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December 2024; Volume 13, Issue 12
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Utah Emergency Medical Services for Children
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Pedi Points
Tia Dickson RN, BSN
PCH Trauma RN, Utah EMSC Nurse Clinical Consultant
Shock is a subtle killer of children. In Utah, many deaths have occurred due to shock, which is tragic because, when recognized early, intervention can prevent these fatalities. The key is timely recognition and prompt treatment. Shock is difficult to detect in children. They are able to compensate for blood loss and other physiological stressors until it is too late. When recognized early, however, medical interventions can significantly improve outcomes. Do you know what to look for?
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Recognizing Pediatric Shock
Sarah Becker, MD
Primary Children’s Hospital
Excerpts from November 11th, 2024 PETOS
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Recognize shock early and treat shock fast!
The risk of death doubles for every hour of persistent shock. Early intervention is crucial. What you do as the first responder matters.
Pathophysiology
To recognize shock, you must understand it.
Simplified, the body’s oxygen and nutrient needs exceed what is being delivered. Untreated, this leads to metabolic acidosis, organ dysfunction and death.
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Recognizing shock
These things should give you a high index of suspicion for shock in kids.
If you have a high index of suspicion, treat it! Often, we try to explain away these symptoms: ‘The child is crying, that’s why he’s tachycardic’ or ‘That blood pressure is low because the cuff is too large.’ Do not hesitate to treat suspected shock!
Monitor vital signs frequently and understand what is normal for each age group. Carry a vitals card or use an app. Blood pressure measurement is also the standard of care (despite some outdated teachings). Hypotension is a LATE sign of uncompensated shock. A useful formula for an acceptable systolic blood pressure is:
70 + 2 x age
Up to 10 years old and then use at least 92mmHg
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Once you have determined that your patient may be in shock, assess whether the shock is compensated or uncompensated. Then, work to identify the specific type of shock present.
Types of shock
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You do this by taking a history and evaluating signs and symptoms. An often overlooked point is that the patient may fit into more than one type of shock.
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In pediatric shock, the relationship between preload, contractility, and afterload is essential to understanding how the heart pumps blood and how the body responds to shock.
Preload determines how much blood enters the heart, contractility affects how strongly the heart pumps, and afterload determines how difficult it is for the heart to pump blood out. Any disruption in these factors can worsen shock and decrease organ perfusion.
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Preload: This refers to the volume of blood returning to the heart (venous return). In shock, preload may be reduced if there’s blood loss, dehydration, or fluid shifts, making it harder for the heart to fill and pump blood efficiently.
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Contractility: This is the heart’s ability to contract and pump blood. In shock, especially in conditions like cardiogenic shock, the heart’s contractility can be impaired, reducing the effectiveness of each heartbeat.
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Afterload: Afterload is the resistance the heart must overcome to pump blood. In shock, especially in conditions like septic shock, afterload may decrease (leading to vasodilation) or increase (in cases of obstructive shock or some forms of hypovolemic shock), making it harder for the heart to pump blood effectively.
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Golden of hour of treatment
During the golden hour of shock treatment, it is crucial to address issues related to preload, contractility, and afterload. The most common interventions for these concerns include fluid resuscitation and pharmacologic agents such as calcium, glucose, and vasoactive medications.
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Initial steps of treatment
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Have a high index of suspicion
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Report your suspicion to the receiving hospital. This information will significantly influence their preparedness and the treatment pathway for your patient
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Provide oxygen even if saturations are normal, maximize delivery
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Warm the child and obtain a weight
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Check glucose and correct it
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Obtain fast access
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Administer fluids: 20ml/kg of crystalloid, administered rapidly (up to 60ml/kg)
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Reassess: after the initial bolus, reassess the patient’s clinical status (heart rate, blood pressure, capillary refill time, urine output) to determine if further fluid administration is needed.
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Consider and treat underlying causes
Your end goal is to restore or improve perfusion and save a life!
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Considerations in Traumatic Shock
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Patients can progress from normal to irreversible shock within 20 minutes, depending on the mechanism, with trauma (especially bleeding) being the fastest. The average child has a circulating blood volume of 80 ml/kg. For example, a 12 kg toddler has about 960 ml of blood, or roughly 4 cans of soda. Because children compensate so well, they can lose up to 1/3 of their blood volume (1.5 cans) before blood pressure changes are noticeable. Children also hide internal bleeding effectively, as “baby fat” can obscure swelling and bruising, and many cannot verbalize or localize pain. Recognizing traumatic shock in children is a time-sensitive emergency.
