Dealing with toddlers

rhan101277

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So I had a 11 m/o who's parents stated he had a two seizures, each lasting about 10 minutes w/ recovery to consciousness. Upon arrival he is not seizing and his vitals are stable. I get out the broselow tape and get accurate drug dosages. He is AAOx3 and fussy, has a fever, so I am thinking possibly febrile seizure. I take off his shirt, put him on the cardiac monitor and pulse ox and administer blow by oxygen. His initial sats were 93%. I draw up versed just in case I have to give some IN, if he has another seizure. He has CBBS and equal chest rise/fall, PERRL, fussy but calmed by mother and then fussy again.

I get more nervous around pediatric patients. Will this always be the case or does it go away?

What would you have done different? I considered IV, but knew I could give medication IM and I was concerned that getting him more fussy and causing him to become hypoxic and maybe re-seizing.

Thoughts?
 
So I had a 11 m/o who's parents stated he had a two seizures, each lasting about 10 minutes w/ recovery to consciousness. Upon arrival he is not seizing and his vitals are stable. I get out the broselow tape and get accurate drug dosages. He is AAOx3 and fussy, has a fever, so I am thinking possibly febrile seizure. I take off his shirt, put him on the cardiac monitor and pulse ox and administer blow by oxygen. His initial sats were 93%. I draw up versed just in case I have to give some IN, if he has another seizure. He has CBBS and equal chest rise/fall, PERRL, fussy but calmed by mother and then fussy again.

I get more nervous around pediatric patients. Will this always be the case or does it go away?

What would you have done different? I considered IV, but knew I could give medication IM and I was concerned that getting him more fussy and causing him to become hypoxic and maybe re-seizing.

Thoughts?

I'm always nervous around kids. My last code as a medic student was a septic 12 week old. I'm not an old salty medic by any means, but everyone I work with still gets the "Oh no, it's a kid call" pucker factor.

As for the seizures, Whith no history and a temp, I'd guess febrile as well. Do you have PO acetominophen? I'm guessing you also don't have rectal valium in your protocols.
 
No I would have given Versed IN, dose based on broselow tape.
 
So I had a 11 m/o who's parents stated he had a two seizures, each lasting about 10 minutes w/ recovery to consciousness. Upon arrival he is not seizing and his vitals are stable. I get out the broselow tape and get accurate drug dosages. He is AAOx3 and fussy, has a fever, so I am thinking possibly febrile seizure. I take off his shirt, put him on the cardiac monitor and pulse ox and administer blow by oxygen. His initial sats were 93%. I draw up versed just in case I have to give some IN, if he has another seizure. He has CBBS and equal chest rise/fall, PERRL, fussy but calmed by mother and then fussy again.

I get more nervous around pediatric patients. Will this always be the case or does it go away?

What would you have done different? I considered IV, but knew I could give medication IM and I was concerned that getting him more fussy and causing him to become hypoxic and maybe re-seizing.

Thoughts?

Two 10 minute seizures? With no history? Was he like their 8th kid? Because otherwise I'm thinking poor history, or disinterested parents.

Assuming the kids baseline was healthy, I'm not sure "fussy" can lead to a hypoxic seizure unless you irritate the crap out of an epiglottitis(sp?) patient and cause the airway to close.
 
You did fine IMHO. I do not get nervous around kids anymore, but that is because they are my specialty now. Back when I worked fire based EMS, yeah, kids were "scary". But looking back, I realize the error of my ways.

First, take the parents relation of what happened for what it is worth. I believe most parents when they describe what happened, but when it comes to certain details, I always have some doubt when it comes to what lay people say. One of these details is time. When parents say a child seized for 10 minutes or was unconscious for 10 minutes, I approach it with some skepticism. I am not saying they are lying, I know though that in stressful situations 1 minute can feel like 10. Also, always check your own temperature. I have seen way too many parents relate ridiculously high temperatures, only to find them either normal, or slightly elevated on assessment. I had a parent tell me her child had a 114 degree temp once. I asked if she was sure, and she said absolutely...needless to say, the child was awake, looking around, and crying rather loudly. I was pretty sure the temp was not 114.

Febrile seizure is a good working diagnosis. Good call removing the short. In addition to the general history, find out if mom and dad have been giving Tylenol or Motrin, and if so, how much, also how often. I find that quite regularly parents are under dosing their kids on antipyretics and/or not adhering to an effective dosing window.

Of course follow your protocols, but I know in many cases if their is a high index of suspicion for a febrile seizure, we will not immediately administer narcotics at the onset. Febrile seizures are generally short in duration, and with the interventions you took (shirt off, controlled ambient temperature) the likelihood of repeat is low. If the seizures are persistent or last longer than a couple of minutes, then we begin to look at pharmacological intervention.

Sick kids get dehydrated. While an IV is not always necessary (especially if they will still tolerate PO without emesis) refrain from making excuses for reasons not to start a line. The "I don't want to upset them" excuse is only valid in certain situations, the only one I can really think of is epiglottitis, or maybe a cardiac defect where any vagal stimulation might cause adverse cardio pulmonary effects. As always use sound judgement when weighing risks to benefit.

I kind of get on a soapbox when it comes to medics talking about not wanting to do certain procedures solely because it will upset the patient. I can say this because I used to make excuses for not starting a line...a long time ago in a former life. Now, if a pediatric patient needs and IV, they get an IV. I know it will upset them, but I also know that it is a necessary step in properly caring for the patient in certain situations. I can't let the fact that I don't enjoy causing kids some minor pain or discomfort to perform a procedure stand in the way of me performing that procedure when necessary.

The "getting hypoxic" and possibly having another seizure rationale is a little weak. I have never seen a kid have a seizure when starting an IV.

Like I said, it isn't the worst care I've seen given to a kid. With that in mind, please try not to be the medic who comes in, and when asked about a certain intervention says "I didn't want to upset them."
 
I think it sounds like u did ok. U ensured airway and breathing and administered O2. You took passive measures to reduce temp and had med ready in case it was needed.

I prob would have attempted IV access at least once. Its the only way ur gonna get experience sticking peds... just do it. The kid is gonna cry and fuss the same for the ED nurse of Tech.

I have 3 kids so they dont bother me that much. I approach them with almost same confidence level as adults. The more ur exposed to peds ur anxiety level will decrease.

And good point someone made on the tylenol if u have it and parents havent given it recently. If not in protocols assist parent in giving it if on hand.

Overall It sounds like u did fine.
 
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No need to get scared around kids, they're built pretty ruggedly, especially in the first few months, you can't really break them =)
 
Thanks for the feedback so far, next time I get a peds call I will definitely attempt an IV if indicated. I should have in this case, I had plenty of time to do so.
 
Agreeing with the others that being scared of kids is less than helpful.

Just wondering, how did you transport him? Was he in a car seat?
 
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Now that I know you used a pedi mate, you've just moved up in my book!
 
I wish I could take a class or work in an area just for kids sometimes to just get over that 'fear'. PALS/PEPP doesn't really do anything to me.

Also, IN? intranasal? You can do that? OOOOOOOOOOOOH my I would kill to have that in my protocols anywhere near here.....
 
For most of my ped's pts. on my first assessment. #1 sceaming and crying is good. #2 if they are scared of me this is good. It's when they are quite and do not care if you touch them that worries me.
 
Somene say Motrin?

Hm. What are Reye Syndrome chances? Not relevant to the purported sezures, but a good history is a good history.

Sounds good overall, and a little like a "first-kid" parent. After the first one (whom you wrap in cotton padding and sterilize everything they are going to put into their mouths), the next ones get a lot less guarding. Follow your analysis and your protocols, and don't let your anxiety or that of parents/bystanders affect your judgment.

Ten minute seizure and no postictal. Good. You carry the very small pediatric pulse ox probes?
 
We have disposable pediatric pulse ox probes. I put this one around his great toe.
 
Listen to WTEngel, he probably has transported more truly sick kids than most of the rest of us combined.

I didn't get comfortable even being around kids until I had my own. Understand this isn't a very cost effective educational model :D. Most of us are going to have a high pucker factor on kids that are experincing a major illness/injury due to societal taboo and lack of experience.
 
Yeah even in clinicals I only got (4) 12 hours shifts in the pediatric ER. Only one IV allowed 12 yo, by staff, and I was successful. I got no IV attempts on any patient less than 5yo. I felt like I learned a good bit though, most IV attempts, for peds, took more than two attempts. I should have tried though. Thanks for everyone's advice so far.
 
Listen to usal, he knows what he's talking about! Haha...

Thanks for the compliment. I had the luxury of learning from one of the best pedi / neo nurses out there... You might know her.

Rhan, don't stress to much about the line. I would have been more concerned if you spent half an hour and 5 attempts trying to get a line and completely disregarded the need to remove some of the child's clothing so he could better thermoregulate.

The catch 22 here is that the sick kids who really need a line are the ones you will have the most trouble with (unless you are a certain nurse usal and I know...she can get a line in anything!) healthy kids or "not so sick" kids are fairly easy.

You really just need to take advantage of every opportunity you can to expose yourself to peds.
 
The problem is simple. Most medics, myself included, get a little amped up when we deal with kids because we simply don't see enough of them, never mind having to perform critical interventions. Having one's own child is a great way to get used to holding kids, but it doesn't make it easier when you have to stick one or tube one. I've got one of my own... but you can bet my hands would shake if I had to fish a lego out of his airway with McGills.

We need to see more sick kids. We need more education. Guys and Gals, we need to get better at this stuff, or it's going to go away and these skills will be relegated to the Advanced Practice Paramedic. PEPP and PALS just don't cut it.

Let's look at the highly contested pediatric ET.

I think every study I've read regarding pedi tubes and paramedic skill decay shows that we are simply not qualified to perform most of the interventions we think we are, including ETT.

How do we work to keep our skills sharp? How many pedi tubes to we need each quarter before we're baseline competent? Hell, how many of us were EVER baseline competent? (One study says a 90% probability of a "good intubation" required 47 student intubations. Did any of us get THAT many?)

A Randomized Controlled Trial to Assess Decay in Acquired Knowledge among Paramedics Completing a Pediatric Resuscitation Course.
Academic Emergency Medicine Volume 7, Issue 7, pages 779–786, July 2000


Paramedic Training for Proficient Prehospital Endotracheal Intubation
Prehospital Emergency Care January-March 2010, Vol. 14, No. 1 , Pages 103-108


Laryngoscopic Intubation: Learning and Performance
Anesthesiology: January 2003 - Volume 98 - Issue 1 - pp 23-27
 
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For most of my ped's pts. on my first assessment. #1 sceaming and crying is good. #2 if they are scared of me this is good. It's when they are quite and do not care if you touch them that worries me.

Well, as a 12 year old kid - I don't seem scared around Paramedics. To be honest, I try to tough it out instead of crying out loud, and letting them do what they need to do. Of course that's for kids around my age, but I'd be worried too if this was the case to a 1 year old.
 
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