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Bronchioles can become inflamed and filled with mucus, blocking the airway. Pertussis, or whooping cough, is caused by a bacterium and can be prevented with vaccination. Lack of vaccination can lead to a resurgence of diseases. Symptoms of pertussis include coughing, sneezing, and a distinct whooping sound. Airway adjuncts like OPAs and NPAs can help maintain the airway. Oxygen can be delivered through various methods like nasal cannulas and non-rebreather masks. Shock can occur in children due to trauma, dehydration, infection, or heart diseases. Children compensate for blood loss better than adults, but can decompensate quickly. So, this is where the airway issue becomes serious. More widespread in the weekends and spring months, bronchioles become inflamed, swell and fill with mucus. Airway can become completely blocked by this mucus, so have suction available. Look for signs of dehydration, especially in infants, look for those sunken bronchioles that force the intervertebral shortness of breath and de-burp. Use a calm demeanor when approaching, keep the child calm, put him in a position of comfort. Treat the airway of breathing, have suction available, warm, humidified oxygen, call ALS back up and transfer. Pertussis, also called whooping cough, caused by a bacterium spread in respiratory droplets, was found in the United States because we vaccinate for it, DTE, diphtheria, tetanus, pertussis. The only problem is that we have a lot of people in this country who are not vaccinated, whether they come from other countries or they decide not to vaccinate, the anti-vaxxers so to speak. In order to eradicate an illness, you have to have 90% or more, 95% or more vaccine rates in the country. Unfortunately, in today's society, most of the illnesses that we vaccinate for are under 90%, and so that's why we have a resurgence of all these smallpox, smallpox every year, we find all kinds of pertussis, diphtheria, we're finding these now. So you didn't vaccinate for smallpox anymore? No, and now it's coming back. So it was eradicated, yeah. But it's eradicated in the United States, but it's common in other preferable countries, and then they come over here and they break with it. Here, you go through the process of gray cards, of course, to get all the vaccines, even if you have them in a different country, all the vaccines come back. That's if you come in illegally. If you come in illegally, it doesn't matter what you have, and that's the problem, is we have 20 million or so illegals, and they have no medical screening whatsoever, so we don't know what they have. And 20 million, that's almost, that's like 7% of our population. So then we narrow down, and even if everybody in the country was vaccinated, 20 million people coming in, we drop below that 95%. Signs and symptoms, coughing, sneezing, and runny nose. Coughing becomes more severe with a distinct whooping sound. The kids will have a terrible cough, a really bad coughing fit, and then they'll inhale, and they'll have that whooping sound, and that's where they get the term whooping cough. They can develop pneumonia, and it can develop into respiratory failure. That's the problem with pertussis. That's the reason why we vaccinate for it, because children prior to the vaccination die from it. The idea is to keep the patient, keep the airway patented open. Make sure you're wearing, with any cough, any fever, wear a mask, gloves, goggles, put a mask on the patient. Airway adjuncts, devices that help maintain the airway or assist in providing artificial ventilation. OPAs, NPAs, pipe blocks, BPMs. You know, we talk about the eye gels as well, which we talked about. OPAs keep the tongue from blocking airway and make suctioning easier. Keeps the tongue off the back of the throat. We talked about how these should not be used in conscious patients, because they'll vomit, or any patient with a gag reflex or those who ingest caustic or petroleum-based products, because when they vomit up, it'll burn the airway a second time. So we don't want to initiate or cause vomiting. Nasal peritoneal airway, usually well-tolerated. Kids will take them. Used to respond to pediatric patients or patients who are obtunded or lethargic that won't take an OPA, but we want to make sure we maintain a good airway. They're great in, you know, diseasing patients, because I can put it in and leave it in, so if they go in and out of seizures, it protects the airway. You know, drug or toxic ingestion drug overdoses, things like that. Used in association with respiratory failure. Rarely used in infants younger than a year. We do have NPAs that would work, but we generally don't put them in. Should not be used if there's nasal obstruction or, of course, head trauma. We know that's the con. I just have a question for you. What is low flow? I had a patient the other day that had 25 cc's of low flow, and they didn't, like, transition to CPAP or anything. Like, they didn't have CPAP or anything, but what's, like, a low flow? Is that the same thing as the can... The low flow, well, low flow would be, like, two to four liters. Is it the same? Like, you would still use that same kind of cannula bottle, the same air bottle? Yeah, yeah. You just... In other words, low flow. In other words, they don't have high flow oxygen. It's low flow oxygen. Okay. Two to four liters is low flow oxygen. Okay. Just enough to keep them open. That's all. Nasal peritoneal airways. There's a problem. They become obstructive. Again, you put them in. That's why we don't like to put them in in infants, because they get a lot of mucus, and they get clogged up. But even in younger children, they can get clogged up with blood vomitus or swelling from the tissues. They stimulate the vagus nerve. If you push it in too quickly or too rapidly or force it in, you can actually stimulate the vagus nerve, which is the back of the throat, which can slow the heart rate. It may cause spasms of the larynx, causing vomiting. It should not be used in pediatric patients that have facial trauma and, again, hand or head trauma. Several options for pediatric patients' oxygen delivery. What you do is you take the oxygen tubing, you turn the oxygen up to 6 liters per minute, and you put it in a cup, and you put the cup, have mom hold the cup near the baby's face. Not on it, just near it. Or, as mom's holding the baby, you can literally slide it. Tell mom to keep your arm there. You can slide the oxygen tubing up so it's near the baby's face, but it's not blowing on the baby. Both of those will usually deliver about 30% oxygen. That means you'll know it's full right there. Nasal cannula is 1 to 6, so it is 24 to 44% oxygen. Nasal cannula is usually pretty well-tolerated in infants. Non-rebreather masks, 10 to 15 liters. And, again, I'm not going to put 15 liters per minute on a 3-year-old child if I'm bagging them. 10 liters is more than enough. Non-rebreather masks, nasal cannulas, or simple masks, is indicative of pediatric patients who have adequate respiration. Again, if I have good respirations, but I need oxygenation, non-rebreather. If I have poor respiratory drive and need oxygenation, we're going to bag them. Low-buy, less effective than a face mask, but sometimes patients will only tolerate this. Place the tubing hole into the bottom of a cup, or you can put it directly, slide it in between the mom and the baby, underneath the arm. Connect it to 6 liters of oxygen and hold the hose for the cup 1 to 2 inches away from the baby's face. It gives more than 2 months out. Nasal cannula, we talked about it. It's the same way. It goes around. It goes into the nose and then around the ears and comes out, and you kind of clip it that way. And, again, it's usually well-tolerated. Here's the cup method. And, again, let's say I don't have a cup. I can literally slide the hose underneath mom's arm and kind of hold it this way so it's blowing at the child. There's the nasal cannula right there. Non-rebreather mask and a BVM. There's the non-rebreather mask and a BVM. We see these in respiratory, right? We talked about these. Two-person BVM. It's always better to have two-person versus one-person BVM. I know we practice one person when we do the CPR because there's only one person to do it. But, usually, on a scene, especially with a sick child, you're going to have multiple people. Have, you know, you have somebody hold a good mask seal, right? So, if I'm holding the mask seal and you're ventilating, I can hold the seal better. I can get a better seal. And you have, you can watch more because you're not trying to do two skills. You can watch my ventilations better. Cardiac arrest in pediatric patients is associated with respiratory failure and arrest. We talked about that. Children are affected differently by decreased oxygen concentrations. They become hypoxic. Their heart rate slows, becoming more bradycardic, right? Many times, they'll stop. Their heart rate will stop before they stop breathing. So, we have to be careful about that. Many times, they'll stop. Their heart rate will stop before they stop breathing. So, we want to make sure that we oxygenate. We don't want them to get bradycardic. We don't want them to get bradypenia. Shock. Shock develops when the circulatory system is unable to deliver a sufficient amount of blood to the organs. It results in organ failure and, eventually, cardiopulmonary arrest. Compensated is early. Decompensated is a later stage. Children go into shock 25% faster than adults do. But they compensate up to 50% blood loss. So, they compensate better than we do. But when they decompensate, they decompensate very rapidly. We kind of decompensate slowly. They decompensate very quickly. So, you've really got to pay attention. Common causes include trauma with blood loss, dehydration