Using adult pads on 1-8yo's

[Melbourne MICA]

Working in education department at the moment. We have to give some very clear instructions to our staff on pad placement on kids around the 10kg/1yo but have a very interesting problem with exactly where to put the pads - adult pads that is.

Read on.

The problem is this.

First, we obviously have and use paed and adult size defib pads.

Unfortunately, the Phillips paeds pads we use are not recommended by the manufacturer for use on kids >10kg in weight - so thats' the about 1yo age group and above. The instructions on the packet recommend using adult size pads above the 10kg weight.

The reasoning behind this is twofold.

Because the paeds pad is small it becomes more and more dangerous (and less effective) to start delivering larger and larger joules through the paed size pad because this can cause serious injury to the infant/child. The current has to be distributed over the largest area possible to be both safe and deliver the correct joules for weight relative to impedance of the skin - its how the machines algorhythm works.

However,and this is where the problem starts, where do you put a bloody great adult pad on a 1yo child?

There are obviously two positions that come to mind - Anterior/anterior (standard adult position) and anterior/posterior - (sternum and between the shoulder blades at the back). With me so far?

The A/P spot is dumb because the sternum is obviously where you apply your compressions - right on top of the pad - not good for the pad, in fact sort of contraindicated for use. If you use an adult pad there the same problem occurs even if it fits the spot. Seems the manufacturer was thinking more about the pads use for monitoring, pacing and cardioversion. The didn't think much about CPR and defib (and poor old ambos!!).

So you go for Ant/Ant. How the hell do you fit an adult size pad on the R upper chest of a 1yo child? It's way too big - and yes we checked.

So what is the alternative?

Any ideas guys? Have you already come across this problem?


Cheers

MM

 

[MrBrown]

Brown has not encountered this problem, nor does he wish too; man you run into a room of ambos and yell "PAEDIATRIC!" .... watch how fast they scarper!

Have you checked with Phillips at all regarding this?

We have just started to use the MRx so I will ask around for you but this is the reason we should go back using the old school Lifepak 10 with paediatric paddle inserts. Ah the old days how I miss them.

Hey scarper rhymes with Archer, where is Frank when you need him surely he'd have this figured out using that trusty whiteboard of his! I have a few achient MICA training videos from the 90s of his, great stuff!

 

[skivail]

The only rule I have heard is as long as there is more than 1" between pads when in the A/A configuration, you are good to go.

 

[dudemanguy]

Brown has not encountered this problem, nor does he wish too; man you run into a room of ambos and yell "PAEDIATRIC!" .... watch how fast they scarper!

haha aint that the truth.

My second 911 call during EMT-B clinicals we were diverted to an unresponsive, apneic premature infant. I was scrambling in the back of the ambulance to get everything ready for the moment we arrived, and dispatch came over the radio informing us police had done a snatch and grab and were in route to the hospital. We met them at the ED and the baby was crying and moving around. I took back all the *****ing I had been doing about not getting any "good" calls, and read and reread the pediatric chapters in my textbook before my next clinical.

 

[reaper]

Place right pad offset of sternum, to the right side. Pt Apex pad on back of child. Works great and most companies endorse this way.

 

[Shishkabob]

Hopefully they're working on airway before worrying about defib (and you're explaining why) but per AHA, and some AED manufactures

The American Heart Association (AHA) recently issued an advisory statement on the use of adult AED pads on children. In it, the AHA concludes that as a last resort, AEDs “may be used for children 1 to 8 years of age who have no signs of circulation.”

“In such cases,” Dr. Streitweiser says. “Pad 1 should be placed just to the left of the sternum and pad 2 should be placed on the back just below the child's left shoulder blade.”

One pad front, one pad back.

 

[Melbourne MICA]

Options

Linuss and reaper - thanks guys that's two options for starters. I'm aware of the AHA notice - I was just reading about it last week, but it refers to AED's not manual defib and if I remember correctly they are talking about desperation stuff for 1st responders with no options left if they are (were) excluded from using an AED auto defib for paeds. It's also something to do with the limitations of the automatic algorithm built into AED devices.

Nonetheless two good starting options to look at. Thanks heaps guys.

PS if you have any hyperlinks to the manufacturers who offer alternate placements for the 1yo 10kg defib with adult pads it would appreciated.

My boss was wrapped when I told him I knew how to pick the brains of several thousand ambos over this quandary - the ever willing troops at EMT life!!!

It's not what you know in life, it's who you know.

If I can ask a small favour, any more posts/suggestions with some supporting information/links if possible much appreciated.

Cheers

MM

 

[Shishkabob]

I don't see how manual vs AED can change much of what's going on because of pad placement, but...

Your monitor/defibs don't have an AED option?

 

[bstone]

Wat is the concern regarding adult pad placement? Is the concern of deliverly too many Joules or delivering a shock over a much larger area than normal, possibly injuring other organs?

 

[MrBrown]

I think the problem is the adult pads on small infants given the disproportinate size of the pad to the child.

See this is why we need to go back to the nineties when the LP10 had paediatric paddles. Oh the 90s how I miss thee :unsure:

 

[Melbourne MICA]

Defib Pads

The problem is producing a work instruction for staff should they put in to a situation where they have to use an adult pad on a 1yo infant that needs defib. It's not a very likely scenario but should anyone come across it they have to have clear set of guidelines on how to deal with it from this department - thats our role.

Naturally the pad placement has to be compliant with manufacturers instructions, has to be safe for both patient and operator and as I said has to comply a clear instruction on what to do.

Unfortunately even the manufacturer of our pads Phillips doesn't know what to do. So our issue is simply to come up with a clear description of where to put the adult pads on a 1yo 10kg pt that's safe and compliant.

If anyone has links to studies or manaufactururs instructions for alternate placments it would be appreciated. I haven't had much luck finding any as yet.

Cheers guys.

MM

 

[lightsandsirens5]

Place right pad offset of sternum, to the right side. Pt Apex pad on back of child. Works great and most companies endorse this way.

Yep, that is what we do.

 

[usafmedic45]

Place right pad offset of sternum, to the right side. Pt Apex pad on back of child. Works great and most companies endorse this way.

We just made a "pediatric and butter" sandwich (as described by a coworker) by placing one pad on the front (no offset) and one of the back, regardless of whether they were pedi or adult pads. I have used both, although we almost always had pedi pads. The only time we did not was the day from hell where we had three pediatric arrests in 12 hours, all handled by one crew including myself.

This "front and back" method was also our medical directors recommended practice for adults whenever feasible (read as: they weren't so fat we couldn't roll their fat butts over to put the other pad on the back). The reason for the departure from the "standard" practice of pad placement was to assure the electricity was going as directly through the heart as possible.

 

[Melclin]

Edu-what?

Wouldn't someone on Medical standards know these things? Like Leanne Grig?

What do they do in hospital?

Why not ask someone over at RCH to word you up? Simon Young over there seems like a perfectly amenable sort of fellow (from the 15 milliseconds I've spoken with him ), not opposed to taking a moment to educate a lowly paramedic and I figure he's probably not alone - he gave our paeds trauma lectures after all.