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Pediatric PotpourriSince we are on the subject of pediatric care, it seemed an appropriate time to identify some of the issuesthat we have identified over the past several months with respect to pediatric care. These include pediatric RMAs,pediatric drug dosing, pediatric airway management, pediatric cardiac arrest, and our pediatric protocols.Pediatric RMAs Among all of the things that changed in the latest version of the RMA document, onething that did not change was the lower age limit for RMAs. Because of the issues with verbal communication inyounger patients, the different conditions specific to pediatrics and the fact that each of you has very few chancesto evaluate sick patients in this age range, OLMC contact is required for all RMAs for patients under the age ofsix.Since the new RMA policy was enacted, we have been following the compliance with this and other partsof the RMA procedure. We continue to see several cases a week for which patients under the age of six have anRMA disposition without OLMC contact. Like other areas of this policy, keep in mind that this age requirementwas put into place to protect both you and the patient. And it is certainly more than a rubber stamp.In the past year, there were 688 patients under the age of six for whom you contacted OLMC for thepurpose of an RMA. In ninety-nine of those cases (nearly one in seven), the patient was subsequently transportedto the hospital. Whether this was because the parent changed their mind, because the OLMC physician was ableto convince the caretaker of the need for transport, or because some additional information / history was able tobe identified that made transport necessary, it demonstrates the reason for this requirement.Pediatric Drug Dosing As every paramedic knows, Appendix J has been removed from the protocols andthe Broselow Tape has been replaced with the term “length-based dosing device” in our protocols. But what youmay not know is how rarely we actually give medications to our pediatric patients.In the past five years, less than 5,000 medications have been given to pediatric patients each year. Whenyou consider that most of these patients received multiple medications, what it means is that each of you is likelyto only provide (and therefore have to calculate a dose of) medications to a pediatric patient once or twice a year.Like all other aspects of pediatric care, what this means is that there is a need for you to review themedication dosing for pediatric patients often. Although you should always use the length-based dosing device todetermine these doses, there will undoubtedly come a time when you have a patient in need of medications but noimmediate access to the dosing device. Therefore, my recommendation is to spend just five minutes a monthreviewing the dosing for the most common pediatric medications (while driving, on the train, waiting for yourpartner to finish an ePCR) and then later check yourself to ensure that your memory was correct.September 2009 – Journal CME Newsletter page 12 of 18
Like so many other aspects of pediatric care, there is one equation that will nearly always help in this situation.Knowing the adult doses of the medications that you use, just divide that by 50 to get the mg/kg dosing forpediatric patients. To show how accurate this method can be and the drugs for which it may be inaccurate, Table1 lists the most common pediatric medications and their dosing.Drug Adult Dose Adult Dose / 50 Pediatric DoseAdenosine 6 mg IV 0.12 mg/kg 0.1 mg/kgAmiodarone 300 mg IV 6 mg/kg 5 mg/kgAtropine 1 mg IV 0.02 mg/kg 0.02 mg/kgDextrose 25 g IV 0.5 g/kg 0.5 g/kgDiazepam 5 mg IV 0.1 mg/kg 0.1 mg/kgDiphenhydramine 50 mg IV 1 mg/kg 1 mg/kgEpinephrine (1:1,000) 0.3 mg IM 0.006 mg/kg 0.01 mg/kgEpinephrine (1:10,000) 1 mg IV 0.02 mg/kg 0.01 mg/kgLorazepam 2 mg IV 0.04 mg/kg 0.05 mg/kgMidazolam 10 mg IM/IN 0.2 mg/kg 0.1 mg/kgTable 1: Adult versus pediatric drug dosingPediatric Airway Management Much like pediatric drug administration, the need for pediatric airwaymanagement is rare. And given the preference for basic life support airway management, the need for pediatricintubation is rare.Also like pediatric medication administration, the length-based dosing devices provide the appropriateendotracheal tube size to be used for pediatric patients and the depth to which they should be inserted. But forthat possible moment in which you find yourself with such a device and with a patient in need of immediateintubation, it is worth reviewing the other ways in which you can determine the appropriate tube size:Tube size = 4 + (age / 4)Tube size = (16 + age) / 4Tube size = patient’s pinkyTube depth = tube size x 3Particularly for infants and young children, it is important to select the correct tube size. A tube that is toolarge will damage the vocal cords. And because the uncuffed tubes are only effective when the cricoid (thenarrowest portion of the pediatric airway) forms a physiologic cuff, a tube that is too small will produce asignificant leak and possible result in effective ventilation.Pediatric Cardiac Arrest As Chief Fitton mentions in the Officer’s section below, a recent review ofpediatric cardiac arrests found that 30% did not have an AED or ALS monitor applied. For these calls, which canbecome the most stressful of all, it is critically important to take the time to provide complete and proper care,including AED or ALS monitor use.September 2009 – Journal CME Newsletter page 13 of 18
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