Tia Dickson, RN, BSN

Primary Children's Hospital

Seizures are the most common pediatric neurologic emergency and account for around 15% of all pediatric EMS calls which rarely come wrapped nicely as a "seizure" complaint. More often the call will be made for a child choking, altered, or unresponsive. In our last PETOS presentation, Dr. Chris Ryba took us through one of these calls which is summarized here.

Chris Ryba MD, EMS Fellow, University of Utah

Excerpts from March 14, 2022 PETOS—Interesting Prehospital Pediatric Cases

Chris Ryba completed his EM residency at University of Wisconsin where he served as a flight physician. He also has prior experience working as a paramedic in Chicago, IL.

On arrival: Patient was lying on his right side with his eyes closed. He was crying. He did not interact with providers and allowed vitals to be obtained without fuss.

Assessment: HR 138, RR 26, O2 89% RA, BG 135, GCS 10, Temp 100.4. Lungs clear, oxygen started, and restored saturations to 100%.

History: Grandpa saw child walking by with a cup and cookie. The child suddenly dropped to his knees with his body shaking then became stiff. His eyes rolled back and he became blue. Grandpa believed the boy was choking, called dispatch, and was instructed to begin chest compressions. After about a minute the child began to cry. No family history of seizures.

Typical presentation: No vocalization, surprise/worried facial expression, or unresponsive.

Actions for full obstruction:

• Make one attempt to clear any obvious obstruction
• For choking infants, apply a sequence of 5 back blows and 5 chest thrusts until the item becomes dislodged or the patient becomes unresponsive.
• For children, use the abdominal thrust maneuver and continue until the obstruction resolves or the patient becomes unresponsive.
• Once unresponsive. begin CPR.

Begin CPR, starting with chest compressions. Do not check for a pulse. Each time you open the airway to give breaths, open the victims mouth. Look for the object.

• If you see an object that looks easy to remove, remove it with your fingers.
• If you do not see an object, continue CPR.

Actions for partial or resolved obstruction:

• Avoid agitation
• Allow family member presence and position of comfort
• Provide supportive measures as needed

En route: Patient was transported to PCH and became more alert but did have a repeat temperature of 101.4. The crew felt the presentation was more likely a febrile seizure than a choking event.

Actions for simple febrile seizure:

• Generally supportive care
• Provide reassurance to the family
• Evaluate for source of fever (most often a virus or upper respiratory infection)
• May not need to transport but family will often prefer it

Actions for complex febrile seizure:

• Follow the seizure treatment pathway

On arrival: Patient found supine with eyes open with limited response. He stated his name and could follow simple commands but was otherwise nonverbal.

Assessment: HR 126, RR 22, BP 136/86, O2 84% RA BG 135, Temp 36.8. Lungs clear. The rest of the exam was unremarkable.

History: Bystander reported patient was in class when he began to stare off into space which was recognized as his seizure start. While walking to the med room, he became unresponsive then had tonic-clonic activity.

Patients medical history: Known history of epilepsy, 28wk premature and very low birth weight, autism, and an unknown genetic disorder.

Treatment on scene: 10 mg IN diazepam (rescue med) was administered by school staff. IV and 400 cc of fluids started by EMS as well as 4L of O2 with good response. Weight of 25 kg (determined by Handtevy app).

En route: Patient had an additional 60 second seizure witnessed but resolved before administering 2 mg of IV Versed. The patient's eyes were open spontaneously, he localized to pain, and moaned following the event but there was no intelligible verbal response. A second seizure occurred and an additional 2 mg of IV Versed was given. ETCO2 was noted to be 80-84 and thus respirations were assisted by BVM for shallow irregular respirations. Transported to PCH.

In this case the patient was treated appropriately in the field with medication dosing per their protocol. The hospital was suspicious that this patient was in status. Across the board, medical providers tend to under treat seizures and more particularly status epilepticus.

From adult research: "Prehospital midazolam use and outcomes among patients with out-of-hospital status epilipticus" by Gluterman, Et Al. in 2020 in the journal, Neurology.

• Found that underdosing of benzos in status/seizures often occurs due to provider concern for causing respiratory depression.
• Found that higher doses of midazolam did not increase risk of respiratory side effects but limited the risk of need for further rescue therapy.

Patients with lengthy respiratory insufficiency (a long, unbroken seizure) who are given these drugs are at a higher risk for acute respiratory decompensation (they stop breathing). Early intervention can decrease the chance of respiratory failure but if it happens, it couldn't happen in better hands. Prehospital providers know how to bag and are capable of maintaining the airway during transport.

MEMORANDUM

TO: NASEMSO Members

FROM: NASEMSO Pediatric Emergency Care Council

SUBJECT: Defibrillator Pad Incompatibility

DATE: January 25, 2022

This information was brought to the Board of Directors who supported its distribution to members in the interest of protecting the public.

Situation:

The NASEMSO Pediatric Emergency Care (PEC) Council recently learned of several issues regarding automatic external defibrillator (AED) pad incompatibility, with multi-function defibrillator and AED pads not being used in accordance with manufacturer’s recommendations, particularly in pediatric applications.

Background:

In recent inspections, it was identified that some EMS services and/or their personnel are utilizing incorrect pediatric defibrillator pads with various manual monitor/defibrillators and AEDs. This results in an inability to deliver therapy across all age and weight ranges. On November 29, 2021, the Massachusetts Office of EMS issued a statewide memorandum regarding this issue and shared it with the NASEMSO PEC Council. Subsequently, this has been found to be occurring in several other states as well.

Assessment:

Examples include:

• Zoll Pedi-padz: These defibrillator pads, although manufactured by Zoll, are not compatible with the Zoll AED Plus units and will not plug into the unit. The pediatric pads required for the Zoll AED Plus units are the Pedi-padz II. The Zoll AED Plus Administrators Guide, page 30, states to use “ZOLL Stat-padz II, CPR-D-padz or Pedi-padz II” and to “Only use electrodes labeled “Infant/Child” on children less than 8 years old or weighing less than 55 lbs. (25 kg). Use CPR-D-padz® if patient is older than 8 years or weighs more than 55 lbs. (25 kg).”
• Physio-Control Lifepak-15: Use of non-manufacturer recommended pads for LP-15 units, with the intent of using them for pediatric patients. These pads have therapy limitations for both age and weight ranges for infants and children in both the manual and AED mode on the LP-15. The pads’ packaging states that in manual defibrillator mode, these pads cannot be used for patients who weigh less than 22 pounds, and in AED mode, are not to be used for patients younger than age 8. As a reminder, providers cannot use an LP15 in the AED mode for pediatrics, regardless of pad type. The LP15 operator’s manual, in section 5 pages 5-7, under “Automated External Defibrillation (AED)” states, “In AED mode, the LIFEPAK 15 monitor/defibrillator is not intended for use on pediatric patients less than 8 years old.”
• General: Some AEDs have been identified that were accompanied by pediatric pads with packaging that had red writing and a circle with a line through it around an AED symbol that stated, “not for AED use.”

Recommendation:

Although pediatric defibrillation is an uncommon event, ensuring that properly compatible equipment is available is one of the keys to this life-saving intervention. We recommend state and regional EMS leadership share this information and remind all EMS, fire, and other public safety agencies to double-check all monitors and AED units to ensure they have the correct manufacturer recommended pads stocked in all units. For questions, please refer to the manufacturer instructions for the device, contact the manufacturer, and/or contact state or regional EMS leadership.

References

1. Lifepak-15 Operators Manual https://www.physio

control.com/uploadedFiles/Physio85/Contents/Emergency_Medical_Care/Products/Operating_Instr uctions/LIFEPAK15_OperatingInstructions_3306222-002.pdf

2. Zoll AED Plus Administrator’s Guide https://www.zoll.com/-/media/product-manuals/aed-plus/01- english/9650-0301-01-sf_yd.ashx

3. Massachusetts Office of EMS Memorandum

https://www.cmemsc.org/images/Announcements/Memorandum_Ensuring_Defibrillator_Pad_Com patibility_to_Provide_Effectivepdf.pdf

The 2022 EMS For Children Survey is complete!

THANK YOU!

We are excited to announce Utah's EMSC has a NEW PROGRAM MANAGER!

Jared Wright

• jaredwright@utah.gov
  
• Cell: 801-230-4721
  

The majority of my EMS career was spent in Tooele County for Mountain West Ambulance where I worked as a paramedic & training officer. For approximately six years, I've been instructing EMT/AEMT, AHA, and NAEMT courses. I am a Weber State University paramedic graduate. I started at BEMSP as an Educator Specialist last year. I'm excited to join the EMSC team!

The EMSC Innovation and Improvement Center has compiled a list of currently available state EMSC pages with PECC information as a resource for all PECCs. These are located here: https://emscimprovement.center/collaboratives/pecclc/resources/program-managers/―the links are located under the “EMSC Program Resources  Webpages.

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.

Have you attended a home birth transfer of an infant or a mother to a hospital and saw ways the process could be improved? Have you seen midwives who have really great systems and communication and wish they all did? Help us learn how to improve the collaboration and communication about birth transfers by giving feedback to the Utah Women's and Newborns Quality Collaborative!

Find out more about our work and the improvement tools we have created here: https://mihp.utah.gov/uwnqc/out-of-hospital-births

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.

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