The Pediatric Assessment triangle relies on 3 predictors for the pediatric patient’s condition: 1) Appearance, 2) Work of breathing, 3) Circulation.

In contrast to adult patients, pediatric patients do not follow simple rules and as such, there is no one “magic number” to use as a predictor for patient condition, such as SBP in adults. In contrast, the best predictor for pediatric patients is getting the whole picture. No one vital sign trumps, the other instead they all build on one another to provide a better picture of what is happening. The most important part of a pediatric call is knowing recognizing that they are sick and knowing which tools can be used to help them.

IV’s:

One of the main takeaways from the discussion with Jon is that skills do not make a medic, decision making is what makes a good medic. One of the areas for improvement in terms of IV fluid resuscitation is knowing when a patient will need an IV. This can be determined by the simple paramedic handshake and PAT assessment. Another consideration is that if there is little success with IV insertion, and your pediatric patient is clearly sick, considerations for IO access should be made. Knowing the time and place for the more unconventional treatments, such as IO fluid resuscitation, are critical for the outcome of the patient. The key point is not whether you do it, but whether or not you are able to recognize when it is needed.

Airway:

Airway management is crucial in pediatric patients, especially when you consider that the majority of pediatric emergencies are respiratory in nature. Respiratory illness is a prevalent issue in pediatric patients because the underlying anatomy is smaller, meaning that any pathology will have a more profound impact on the patient. A big emphasis on airway management is not discounting the efficiency of minimally invasive procedures such as the use of BVM ventilations, over intubation. Prehospital studies show evidence that the best-case scenario for prehospital intubation is the same outcome as BVM ventilations. Other alternatives include the use of supraglottic airways (SGA), which help to minimize the worry of the BVM mask seal during ventilations. The most critical consideration for pediatric airway management is proper ventilation by not either over ventilating or under ventilating. A good marker of this is ventilating until there is chest rise and fall, or by monitoring EtCO2.

Pediatric Cardiac Arrest and Resuscitation:

One of the main differences between pediatric cardiac arrest is that there is rarely a shockable rhythm present. Furthermore, pediatric patients are not the patients that you will be rushing to the catheter lab for rapid emergency surgery, mostly because their hearts are generally healthy with no underlying pathologies, and most pediatric cardiac arrests are respiratory in nature. Studies show that the best outcome during pediatric cardiac arrest is early recognition of cardiac arrest, good quality and early CPR and early defibrillation. Furthermore, a 2015 study showed that the worst outcome for pediatric cardiac arrest calls were those with a scene time of less than 10 minutes. When compared to calls with a scene time of 10-35 minutes, the rate of a return of spontaneous circulation (ROSC) was reduced by half in calls with a scene time of less than 10 minutes (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4540668/).

Pediatric “soft skills”

With experience comes a certain level of comfort, but there are some things that can be done to alleviate the stress and things easier. A lot of the pressure/stress comes from self-imposed stress. Anything you can do to minimize your cognitive load is tremendously helpful. Examples include using a broselow tape, apps, pre-calculating your medications on route, etc. Another tip is to stop “making it about you”, and to involve the parents as much as you can. In line with that, communication with the parents is key, and immediately gets them on your team. Jon’s 3 rules to parents: