Tia Dickson, RN, BSN

Primary Children's Hospital

Are you sick of COVID-19? Two years into this pandemic and I imagine you'll be tempted to skip this newsletter. Like you, I'm tired of the subject and tend to gloss over any COVID-19 related news. BUT, as EMS providers you should be aware of what we are seeing in kids with COVID-19 infection, especially since Omicron is now the predominant variant.

Andrew Pavia, MD, director of hospital epidemiology at Primary Children’s Hospital, said in an update to the community, the COVID-19 Omicron surge affects children more than at any other time during the pandemic. Primary Children’s had its highest number of hospitalized COVID-19 patients to date last week. Omicron also affects kids ages 0-4—who are unable to receive vaccines—more than the other variants, he said.

“This is happening despite the fact that Omicron causes a somewhat lower proportion of people to end up in the hospital,” Dr. Pavia said. “The sheer numbers of cases are leading to an absolute flood of sick patients . . . Our emergency departments are really overwhelmed with sick children coming in with respiratory disease. It is largely COVID, and there’s also a fair amount of respiratory syncytial virus (RSV) still, there’s influenza, there’s parainfluenza, and there are other viruses.”

Dr. Pavia said we do have effective treatments for COVID-19, but those treatments are in short supply. Supplies are likely to be better in February and March, so he asked people to avoid behaviors of greater risk until then. “The best thing you can do is not get infected right now, wear your mask, and get your booster if you haven’t gotten it,” he said. Officials project Omicron may peak in our area sometime in February.

Croup is traditionally caused by the human parainfluenza (HPIV) virus but since Omicron hit, Primary Children's ER has been overrun with croup caused by Sars-CoV2 (COVID-19). And while croup is usually seen in children younger than age 5, the "COVID croup" is being seen in children as old as age 12.

Transport Tips

• It’s especially helpful to keep the patient calm
• Allow parent presence when possible
• Treat fever with Tylenol® or ibuprofen
  
• Cool mist may be used if available*
  
• Cool night air environment is helpful

*Mist may not be effective, but does allow time to calm the patient down.

Racemic epinephrine

• 0.5 cc/kg of 1:1,000 epinephrine (max 5 cc) via nebulizer
• Treatment lasts 2-3 hrs; disease lasts 2-3 days
• Use of epinephrine requires a minimum of 3-hour ER observation so avoid for mild, stable, or improving cases*
• If used, don’t aggravate the patient

*Indications for Epi: Moderate to severe distress not relieved by calming and pain control.

Dexamethasone (In the Emergency Department)

• 0.6–1 mg/kg
• Oral works as well as IM
• Onset < 4 hours
• Useful to give as early as possible

Bronchiolitis is an inflammation of the bronchioles, usually the result of a viral illness. Respiratory Syncytial Virus (RSV) is the most common viral cause but parainfluenza, adenovirus, rhinovirus and now Sars-CoV2 (COVID-19) are other known pathogen causes.

Bronchiolitis

• Most often in children, ages 0 to 24 months
• One of the few viral infections that can cause serious illness in newborns
• Incidence is approximately 2.2 per 100 children annually

Symptoms

• Nasal secretions (lots)
• 1–4 day history of congestion with a low-grade fever
• Parents of infants will often report poor feeding, lethargy, or agitation
• Breathing problems, including wheezing, retractions, and a “noisy” cough

Treatment (supportive care)

• Ensure adequate hydration and oxygenation
  
• Carefully monitor for complications
• The first line treatment in the ED is naso-pharyngeal (nose and throat) suctioning.

1. Thorough suctioning can can greatly improve distress (often no other treatment is needed). Many pre-hospital providers are reluctant to perform naso-pharyngeal suctioning, but it can be your most effective treatment for bronchiolitis.
2. Bulb suctioning is a good tool.
3. To go deeper, 8Fr suction catheter will work well on most pediatric patients. If secretions are thick and the nares are large enough, a 10Fr works better. Measure the distance from the tip of the nose to the ear lobe then insert the catheter into the airway to your measured point. Apply suction as you remove the catheter. Try to keep the treatment under 10-15 seconds and let the child catch his or her breath between attempts. If the child has thick secretions you can use a NS solution to soften things up (0.5mls in neonates to 2mls for older children). Observe the child’s respiratory rate and quality, color, heart rate, and SaO2 throughout the treatment.

• If the child is hypoxic even after suctioning, give oxygen to keep saturations greater than 94%. Hint: infants tolerate a nasal cannula very well and it’s easier than chasing them with blow by.
• Effectiveness of bronchodilators (such as Albuterol) in bronchiolitis is unproven. Our ED’s current practice is to try one nebulized albuterol treatment (2.5mg). If there is no improvement, albuterol is discontinued.
• If the patient continues with severe distress, intermittent apnea, or apparent respiratory failure we implement high-flow, positive pressure ventilation, or endotracheal intubation.