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In traumatic shock the ultimate goal is to stop the hemorrhage and replace what has been lost. Blood for blood, plasma for plasma, and FFP as needed.
1. STOP the bleeding
2. Restore and maintain blood pressure in a normal range for age
3. Avoid over-hydration, reassess after every 20ml/kg bolus and consult OLMC after 60ml/kg
4. Resuscitate with balanced blood component replacement when possible
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Pharmacy Facts
Greg Nelsen, PharmD
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If medications are required to help maintain blood pressure, you have a choice of epinephrine or norepinephrine. Follow your medical control for which to use first but at PCH the first choice is usually epinephrine.
Epinephrine and norepinephrine are both vasopressors, but they work a bit differently:
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Epinephrine: It constricts peripheral blood vessels, which helps return blood to the heart, and it also increases the heart rate. This makes it useful when you need both to improve blood pressure and support cardiac output (e.g., in cases of shock with poor heart function).
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Norepinephrine: It primarily constricts peripheral blood vessels, which increases blood pressure but has little to no effect on the heart rate. It’s more focused on improving systemic vascular resistance (SVR) and is typically used in cases of septic shock or other conditions where vascular tone is low.
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Dosing
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Epinephrine: 0.1–1 mcg/kg/min IV/IO
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Norepinephrine: 0.05–0.1 mcg/kg/min IV/IO, up to a maximum of 2 mcg/kg/min
Both should be titrated to maintain a systolic blood pressure (SBP) > 70 + (age in years × 2) mmHg.
Summary
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Skills refresher:
Push Pull Method for Pediatric Fluid Administration
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Patho deep dive:
Definition and Pathophysiology of Shock
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For additional guideline direction check out the UPTN website or the new app, “Utah PTN” on android and apple devices.
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CME credit for this issue
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Training officers may review the topic above as a team training AND perform a simulation/skills check as directed. Once complete, send a roster of participants to Utah.PETOS@gmail.com and those listed will be issued 1-hour of CME credit from the Bureau of EMS, DPS.
Individuals who don’t have a training officer can get CME credit on their own by viewing a PETOS presentation in our archives and completing the instructions on the webpage.
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Skills checking
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Review the newsletter content with your team.
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Watch both video links above.
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Practice simulation scenarios from one of these sources:
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Your agency PECC may access their shock scenario from EMSC
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EMS Simbox (Sick Neonate)
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Investing in pediatric emergency care could save more than 2,100 children’s lives annually, study finds
A new study has found that high levels of Pediatric Readiness in all EDs could save 2,143 children’s lives each year and cost between $0 and $12 per child resident, depending on their state. The landmark research, published last Friday in JAMA Network Open, is the first to identify totals of lives that could be saved nationally and by state. The research adds to a growing body of evidence that Pediatric Readiness is both imperative and achievable for all EDs. The study, which has received attention from national media, including The New York Times, was led by Craig Newgard, MD, MPH, of Oregon Health & Science University, with senior author Nathan Kuppermann, MD, of Children’s National Hospital. Learn more.
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EMSC Pulse
National EMSC has a newsletter filled with fantastic pediatric information, resources, and links. Check it out!
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Congrats to our famous FAN
Jeff Wilson was awarded the Spirit of Service Award last month. Congratulations to the 2024 Governor’s Spirit of Service Award winners!
”Service is not only an integral part of our administration, but it’s part of who we are as Utahns. When we do something good for others, we enrich our own lives. These individuals are great examples of fostering empathy and community, reminding us that we’re all brothers and sisters. Lt. Governor Deidre Henderson and I were honored to recognize them today”
-Gov. Spencer Cox
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Autism awareness training (agency and hospital)
If your agency is interested in the John Wilson Autism Training or in receiving the free autism kits, contact Jeff Wilson, PM @jeffwilson122615@gmail.com.
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Do you know about the Medical Home Portal?
The Medical Home Portal is a unique source of reliable information about children and youth who have special health care needs (CYSHCN) and offers a “one-stop shop” for their:
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PECC development
For Utah hospital and EMS Agency PECCs
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Pediatric emergency care coordination:
Having pediatric emergency care coordinators (PECCs) in the ED is the most important strategy for improving Pediatric Readiness and is tied to double-digit increases in Pediatric Readiness scores. To help support clinicians in the role of the PECC, the EMSC Program has released the third module in its ED PECC learning module series. The modules include step-by-step instructions for evaluating the readiness of your ED, strategies for getting buy-in to develop the PECC role, PECC job descriptions, and more! The modules are free and open-access. View them here.
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Prehospital assessment process highlighted
A paper outlining the methodology behind the Prehospital Pediatric Readiness Project Assessment was recently published in Academic Emergency Medicine. The publication describes the evolution of the first comprehensive, nationwide assessment of pediatric capabilities of EMS and fire-rescue agencies, from the development of a scoring algorithm to pilot testing. More than 7,000 agencies responded to the assessment, which closed July 31. Read the paper or learn more about the project.
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Understanding the PECC role
For hospital PECCs
For EMS PECCs
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PECC quarterly meeting
You will receive an invitation with the link through email. If you are a PECC and don’t receive this invitation contact our program manager, Jared Wright jaredwright@utah.gov.
When?
Tuesday, Feb 18, 2024, 10:00 AM
Southern PECC workshop
PECCs are encouraged to attend an in-person PECC workshop each year to receive up-to-date pediatric training, direction for your PECC role, and to participate in networking with other PECCs statewide. These workshops are free to designated hospital and agency PECCs. We will offer one in the northern part of Utah and one in the southern part each year.
When?
May 22th, 2025
Where?
St. George Regional Hospital, St. George, Utah
PECCs register here
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Pediatric education from Utah EMSC
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Pediatric Emergency and Trauma Outreach Series (PETOS)
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PETOS (pediatric emergency and trauma outreach series)
This course provides 1 free CME credit from the Office of Emergency Medical Services, DPS 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.
Upcoming topics
December 9th, 2024 – Pediatric seizures and status epilepticus with Maija Holsti, MD
January 13th, 2025 – Hangings with Stuti Das, MD
02:00 PM Mountain Time (US and Canada)
Join Zoom Meeting
https://zoom.us/j/98193757707?pwd=UzdNeXppQUdtZ01KZUp2UFlzRk9vdz09
Meeting ID: 981 9375 7707
Password: EmscPCH
Archived presentations can be viewed and also qualify for CME credits. You can access them at https://intermountainhealthcare.org/for-professionals/PETOS.
To obtain a completion certificate—follow the instructions on the website
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Other pediatric education for all
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Current Concepts in Neonatal and Pediatric Transport Con.
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February 19-21, 2025
47th Annual Current Concepts in Neonatal and Pediatric Transport Conference
https://intermountain.cloud-cme.com/transport2025
Radisson Hotel Downtown Salt Lake City, UT
*Virtual Option available
22 possible AMA and ANCC credits and Respiratory Care Credit
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Children’s EM-mersion webinar series
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Intermountain Children’s Health Emergency Management Team is offering a weekly (every Tuesday) 30-minute educational opportunity for all hospital-based EM’s and PECCs in Utah and the surrounding Intermountain West.
We will delve into different pediatric planning topics such as decontamination operations, reunification, behavioral health, isolation/quarantine, and more! The goal is to help you better plan for pediatric patients at your facilities!
This weekly series is designed for you to attend whenever you can—you do not need to attend all sessions.
Register here for the rotating topic schedule.
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University of Utah pediatrics ECHO 2024
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The Pediatrics ECHO is back! For those new to Pediatrics ECHO, you can earn CME for participating in a case-based learning session with experts in a variety of pediatric topics.
You can view previous session recordings and other programs on the Project ECHO page. CME is available for participation in these classes.
More Information
Note the University has a new EMS education website.
When? Wednesdays 12 – 1 pm (MT)
December 11, 2024 IgE Mediated Food AllergiesErik Newman, MD
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University of Utah injury prevention learning series
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University of Utah’s EMS trauma grand rounds
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Hospital-focused pediatric education
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Primary Children’s pediatric grand rounds
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Offered every Thursday, September-May
Offering both RN and MD CME
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 a.m. to 9 a.m. from September through May in the 3rd Floor Auditorium at Primary Children’s Hospital and at Lehi a broadcast will be held in the Modersitzki Family Education Center: First floor in rooms 1 & 2.The lectures are also broadcast live to locations throughout Utah and nationwide. Click on this link to view the broadcast: https://www.youtube.com/channel/UCNQP-M_3-PdPDvnICr2Fjpg
Connect live
Click here for the PGR PCH YouTube channel to find the live broadcast. Archives (without continuing education credit) will be posted here within 1 week of the broadcast.
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Emergency Medical Services for Children Utah, Bureau of EMS, Department of Public Safety
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.
Email: tdickson@utah.gov
Website: https://ems.utah.gov/
Phone: (801) 707-3763
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