from diarrhea, and vomiting. An infant with two hours of vomiting and diarrhea can develop hypovolemic shock. If they're not in taking anything. Severe infection, like septic infection, or neurological injury, like neurogenic shock. Anaphylaxis. Diseases of the heart. These are congenital diseases. Kids don't have heart disease from, you know, eating pork rice. Although, I will tell you. I remember years ago, I had a friend who worked in pathology at Brown Hospital. He worked with a doctor, Lee, who did the autopsies for pathology. And every now and then, he'd ask me if I wasn't doing anything. Hey, you want to come in, we're doing an autopsy, whatever. And I'd brush down to see it. Because he'd let me go in. And I remember him doing autopsies on a couple of kids. One kid was five years old. He died of whatever the trauma was. And he showed me the blood vessels. The arteries had cholesterol. Five years old. Cholesterol. Blockages in the arteries. Where does that come from? McDonald's and Burger King, three times a day. Yeah, that's what happens. Fatty foods. Believe it or not, at that age. Now, there's some congenital part to that as well. There's some congenital part to that as well. Because the child probably had abnormally high cholesterol. But high fat diet with lack of exercise. The kid was a heavier kid. That's what you get. Imagine that. Five years old. Tension pneumothorax, which can lead to a cardiac tamponade. Blood or fluid around the heart, which can be caused by pericarditis. Which is an infection of the heart. Myocarditis. Teenage patients respond differently than adults to food loss. They respond by increasing heart rate, increasing respirations, and showing signs of pale or blue skin. Right? They compensate for that. Signs of shock. Tachycardia. Poor capillary refill. Greater than two seconds. Right? Capillary refill. Plus one. Plus two. Plus three. That's a bad sign. Changes in mental status. They might become combative or maybe lethargic. Treat shock by assessing ABCs and then high flow oxygen. Stop external hemorrhage. Call ALS. Right? You can put them in the Trandellenburg position if you have to. Raise up the legs. Blood pressure does not fall until shock is severe. Our blood pressure, we decompensate. We've got some time with decompensation. When children decompensate, it goes from decompensate to irreversible very quickly. They go to irreversible very quickly. We don't want them to decompensate. Treatment for shock. Limiting your management to simple interventions because we want rapid transport. We don't want these big intricate things. We want to make it quick, simple, and get moving. Call ALS for IV fluid. Do not waste time performing field procedures. Ensure airway is open. Prepare for artificial ventilation. Control bleeding. Keep the patient warm. Psychological medicine. Call ALS. Stop the bleeding. Give supplemental oxygen. Monitor airway and breathing. Position of comfort. Keep them warm. Call ALS. Anaphylaxis. We all know about anaphylaxis, right? Children carry epipens to where they have them in the schools and things. Children die every year because they, most of the time, it's either delay in seeking care or it's the first time anaphylaxis. Somebody was sensitized to something but they never had a reaction and they're severely allergic to it and they need it again. Boom. And they pop an allergic reaction and they die from it. It happens. I just found a reel of a dad taking his kids to the hospital and trying to give them a new fluid. He said, it's better here than where it comes. Or you can wait until after a child. This is a problem. Many things, they believe that some allergies develop because kids are introduced to fluids too quickly. That's why you don't give eggs to a child, to an infant. Always wait. It's good to wait about 14 months before you start introducing a child to fluids. Don't our bodies change every seven years? Every seven years your body changes. You can outgrow an allergy. Common causes of insect stings, medications, and of course the most common is food allergies. Hypoperfusion, which is a drop in blood pressure, stridor or wheezing, increased work of breathing, restlessness, agitation, sense of impending doom. I don't think too many infants or small children, I've got to tell you, I'm going to die. They don't even talk, and hide. Treatment, high flow oxygen, maintain the airway, position of comfort, and either epi auto injector or draw up, you know, the check and inject. What is the dosage for a child? Under 55 pounds, 25 kilograms. 0.15, half the dose. Half the dose. Bleeding disorders, hemophilia is a congenital condition in which patients lack normal quality factors. There's factor VIII, factor IX, which is hemophilia A, hemophilia C, and then there's von Willebrand, which is more common in women. Most forms are hereditary and severe, predominantly found in the male population. I think it's five times more popular in males than females. Bleeding may occur spontaneously. A true hemophiliac can bleed to death from a bruise. All injuries become serious because the blood does not clot, and especially if it's internal, you're not going to recognize it. Oh, look! AEIOU tips. Wow! You might see that as a final exam question. Or you might see it as an extra credit. Alcohol, epilepsy, endocrine, or electrolyte. Insulin, opiates, drugs. Or uremia, which is kidney failure. Trauma, temperature, which would be hyper-hypothermia. Infection, poisoning, psychogenic causes. Shock, stroke, seizure, syncope, space, occupied lesions, and subarachnoid hemorrhage. That's kind of a bigger list than I need. And that's 35-11. That's in a couple of places in your book. I know. I've seen that. That was before, too. Signs and symptoms vary from simple confusion to lethargy, obtundation, and unresponsiveness, as they put it. Management focuses on ABCs. Make sure they're taken care of. Make sure they're oxygenated and transferred. Seizures result from disorganized electrical activity in the brain. That's actually the definition of a seizure. Seizure activity caused by disorganized electrical activity in the brain. Manifests in a variety of ways. In infants, it could be, ever see a baby when it lies, kind of moving around, it's kicking its arms, it's doing all kinds of stuff? If you see a rhythmic motion in infants, like a bicycling motion, if they're doing a rhythmic motion, that is a common sign of a seizure. Babies don't do anything rhythmically. They have no rhythm, right? More obvious in older children are repetitive muscle contractions and unresponsiveness. Usually a baby that's unresponsive when you snap the fingers or talk to it or touch it, and it's got that rhythmic movement, that's generally a seizure. What about when they're eight? When they're what? When they're eight, but not snapping. When they don't listen to you? Oh, that's different. Eight-year-olds? Then you just kick them in the ass. Common causes of seizures. First of all, child abuse with head trauma. Things like that. First of all, child abuse with head trauma. Things like your shaken baby syndrome. Electrolyte imbalances, which is not uncommon for, you know, children who are sick, who have vomiting and diarrhea. Fever, we call that a febrile seizure. We talked about that. Hypoglycemia, low blood sugar. Infection, ingestion of toxic substances. Alcohol or drugs. Lack of oxygen, hypoxia. God bless you. Medications, poisoning. Maybe they have a seizure disorder. Maybe they have a congenital seizure disorder. They might not even know it. Recreational drug use, head trauma, and no causes can be found, which kind of go along with a seizure disorder or epilepsy. And when we talk about recreational drug use, youngest heroin patient I ever saw, nine. Once a seizure stops and muscles relax, it is referred to as the post-ictal state. The longer and more intense the seizures are, the longer it will take for the imbalance to correct itself. It can take up to 30 minutes. For a full tonic-clonic seizure, the full skiv-a-quiver on the ground that lasts for 10 minutes, you can have a 30-minute post-ictal state. Post-ictal state is over once normal level of consciousness is regained. Once they can ask and answer questions appropriately, it's pretty much over with that. The body has to reset itself, right? Seizures that occur every few minutes without regaining consciousness for a seizure lasting longer than 30 minutes is called status epilepticus. This is a life-threatening condition. What is the life-threatening cause? Lack of oxygen. Lack of oxygen. The patient's not breathing. This is where we want to put an NPA in. We want to put them on high-flow oxygen. Bag them in between if you can. If the patient does not regain consciousness and continues to cease, protect her from chronic cells, call ALS. We can give them medication. We can give them birth control. If the patient has valium, rectal valium, they call diastat. It's a rectal injector. It helps PAMP give it to the baby or give it to the child. So management, secure and protect the airway are priority. Position the head in an open position. Clear the mouth with suction. Use the recovery position if the patient is vomiting. Provide 100% oxygen by non-reglator or blow-by method. Bag them. Get no signs of improvement. Some caregivers will have, again, that diastat, which is diazepam, which is valium. You are authorized by OEMS to assist the payer in giving it to the child. Obviously, if the parent needs help giving it to the child, they can do it. Diazepam is like a low... like a benzo kind of... Valium. Benzodiazepine. Valium. It's higher than lorazepam. There's Ativan, which is lorazepam, and then there's valium, which is diazepam. Works great for seizures. We, at MedStar, we give her a shot because we don't care about it. We'll only take five minutes. Take a break.