Croup and bronchiolitis are common ailments in the pediatric population. Most patients will recover quickly but as pre-hospital providers you will see the sickest of the sick.

The correlation between COVID-19 and seizures is not well understood but first time seizures have been seen in patients positive with Sars-CoV2.

Seizures are a neuromuscular response to an underlying cause such as: epilepsy, hypoxia, hypoglycemia, head injury, recent illness, poisoning, and infection (such as COVID-19). Seizures happen when the electrical system of the brain malfunctions. Brain cells keep firing and the surging energy can cause muscle spasms and unconsciousness.

Clinical Presentation: May include: altered level of consciousness, tonic/clonic muscle movement, eye deviation, tachycardia, tachypnea, bradycardia, bradypnea, twitching, or staring episodes.

Most seizures stop on their own in less than 5 minutes and do not need pharmacological treatment. However, there are medical interventions which should be done during the active phase.

• Apply oxygen: Most patients who have a seizure are hypoxic. Even if they are not hypoxic, oxygen can help slow the progression of a seizure.
• Have suction available.

• Order or prepare medications.
• Check temperature and treat fevers with rectal acetaminophen: fevers can lower the seizure threshold in a patient.
• Gain IV access.

Seizures which last longer than 5 minutes need pharmacological treatment because the longer the seizure, the more difficult it is to stop.

Benzodiazepine treatment is the first-line treatment. Benzodiazepines can be given rapidly through many different routes (IV, IN, PR) and effectively treat seizures. IN Midazolam (Versed) is the first line benzo. A second dose of a benzodiazepine should be given if the seizure does not stop within five minutes after the first dose. If the seizure continues, another class of medication should be used as multiple doses of benzodiazepines have not proven to be effective and are likely to cause respiratory depression.

Key Points

• Medications used to stop seizures often cause temporary respiratory depression so monitor closely for apnea after the seizure is controlled and support breathing as needed.
• Be aware that medication to control seizures may cause hypotension in patients.
• If seizures are due to a traumatic brain injury, actively monitor for hypotension.
• The chance of death or disability increases with duration and frequency of seizures.
• Status epilepticus is defined as seizure lasting longer than 5 minutes or multiple seizures without return to normal consciousness between.
• Often a patient with recurrent seizures may be in non-convulsive status epilepticus in between and may appear post-ictal.
• A seizure burns glucose and hypoglycemia can cause additional seizures. Check and treat for hypoglycemia.

Syncope or fainting has been described as a symptom associated with COVID-19 infection as early as July 2020. There have been many anecdotal cases of patients who present with syncope as the only initial symptom of COVID-19 infection. Some COVID-positive patients show cerebellitis on a CT scan.

Acute cerebellitis is an inflammatory syndrome characterized by acute onset of cerebellar signs/symptoms (such as ataxia, nystagmus or dysmetria) often accompanied by fever, nausea, headache, altered mental status, and brain magnetic resonance imaging (MRI) abnormalities of the cerebellum. This may be tied to syncope but the exact mechanism is still debated.

It's important to recognize the possibility that your syncopal patient could have an active COVID-19 infection when transporting. Take appropriate isolation precautions to prevent the spread of infection.

Sudden onset of a single swollen eye or both eyes and most providers think anaphylaxis. But facial swelling is seen with COVID-19 infections, especially around the eyes. Parents also report red eyes or pink eye.

Multisystem Inflammatory Syndrome in Children (or MIS-C for short) is a condition that has been related to COVID-19, commonly believed to be an “over-reaction” of the immune system in fighting the COVID-19 virus. The condition is extremely rare among children, even those affected by COVID-19. The condition involves inflammation of the heart, liver, and other organs throughout the body, and symptoms of the condition include fever, low blood pressure, abdominal pain, sore throat, headache, vomiting, rash, and pink eye.

Improving Pediatric Sepsis Outcomes (IPSO) comparing MIS-C to sepsis.

This is a fantastic summary of MIS-C

You can find the webcast recording and slides here: www.childrenshospitals.org/.../MultisystemInflammatory-Syndrome-in-Children-or-Sepsis-Evaluating-an-Emerging-Syndrome

You’ll need to scroll down to the bottom of the page to view the recording.

The AAP recommends COVID-19 vaccination for all children and adolescents 5 years of age and older who do not have contraindications with a COVID-19 vaccine authorized for use in their age group.

• Children with previous infection or disease with SARS-CoV-2 should receive COVID-19 vaccination, according to CDC guidelines.
  

• Pediatricians are encouraged to promote vaccination through ongoing, proactive messaging (i.e., reminder recall, vaccine appointment/clinics), and to use existing patient visits as an opportunity to promote and provide COVID-19 vaccines.
  

• Pediatricians’ (and other healthcare providers') role in promoting vaccination among their patient population and in their community is critical, especially among those at highest risk for severe illness, hospitalization, and death from COVID-19, as well as their household contacts.

• For additional guidance on COVID-19 Vaccine for Children (aap.org; https://www.aap.org/en/pages/2019-novel-coronavirus- covid-19-infections/covid-19- vaccine-for-children/).

The Centers for Disease Control and Prevention (CDC) announced new recommendations Wednesday, January 5, to expand eligibility of booster shots to those 12 to 15 years old. They recommend adolescents 12 to 17 years old receive a Pfizer-BioNTech booster five months after their initial Pfizer-BioNTech vaccination series. Here is a summary of some changes now recommended by the CDC:

• Immunocompromised children ages 5 to 11 should receive a third dose of Pfizer-BioNTech 28 days after second dose.
• Pfizer-BioNTech booster is now recommended for everyone 12 years and older.
• The recommended waiting period between the second dose and booster has reduced to five months for Pfizer-BioNTech vaccine; no change for Moderna and J&J.

Children have experienced significant changes in routines and stability related to COVID-19. Medical providers for children are being asked about how to respond to these psychological needs. The National Childhood Traumatic Stress Network (NCTSN) and the Center for the Study of Traumatic Stress (CSTS) provided valuable guidance for medical providers on this issue. See the following links for more information:

• NCTSN- Parent/Caregiver Guide to Helping Families Cope with COVID19
• CSTS- Helping Homebound Children During an Outbreak

Caseloads and vaccination rates among Utah's school-aged children

coronavirus.utah.gov/case-counts/

Covid-19 Trackers

Johns Hopkins Global tracker (desktop)

Johns Hopkins Global tracker (mobile)

Utah Department of Health

The 2022 EMS For Children Survey is live and we are leading the pack! You have until March but don't wait to the end. It will only take six minutes to complete. Among other questions they will ask . . . Does your agency have a PECC?

The answer is YES!

PECC's are you a Handtevy Instructor? Would you like to be? There is an instructor class happening in March and we have 3 scholarships to cover your cost. Contact Mark Herrera (markherrera@utah.gov) by February 19th if you would like to be considered for the scholarship.

Handtevy Instructor Course

• $299 a person (3 scholarships available for PECCs)
• March 11th, 2022
• 0800-1700
• Mountain View Hospital
• 1000 E 100 N
• Payson, UT 84651

Along with our PETOS monthly lecture series for EMS: The University of Utah offers a virtual pediatric series each month called Project ECHO. The topics are less EMS-focused but the general pediatric information is excellent. Consider tuning in, and passing the event information on to other providers in your community. See details below.

National blood shortage calls for people to donate blood, conserve supplies

The United States faces a severe shortage of blood products and associated supplies. Limited staffing and supply chain issues at the American Red Cross impact both collection and processing, and donations have declined nationally since 2020. The COVID-19 Omicron variant surge compounds blood product needs.

How significant is the shortage? The shortage is so severe that the American Red Cross has declared a national blood crisis. The COVID-19 pandemic has produced a situation in which overall blood donations are down by 10 percent nationally.

Caregivers and their friends and families are invited to donate at the American Red Cross or at ARUP. To find an available appointment may require you to book two or more weeks out, but your donation will still be very appreciated.

Find a drive by clicking the picture above.

Do you have a question for our EMSC Medical Director, Hilary Hewes, MD, PCH, ER Attending Physician about this newsletter topic or anything related to pediatrics? Shoot an email to the following address tdickson@utah.gov.

Project Overwatch and the Utah Women in Law Enforcement non-profits have partnered to create a women’s first responder peer network in the state of Utah. The first annual “LIFE” event will be hosted Friday April 29-May 1, 2022. This event will be open to women who are military veterans, police officers, and/or firefighters. This event will include the following:

● Individual trauma assessment ● Trauma resources ● Resiliency ● Teambuilding ● Mindfulness ● Meditation ● Yoga ●Leadership ● Archery ● Indoor rock climbing ● Networking ● Mentoring

Every aspect of this event focuses on the mental wellbeing of our women military veterans, women police officers and women firefighters. This will be the first of many retreats for female first responders hosted at the National Ability Center in Park City and the Utah Valley University Wasatch Campus in Heber. Cost for the event is $300 per participant. This cost covers housing, events, and most meals. Participants will be responsible for their own dinner on Saturday night. There are 30 spots available and there will be an application process to participate. The application can be from a supervisor or a self-nomination. Please visit the following link to complete the application for your female first responder: https://forms.gle/yJaCtYwmwb5TuSBW9. Deadline for applications is February 28, 2022.

Applicants who are accepted will be notified as quickly as possible. Should you have any questions regarding the application process or event, please contact Dr. Marcy Hehnly at mhehnly@project-overwatch.org or marcy.hehnly@uvu.edu. She can also be reached at the number listed below. Scholarships are available, please consider nominating someone who would benefit regardless of your financial limitations.

Dr. Marcy Hehnly Retired Cobb County Police Department,

GA Project Overwatch Vice-President

www.project-overwatch.org

678.524.0103

Pediatric Education for the Prehospital Provider

Register online at www.peppsite.com. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($21.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, no matter where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth