(Transcript is automatically generated)

Erik: [00:00:00] These can be scary kids. Mm-hmm. Get a full picture and no, it's not the most common thing. 

Matt: If you walked into a kid drowning in a pool. Yeah. Would you walk up to the pool and go, Hey, what's up buddy? My name's Matt. What's going on today? Like,

Narrator: You are listening to EMS, with your hosts Erik Axene and Matt Ball. 

Matt: But we're getting ready for the Arctic freeze here, Erik. 

Erik: Are you ready? 

Matt: Yeah, I mean, I think they always kind of freak out a little bit. I, I'm from Chicago, so I don't really freak out about cold weather. 

Erik: Well, we talked a lot about things that we need to do for, you know, preparation.

I call it winter wisdom. 

Matt: Yeah. 

Erik: You got the four Ps of winter wisdom. Have I told you these? 

Matt: The four Ps? No, you have not told me these. 

Erik: Take care of your people, your pets, your plants, and your pipes. Yep. So if you live around people who are, you know, older folks, 

Matt: right. 

Erik: Check on them. 

Matt: Yep, yep, 

Erik: yep see your neighbors. If you have an old person living with you. 

Matt: Yes. My neighbor across the street is recently [00:01:00] widowed. Yep. 

Erik: Yeah. These, these are the folks we need to check in on. Yeah, yeah, yeah. Buy 'em some when you're over, you know, emptying the shelves of water, get them a crate water too. 

Matt: 47,000 rolls of toilet paper and 67 gallons of milk that you're not gonna drink for two years.

Erik: And if you're cold, your pets are cold. You just got a new dog so, 

Matt: well, first off, if you're, if you're that guy that leaves your pet outside when it's this cold Yeah. Which I realize it's in Texas, but 20 degrees and you leave your dog, it's stupid. Yeah. You're an idiot. 

Erik: Yeah. 

Matt: Sorry. And I will 

Erik: take care of your pets.

The other thing I'll say back with people, um, and know where your, your, uh, shutoff valve is for water. 

Matt: Dear God, 

Erik: protect your property. Actually, we should have a fifth P property. So to know where that is because if you get a blanket of snow in the front yard and you can't find it, it could cause thousands of dollars of damage.

Matt: Do you know how many times, 'cause that's the number one call we get. 

Erik: I know you do. I've been there. 

Matt: And literally go, you ask a grown man, where's your shutoff valve for your house? 

Erik: Uh, I, I don't know. 

Matt: How long have you lived here? 10 years. Like you've lived here 10 years. You're a grown man. You don't, but yeah.

People, 

Erik: well, you know where it is too. It's either the garage or it's either gonna [00:02:00] be out front yard, actually, it's always gonna be in the front yard typically. 

Matt: Yes. Yeah. 

Erik: It's just hard to know where the the, you gotta know where the green box is. 

Matt: Yes. 

Erik: And if it's covered in snow, 

Matt: it's not hard. 

Erik: Just go find it before the snow hits.

Matt: Yeah. Be a man. 

Erik: Yeah. 

Matt: Know where stuff is. 

Erik: And then cover your plants if you're into plants, that kind of thing. 

Matt: I, yeah. We're actually, my wife is out today buying some, uh, burlap wrap for these trees that we had 

Erik: Uhhuh, 

Matt: you know, interesting fact, we were looking at this yesterday, you know, before you get a cold snap, you're actually supposed to water the trees.

Erik: That's correct. 

Matt: Heavily watered, heavily water. I did not know that but I didn't do that because it's raining so much. I thought, well, the rain today would be. 

Erik: We're watering today and then we're turning off the sprinkler system. Yes. Because you don't want your sprinkler system to come on in the freeze and then you're gonna break limbs and 

Matt: Right, right, right, right, right.

That's common sense. Which is not common. 

Erik: And then the last one, of course, the pipes right in your house. Right. Drip the interior pipes insulate the exterior, 

Matt: keep the cabinets open so the exterior heat, like I said, I grew up in Chicago, but the difference in 

Erik: Chicago, they know what the heck's going on.

Matt: Correct. The infrastructure is built around cold weather. They know it's gonna get cold 

Erik: And part of the problem is the building code in In Chicago. Yes, correct. You have to have [00:03:00] only interior. Yes. Water pipes cannot be on exterior walls. No. Here in Texas they can be. 

Matt: Yes, yes, yes. 

Erik: Which really creates problems.

Matt: Yes. Yeah. The infrastructure, well, like roads, I mean like people like, which I get like. Uh, people will freak out about driving, but here we get ice. 

Erik: Yeah. 

Matt: Like I grew up in Chicago, we would get snow. Yeah. I've never seen ice like we get here. Yeah. Right. And it's, you can drive in snow, you can't drive on ice.

Yeah. Right. And then in Chicago you have plow trucks and salt trucks. We don't have that here, although they have been treating the roads like crazy. Yeah. The last two days. But yeah, preparation kind of goes to our topic. 

Erik: So I was thinking actually, and it's, it's funny, it really correlates almost identically in some ways.

Because 

Matt: everybody's freaking out. 

Erik: Yeah. Everybody's freaking out. This is what, this is what scares most paramedics, EMTs, yes. Any pre-hospital provider is a crashing little kid 

Matt: in hospital. Yeah. 

Erik: Yeah. Me too. Yeah. As an ER doc. Uh, and, and our students, we've asked them Yeah. This is one of the things that freaks 'em out.

Yeah. Uh, preparation's the key, right. Uhhuh. And then when we're preparing, it's like when [00:04:00] we're the winter preparation, what we're preparing for is that rare event. Mm-hmm. When we lose power for an extended period of time, 

Matt: if the worst happens. 

Erik: Exactly. 

Matt: Yes. 

Erik: We were actually talking about it with our colleagues this morning.

There are certain things that you can do. You probably won't need it, but if something happens and the crap hits the fan and no power for an extended period of time, you'd be glad you had those things. Yeah, but you're probably not gonna need it. Well, the same thing's true for these these pediatric cardiac kids.

Yes. Most of the time, as we're gonna talk about, it's not related to cardiac stuff. When you've got a crashing kid, uh, we'll talk about that in a minute, but Yeah. Um, but in the event that it is, boy, they can crash fast. Oh yeah. And it could be quite scary. And we gotta get those kids to the right places where they can get fixed.

Yep. Um, so anyway, I guess we get right into it. 

Matt: Let's do it. 

Erik: What is the most common. 

Matt: Well, respiratory is the most common emergency Yeah. That we get called out for. Yeah. You know, we teach everybody, EMTs, paramedics, we teach everybody that, you know, if you've got a kid that's not doing well, respiratory [00:05:00] airway first.

Erik: Right. 

Matt: Airway, oxygenation, that's where you go to first. Yep. Right. And then everything else is secondary to that. 

Erik: Yep. 

Matt: Um, that's always the first consideration. 

Erik: It's kinda like with cold emergencies, right? Getting wet. Yeah. In a cold environment is, is the worst thing. Number one rule for that stay dry for management of is to get 'em outta the environment and get 'em dry.

Dry, keep 'em warm and warm. So, yeah, that's right. Hypoxia, uh, is the most common cause of pediatric cardiac arrest. Really any crashing kid is probably gonna be hypoxia. Medical or respiratory, 

Matt: yeah. Right, exactly. Exactly. 

Erik: And the other thing that you might see, and we'll talk more about hypoxia in a second, but the other one is perfusion.

The kid with an infection. 

Matt: Mm-hmm. 

Erik: The kid with a, with a, uh, it's dehydrated because they're septic. The kid that's, um, you know. Septic because of an unidentified infection of some kind that goes bad. Right. 

Matt: And the good news is, is that again, BLS or ALS, right. The first thing you do on any of those kids is like, get 'em on oxygen.

Erik: That's right. 

Matt: Get 'em on oxygen if you [00:06:00] do nothing else. 

Erik: Yep. 

Matt: Get 'em on oxygen. Whether it's, you know, nasal cannulas, non rebreathers, whatever it is. 

Erik: Yep. 

Matt: Get 'em on some oxygen. Yep. Right. That's, uh, that's where you start and then everything else comes secondary to that. 

Erik: And we're gonna be ending on management and it's gonna circle back to what you just said, and it's nice to keep it simple.

Sometimes you don't quite know what to do. Yeah. While you're evaluating your patient and trying to gather information, put 'em on some oxygen right away and see, see how they do. 

Matt: You know, I always, uh, I kind of joke because I've been on this call numerous. Man, kids yelling right there. But I've been on this call numerous times, whether it's an adult or a kid.

And you go in and like, especially like CHF patients mm-hmm. And you walk in and they're sitting there and you can just hear the, the fluid, you know, you walk in, their lips are blue, they're tripod and they're struggling to breathe. And the paramedics walks in and go, Hey, my name's Smith. Tell me what's going on today.

It's like. They can't breathe. Idiot. Put 'em on some oxygen. Yeah. Right. It's like, it's simple, right? So [00:07:00] I, so what I do is I tell, when I'm teaching this class, I'm like, if you walked into a kid drowning in a pool. Yeah. Would you walk up to the pool and go, Hey, what's up buddy, my name's Matt. What's going on today?

Like, no idiot. You'd go get him out the water. Right? So if somebody's having trouble breathing. Yeah. I mean you might, if you can get a room air set, great. You know, that's fine. Mm-hmm. But by God, get 'em on some oxygen. Yeah. If it's obvious that they're struggling to breathe. If it's obvious, you see blood squirting out of the wound, what's going on there?

Uh, I'm losing blood rapidly. Like I don't need to ask questions right now. I need to 

Erik: Are you on blood thinners? 

Matt: Yeah. Exactly. Yeah. So yeah, use some common sense. But you go on a crashing kid call, you don't need to know why they're crashing right off the bat. If they look like they're having trouble breathing, get 'em on some oxygen.

Erik: Right. 

Matt: Start there and then move down your path, like we'll talk about 

Erik: Yep. 

Matt: Towards the end of this. 

Erik: And whether you, you know, like you said earlier. BLS or ALS provider, we're really, the goal here is to talk about these kids just in general, just to identify these [00:08:00] diseases and knowing too that most of these kiddos that we could be responding to is probably gonna be caused by something physiologic related to the respiratory system or to the hematologic system.

Right. To, to the cardiovascular system, not the heart itself usually. 

Matt: Right. 

Erik: Um, 

Matt: but, and, and we can't fix these things pre hospitally. 

Erik: No. 

Matt: Whether you're ALS or BLS Yes. As an ALS provider of critical care, there's some more options that you have to maybe stabilize your kid, but the important thing is where are you taking these kids?

Erik: Mm-hmm. 

Matt: Get 'em to a, like, obviously if they're crashing, you're probably gonna go to a closest facility. 

Erik: Right. 

Matt: But get 'em somewhere that can treat the underlying issue. 

Erik: Yeah. 

Matt: You know, and, 

Erik: and everybody's transport matrix. There's a certain facility, you know, that can handle pediatric emergencies. Correct. If you're in an outlying area with long transport times, some of the critical care things you may need to do could be pretty daunting and you may need to 

Matt: Helicopter 

Erik: May call in helicopter.

Exactly. So, um, but most, most, you know, most agencies have certain [00:09:00] number of hospitals that they transport to just make sure you go to the right one. 

Matt: Correct. 

Erik: Yep. We have a number of them out where I'm a medical director and we know which ones have that pediatric ICU. Mm-hmm. The, the neonatal ICU. Mm-hmm.

We know, we know where these kids go. And then obviously downtown, 

Matt: can I tell him myself, I almost got in trouble one time, several years back. 

Erik: What 

Matt: we, we went on a kid. Uh, uh, and um, we showed up and the kid was in cardiac arrest. He was 

Erik: how old? 

Matt: It was like eight or 10. Oh, somewhere in there. Older kid. Yeah, old.

Not a baby. Old, older kid. And had a lot of congenital issues. 

Erik: Oh, okay. 

Matt: Yeah, yeah, yeah. Had a lot of congenital issues. Anyway, uh, we get on scene, start working the kid, um, we're doing chest compressions. We get the kid intubated that we've got an IV, we're doing all the things right. Yep. And not very far away was a.

Well, it was a fairly sizable ER, but it's not a pediatric facility. Yeah, right. It's just a normal ER. And it was kind of a slower ER. They didn't get a lot of, we didn't take a lot of [00:10:00] critical patients there. Yeah. It was just kinda like, okay, we'll take 'em over here. They're having a tummy ache or something, you know.

But, um, not that they weren't capable, they just didn't get a lot of volume. A mile down the road was a large pediatric facility. 

Erik: Yeah, 

Matt: right? Uhhuh. And so I was with another senior paramedic that you would know if I said his name, Uhhuh. And we both made the decision, let's go here, Uhhuh. And, 'cause we knew like if we pull into this ER here.

They're not gonna really do anything else that we're not doing. We've got the kid tubed. Yeah, we've got air, we've got an IV, we're giving Epi. I mean, you know, all the things 

Erik: Go to the, go to the, 

Matt: and they're gonna freak out. I mean, you bring a pediatric CPR into most ERs and they freak out. They're freaking out.

Right? Yeah. Where you go to a pediatric facility, this is what they do all day long. Yeah. They're prepared for this. They got the Braswell tapes that they're, this is what they train for. Right. So I'm like, let's drive another mile and a half down the road and take this kid to, so that's what we did. And. My medical director at the time was super nice about it.

He called me the next day and he was just like, [00:11:00] eh, technically that was a violation of policy. 

Erik: I think I know this doctor. 

Matt: Because the kid was unstable, obviously, and he's like, so per protocol, you should have gone to the closest. He said, I understand what you did, and I, I agree with you. 

Erik: I would've applauded it, 

Matt: but he, 

Erik: this is the, is an online medical control 

Matt: he said, all I'm saying is just gimme a call. He said, all I'm saying is just pick up. 

Erik: You called afterwards. 

Matt: I didn't call. 

Erik: Oh, okay. 

Matt: I didn't call. 'cause I was just, I didn't even, I thought, well, this is the right thing for my patient. Let's still, so 

Erik: he must have agreed with you. 

Matt: Oh, he agreed.

He, and he said that, he goes, I agree with what your thought was. He goes, I just wouldn't want you to get nailed because you did something outside of protocol. I see. So next time just pick up the phone and say, Hey, are you good with this? Yep, I'm good with it. Go. 

Erik: Yeah. 

Matt: And then, but you know, lesson learned.

Erik: Well, you bring up a really good point is being aware of the different facilities and, and, and how comfortable you are with pediatrics following your protocols. Yes. I mean, these all, eventually we get to a place where you may be in a situation just like you were in, where I know in our protocols you get to that situation, call on them, medical control.

I, I mean, I would've agreed with you a thousand percent. 

Right. 

Um. [00:12:00] Follow your protocols. That's really good. But transport's a big part of this huge, especially with these things like you said, we can't fix. 

Matt: Yeah. 

Erik: So, um, just a couple things I think we should cover. Um, 

Matt: good job 

Erik: with the, um, with, uh, um, we obviously, um, we were talking about this earlier, is that when a kiddo, whether it's hypoxia or sepsis or a cardiac congenital abnormality. Mm-hmm. Right. Um, the compensation mm-hmm. For a little kiddo is typically, well, it's more predominantly heart rate. Mm-hmm. That heart rate's gonna shoot up. Whereas we have some other things that our adult body can do a little bit more effectively than a kid.

Right. Um, but a kiddo, the first thing you're gonna see, it's like that first warning sign. Actually is an assessment question, but mm-hmm. The first warning sign for a kid of a bad, something bad's going on, I don't know what it is, is high heart rate. Yeah. Anytime you get that little kid with a really high heart rate, it's high for a reason.

Matt: Well, let's, but [00:13:00] let's pause. 

Erik: Yeah. 

Matt: For, you know, maybe we've got some new EMTs or a new paramedic and high heart rate, but high heart rate in the context of they haven't been like outside running around in the heat. 

Erik: Yep. 

Matt: Or they, you know. There's like, why is this kid's laying down? This kid's been sitting there watching tv or this kid's maybe been sick, like mom says the kid's been sick and now his heart rate's 150.

You're like, okay. There's not a known reason as to why the heart rate is so high 

Erik: and a normal heart rate in a 1-year-old 

Matt: is 

Erik: could be 150. Correct. 

Matt: Correct. 

Erik: So you gotta be careful of that too. 

Matt: Yes. 

Erik: The heart rate variability can be quite a bit different in the little tiny, 

Matt: you should have some sort of an app or you should have some guide on your ambulances that tell you what the normal ranges are for kids.

Yeah. Because if you don't have that information, yeah. Uh, it's, it's, you know, like age times two plus 70, everybody knows that for blood pressure. Right? But heart rate is, the numbers are all over the place. 

Erik: All over the place. 

Matt: So like SVT and a 1-year-old, that heart rate's gonna be way higher than in a.

10-year-old, 

Erik: [00:14:00] correct. 

Matt: Right. So you should have some sort of a chart and you can look these up on Google and find the average heart rates for kids. 

Erik: Yeah. I'm looking at it right now. And, and we actually put it in our, our notes that we prepared. Yes. Um, yeah, the, uh, and actually one thing I wanna reiterate, and you and I talk about this a lot, is that we don't just treat the numbers.

No, it's like you said, there's it's context. Look for the reason. The context. Yes, that's right. You got a kiddo that's fever. Yes. You got a kid that's not feeding well, no. You've got a kid who's lethargic. Lethargic, yes. Or whatever. I mean, you've got all these different things that mom noticed. Yes. And that's why she called 9 1 1.

Yeah. So those are, those are some of the contextual things with compensation for kids. Blood pressure's a late indicator, and we talked about this earlier today too, just in. As we're talking about this. Mm-hmm. If you drew a bar graph of how kids compensate, it's like they're doing really long and then all of a sudden drop off.

Matt: Do you know how often I would do blood pressures on kids? 

Erik: Rarely. 

Matt: Hardly ever? 

Erik: Yeah, 

Matt: hardly ever. I mean, unless they were like really, really sick and I was doing stuff, but I [00:15:00] was just doing it to get a feel. I was not As you're like you're saying, I was not relying on that as an indicator of how they're doing.

Erik: No. What do we use? 

Matt: Heart rate. 

Erik: Heart rate, rate, and I would, 

Matt: respiratory rate, I would say. And then, yeah, cap refill. Cap refill. What's their appearance? What do they look like? What's their mental status like you said, are they getting less responsive or are they becoming more responsive since you Correct.

Arrived on scene. Yeah. Blood pressure. I'm just taking that to almost appease the bean counters They're looking at like, well, why didn't you take five blood pressures on this kid that you were in contact with for 25 minutes? Yeah. You know? Because it's not telling me anything, you know? 

Erik: Yeah. That's good.

Matt: So yeah, 

Erik: to me what the, the cap refill does well. Okay. Heart rate. Yeah. That's like a red flag warning. Warning, right? 

Matt: Yes. 

Erik: Uh, but the, uh, the cap refill to me is, is telling me what the organs are experiencing. 

Matt: Mm-hmm. 

Erik: That, that liver or that kidney or the brain. Right? 

Matt: Yeah. 

Erik: It's if you got a real slow cap, refiller, we, we are not perfusing well.

Right. 

Matt: That's 

Erik: right. And if you get that real brisk cap refill and the body's warm in their [00:16:00] febrile, you're in distributive shock, right? 

Matt: Yes. Yeah. If they're hot, hot, yeah. 

Erik: Yeah. So, so there's a lot of different things to consider. Speaking of shock, I think that would be the next place to go. Um, um, because kids have such a high metabolic demand 

Matt: mm-hmm.

Erik: And, and they're, they compensate so well for so long and then they drop off. And that's what I think makes the kids a little scary. Well, 

Matt: they're like efficient. Uh, sports cars, right? 

Erik: Yeah, that's right. 

Matt: They have small fuel tanks, but they require like high octane fuel and they require a lot of it if they're really performing at a high level, right?

Mm-hmm. They're buzzing along. That engine's running at a high RPM. Yep. Right. But then they don't have a big tank. Right. Unlike a truck, you know, like you and me. Yeah, exactly. Well, yeah, Uhhuh and they're cruising along. They can, they're not maybe gonna go as fast. The speed's down the RPMs are down to a normal range.

Right. So until they develop. 

Erik: Yep. 

Matt: Yeah. They have very little reserves and they have high metabolic demand. 

Erik: The way that I like to teach it is like a fire engine. Mm-hmm. Uh, you've got your reserve tank 

Matt: [00:17:00] Yep. 

Erik: Of that water in your engine. Sure. 

Matt: Backup. 

Erik: Right. And so you have time. You can, you could start running off the tank water.

Matt: Yes. 

Erik: But then you've gotta hook up to the hydrant 

Matt: that's right 

Erik: before that tank water runs out. 

Matt: That's right. 

Erik: You and I have that tank water in our capacitance vessels in our legs. Mm-hmm. We hold most of our blood there, actually. Mm-hmm. Mm-hmm. So we, the first compensation with blood loss or low volume would be.

Vasoconstriction to kind of bring up some of that water from the legs, increases our preload, increases contractility, and we can actually maintain a normal set of vitals for a little while before we see any changes. 

Matt: Right. 

Erik: But once we run outta tank water, 

Matt: yeah. 

Erik: Now we gotta compensate by increasing the RPM of the, uh, of the, of the pump.

The pump. Right Pump. Yep. Well, kiddos don't have that tank water. Their, their heart rate's going up right away. 

Matt: Right. 

Erik: And they're so young and their heart is built to. To pump so fast that it will go for a while, but eventually that pump caviates. 

Matt: Mm-hmm. 

Erik: Or the volume's gone and then they just drop off the edge.

Matt: You ought to, they need to look at everything like it's one of two, [00:18:00] like, just because somebody's blood pressure is low. Doesn't mean that the heart's not pumping effectively. 

Erik: Right. 

Matt: Maybe it's a volume problem or, so it's one of three things. It's either a pump problem, a pipe problem, or a volume problem.

Erik: Exactly. 

Matt: Right. So you have to, you have to look at the situation. You can't just go, oh, well, their blood pressure's low. Give them fluids. Maybe they have plenty of volume. That's right. Maybe. Maybe it's a heart problem and a pump problem. And you need to be giving them pressors to increase the heart rate and to vasoconstrict to get, so you have to look at things in context and say, okay, is this a volume problem, a pipe problem, or a pump problem?

Erik: Correct 

Matt: and figure out. 

Erik: Well, this is the perfect transition into the second section here. When we get to identification of these emergencies, the four types of shock which we've outlined, um, hypovolemic shock, like you talked about, is a volume problem. Mm-hmm. You get a kiddo that's septic and that has a low volume.

Yep. They're going to have cold extremities, they're gonna be tachycardic. Mm-hmm. Uh, they're gonna be maybe not producing much urine alternative depending on the age of the kid. Like [00:19:00] your little tiny baby, 

Matt: right? 

Erik: Wow. We haven't had a wet diaper in a while, have we, mom or whatever. You get that history, that's really important.

Matt: Or mom hands you that kid and they don't really react to mom handing this kid off to somebody they've never known before 

Erik: before feeding. 

Matt: Yes. 

Erik: Huge. 

Matt: Yeah. Haven't eaten, haven't had a bottle. You know, and those are questions, you know, like when I went through nursing school, that's a big thing that they push when you're talking about pediatrics is how many diapers.

Yeah. You know, that's, those were test questions that I would get. Yeah. How many bottles have they had in the last 12 hours? Yep. We didn't, at least when I went through EMT and paramedic school, we didn't really get that education. So those are really important questions as A EMT or a paramedic Yeah. That you should be asking moms Absolutely.

Is how many bottles have they had in the last 12 hours? Yeah. How many wet diapers have they had in the last 12 hours? Yeah. Right. That, no, those numbers might not mean anything to you. Mm-hmm. Like normal. Like if they say one or two, that's not a lot. 

Erik: No. 

Matt: Right. But that's very important information for the nurses and fac physicians at the hospital 

Erik: and knowing, and the mom's gonna be the best person to tell you a hundred percent.

She knows the baseline of that kiddo. 

Matt: Yeah, she changes those diapers [00:20:00] every day. Mom or dad, sometimes Dad's the, the guy too 

Erik: for distributive shock, which is a little bit different now. Mm-hmm. Um, as a well, and actually that can be very similar and they kind of. Overlap a little bit, but pure distributive shock with sepsis.

Mm-hmm. Um, you're gonna get massive vasodilation everywhere. 

Matt: Anaphylaxis. 

Erik: Your body wants to vasoconstrict in the extremities to shunt blood to the core. But when you've got a bad blood infection, it causes a bunch of dysfunction of the hoses. It's like all of a sudden all those inch and three quarter lines turned into two and a half inch lines.

Exactly. You didn't want it to happen. Yes. Now you're cavitating your heart rates. Sky high. Yep. Now you can't perfuse. Yep. And uh, 

Matt: you just turn the volume of, or you turn the speed up on your pump and you have less water coming in. 

Erik: Exactly. 

Matt: That's a bad combination. 

Erik: Bad combination organs die. 

Matt: Yeah. 

Erik: Um, and then the, the third we could obstructive shock.

I guess we weren't really gonna get into too much here. That's a hose problem like you talked about. Yeah. Um, but cardiogenic shock, we're gonna really hit that today. Uh, is the, when you know, and this is the perfect transition [00:21:00] into talking about this, is that because of little kiddo's, major compensatory mechanism is the heart itself.

Mm-hmm. When you have a bad heart 

Matt: Yeah. 

Erik: You have, you can't compensate. Yeah. And so most of the time this is gonna be those little kids. There are some cardiac abnormalities that can cause a left to right shunt later on in life. Right. Um, and those are different cardiac, and we're not gonna get into details of cardiac problems.

Yeah. Because there are different ages where they hit. Mm-hmm. But most of the congenital cardiac problems happen in the little tiny babies. Mm-hmm. And that's, uh, that's gonna, we're gonna talk about how to identify that. Um, but, uh, there's, there's a whole slew of things, but again, it's rare. Mm-hmm. This is not common.

Matt: No. 

Erik: Um, 

Matt: very rare. 

Erik: So cardiogenic shock is when you are not well, what is shock in general? Just when you can't get the metabolic 

Matt: inadequate tissue perfusion. 

Erik: Exactly. You can't, you can't get enough oxygen and blood or whatever to the tissues for metabolic function, 

Matt: for whatever reason. [00:22:00] Whether it's you're not getting enough oxygen in, you're having poor gas exchange.

Yep. You have no volume to circulate 

Erik: or 

Matt: you hose, your hose pump is bad. You KA hose. Yeah. There's lots of different reasons. Yep. Why you would have shock. Um, but yeah, that's the, the definition. 

Erik: And so today being more of, uh, we're gonna focus on the cardiac side, on pediatric emergencies, 

Matt: the pump's not working, 

Erik: the pump's not working.

And so there's a whole slew of different congenital abnormalities from tetrology of flow to coarctation of the aorta to. The, you know, transposition of the gray vessel. I mean, there's a whole bunch of stuff. We're not gonna really get into the the specifics, but when you have a a, a kiddo in cardiogenic shock.

Mm-hmm. Because the pump can't keep up or deliver. You basically end up volume overloaded, just congested. Mm-hmm. The, the lungs are gonna sound wet. Um, you know, you're gonna have, um, uh, poor perfusion to the extremities, delayed cap refill, 

Matt: peripheral edema. Well, you 

Erik: have peripheral edema. You're gonna, you're [00:23:00] gonna have a kiddo that's not feeding.

Uh, there's a whole lot of things. Uh, one other thing I'll say too, with the congestion, you can even have an enlarged liver. I mean, it 

Matt: might be hard to tell pre-hospital, 

Erik: right? I wouldn't, I would never hold my medics to that, but I would just mention it. 

Matt: Somebody has ultrasound maybe as a. 

Erik: Yeah. You know, 

Matt: critical care or a paramedic may have that.

Erik: Yeah. So just, just for completeness sake, I guess, but practically speaking, you're gonna have a kiddo or mom says something's wrong. 

Matt: Yeah. 

Erik: Kiddo's not feeding, they're not acting right. They're, they're, they're super tachycardic and, and you might, which 

Matt: they're not gonna say that mom's not gonna say that. 

Erik: We're gonna find those, them.

There's a warning sign. 

Matt: Yes. 

Erik: Why are we tachycardic? Uh, with these congenital problems, you hit that cliff a little sooner now because the heart isn't even capable to compensate fully. 

Matt: That's right. 

Erik: So one of the things you'll notice is you might think, oh, if we can get some fluids in this kiddo, maybe they'll get better.

Matt: Well, let's start off with oxygen. 

Erik: Oh yeah. True. 

Matt: Yeah. 

Erik: Start with oxygen. 

Matt: Get 'em on some oxygen. We're BLS providers. Mm-hmm. Get 'em on some oxygen, you know, check if you can check. Blood sugars. Make [00:24:00] sure it's not a blood sugar issue. Yeah, right. Ask Mom, you, the best thing you can do as an EMT is get good information.

Okay? Take mom with you in the ambulance ride, you know? Depending on where you're at. If you're five, 10 minutes out, you're transporting. Or if you're an hour away, you might be calling for help. But get that kid on SP O2, see what their SATs are. See what their cap refill is, see what that heart rate is.

Compare it to your chart to know, okay, is this normal or is this tacky for this age kit? Yeah. Right. 

Erik: And speaking of oxygen, if you had a newborn baby, 

Matt: yeah. 

Erik: You don't expect to have normal SPO2s upfront, right? 

Matt: Yeah. No, no. It's gonna, no, it's gonna take about 10 minutes. 

Erik: There's all, 

Matt: yeah. 

Erik: Anyway. 

Matt: You're not gonna have an agro, we're 

Erik: treating numbers here, right?

Matt: Yeah. No. Uhuh. 

Erik: We're looking at this kid. The context of this kid. 

Matt: Yeah. If they're blue and not moving and not screaming and crying, that's a problem. 

Erik: Yep. 

Matt: Yeah. 

Erik: And you, so if you see a kiddo that's not responding well to fluids, like you'd expect, like a distributive shock patient to do, maybe a little hypovolemic, 

Matt: right?

Erik: You might want to think, wow, okay, this may be [00:25:00] something cardiogenic, 

Matt: right? 

Erik: It's a newborn baby and been, you know, just a few days old or something like that, just sent home. Now some of these, some of these cardiac abnormalities don't manifest right away. So there's a lot to think about, um, with cardiogenic shock too.

You, um, you know that if you're an ALS provider, you could be in a weird rhythm too. 

Matt: Yep. 

Erik: And get in that, uh, rhythm, uh, if you're, if you have the capability to do so, can help as well. 

Matt: Mm-hmm. 

Erik: And then, uh, it actually could even trigger. You know, chest compressions, there's a lot of things that can happen.

Right. You mentioned SVT earlier. Mm-hmm. If you're in SVT versus sinus tachycardia, you're in sinus tachycardia typically for a reason. 

Matt: Yes. 

Erik: And when you see sinus tachycardia, the brain has told the heart to pump faster for a reason. Whereas if you're an SVT, it could be some sort of a a rhythm problem, 

Matt: an electrical abnormality that's just all of a sudden 

Erik: you're 6-year-old kid that was at school and all of a sudden went into this weird rhythm because of some sort [00:26:00] of a wiring.

You know, malfunction of some kind. 

Matt: Right, right. 

Erik: Um, and so those, the context, like you said is, is really important. 

Matt: Hugely important. Yeah. What were they doing when this started? How long has this been going on? 

Erik: Yeah. 

Matt: You know, oh, they were outside running around with their friends for the last two hours in the heat.

Well, okay. No wonder his heart rate's 160. 

Erik: Yeah. 

Matt: And he's a 5-year-old, right? Um, or no, he's been sitting inside all day. He hasn't been feeling good or 

Erik: Well, and it's different if Joey is at school and at recess. Just had this weird thing happen, right? Mm-hmm. That's an exertional problem of a kid, active, normal kid.

Right? Um, you've gotta think, well, what could be going on, right? Mm-hmm. But then you go, Johnny, that's never been to school. Who's at home with G-tube? You know, uh, you know, some sort of a, maybe a, a chromosomal abnormality. Mm-hmm. A chronically ill kid. Mm-hmm. Um, there are a lot of cardiac abnormalities that are associated with most of these chromosomal disorders.

Right. In fact, most of the time when kiddos die early from these things, it's sad, but is. Is some sort of a structural problem with the heart. Mm-hmm. [00:27:00] That can actually be at play oftentimes. Not always, but always. Right, right. So you get to that kiddo, you go to the home of a chronically ill kid. Those, those folks may be more likely to have.

Um, a cardiac abnormality. 

Matt: And those times, those patients in particular where, you know, they're home with mom or dad, or they have a nurse or a caregiver coming in, your best resource is that caregiver. 

Erik: Absolutely. 

Matt: They will know exactly. Hey, they've got this congenital defect. Yeah, they're on, like if they've got a feeding tube or you know, if they've got a trach or what they, these parents, these caregivers, they know everything.

So mom. You're basically now the paramedic and I'm just gonna sit back here and document because I don't know what to do here. Exactly. I don't know how to, you know, feed your kid or, you know, if they're on a vent on it with a trach. I don't, you know, you might not know how to operate those settings or what.

Yeah. They are the experts at their kids, so use them. Absolutely. This is what's going on. This is what I notice is off. Mm-hmm. The doctor [00:28:00] said, Hey, if the heart rate gets here, or if he, he's normally more responsive than this. Take them with you. They norm normally they'll be able to do all the treatment.

Yeah. And you just transport and then communicate. 

Erik: Yeah. 

Matt: Because they know what to do. 

Erik: Yep. 

Matt: They're, they know what's going on with their kid. Yeah. Unless it hasn't been found yet. 

Erik: No, no, you're right. I mean the, the, uh, these kiddos actually that may, uh, and, and I would say on the flip side of what I said earlier about, um, being, uh, more likely to be potentially cardiac.

Mm-hmm. You have to remember too that these kids can't complain of a sore ear or Right. Pain with urination in their diaper. 

Matt: Right. 

Erik: Um, and it could very well be the more common perfusion issue. Mm-hmm. Or hypoxia issue. Mm-hmm. So don't forget about the fact that most common is the most common 

Matt: Yes. 

Erik: Even in a kid that we may at first blush see a chronically ill kid.

Matt: Yeah. 

Erik: Thinking about these big cardiac problems. 

Matt: Yeah. 

Erik: Could be as simple as an ear infection. 

Matt: Yeah. 

Erik: Or a UTI. 

Matt: Yeah. 

Erik: Uh, getting a full history is good. 'cause like you said, the parents are gonna know. Yeah. Listen, my kid is not acting right. It's not normal for [00:29:00] her to be scratching at her face. Well, her ear was hurting.

Matt: Yeah. 

Erik: And this has happened before. Mom says, 

Matt: yeah, she have tubes in yet, know who knows? This is her fifth ear infection this year or whatever. Yeah. 

Erik: Yeah. So identification of a cardiac problem is, is gonna be, uh, one of those things after you've ruled out some of the more common things. Mm-hmm. 

Matt: And you're ruling out with questions 

Erik: right now, you're looking at the cap refill, you're asking questions, you're, you're listening to the lungs.

Mm-hmm. You're, you're, um, you're, if you are an ALS provider, you've got maybe some rhythm mm-hmm. Strips, you can look at an EKG potentially 

Matt: check your blood sugars, 

Erik: blood sugar, 

Matt: temperature. Yep. 

Erik: All of these things. You got a full picture, you got a full assessment of your, your kiddo. 

Matt: Yep. 

Erik: Um, so, uh, let's talk briefly about some of the, the cardiac abnormalities that are, they're called ductal dependent, and we're not gonna go through the five Ts mm-hmm.

Of ductal dependent lesions, we call it, you know, because that. [00:30:00] The, uh, the ductus arteriosis, um, is, is where the, the, the, the key, the pediatric or I guess neonatal circulation bridges, right? The deoxygenated into the oxygenated blood. Right. And it's dependent upon that, based upon how the, uh, the baby gets the blood from the placenta, from mom.

You have to have that. 

Matt: It's amazing how that happens. 

Erik: It really is 

Matt: amazing. It's absolutely amazing how that occurs at the moment of birth. It's just, it's unbelievable. 

Erik: Yeah, it's unbelievable. 

Matt: Yeah. 

Erik: It just makes. It just, it, I'm in awe. Yeah. Of what the body does. 

Matt: It's, it's amazing. It's, it's absolutely amazing.

Erik: Yeah. That's right. You said it well, right at birth. Yeah. It starts to close up. Yeah. As we breathe. And a circulation, it doesn't shifts sometimes. Yeah, sometimes it doesn't. Yeah. And sometimes it does and it shouldn't. Yeah. It's a DLE dependent. Yeah. So we wanna keep that open and so we, we give certain medications mm-hmm.

Uh, called prostaglandins. Mm-hmm. And we, we, we give that medication, uh, to keep the duct open. Mm-hmm. Because it has to stay open so the baby doesn't [00:31:00] die. 

Matt: Yeah. 

Erik: And uh, so that would be one of those examples of a cardiac lesion where the kiddo's crumping. You know, soon after birth. 

Matt: Right. 

Erik: Right. Um, and, uh, so that, that's just so we know 

Matt: which we're not gonna fix pre-hospital.

Erik: No. 

Matt: Right. We don't carry prostaglandin No. On most maybe critical care. Some critical care. 

Erik: They probably do. 

Matt: Yeah. Yeah, they will. But, 

Erik: but in the ER they'll have it. 

Matt: Oh, a hundred percent. That's why it's, yeah. Identification, oxygenation, get 'em, get 'em going, get 'em, get 'em going. Those are, these are like trauma patients.

Erik: Yes. 

Matt: Where you don't need to be spending a lot of time on scene. 

Erik: Yeah. 

Matt: You need to be getting en route. 

Erik: Now there are some other lesions for older kiddos, um, that we're not gonna get into a lot of these things right now, but they're, the parents will know about it. 

Matt: Yeah. 

Erik: My kiddo has hypoplastic left heart syndrome and he's on the fourth of however many surgeries.

Yeah. As they get older. Yeah. Uh, it's a series of surgeries. Mm-hmm. These kiddos get, uh, to fix this, this anatomic problem with their heart. Right. It's called hypoplastic left heart syndrome anyway. Mm-hmm. Um, but, [00:32:00] but mom's gonna be able to tell you. Yeah, yeah. You know, he's not scheduled for his next surgery for another year.

Uh, but we can have problems with these kids. These kids are likely to be needing to go to a specific facility. Yep. Mom recognizes the signs, they know what to look for. Yep. They're gonna be absolutely crucial for you. 

Matt: Yes. 

Erik: And then you've got other abnormalities like tetrology of flow, where you're gonna have a school aged kid that has Tet spells.

Mm-hmm. You know, you may or may not be catching this for them. Maybe it's something that the parents know about already. Right. There are some lesions that that can, you can live with longer and can manifest later. 

Yeah. 

And then, uh, you've also got. Some of the kiddos with the, um, some of the cardiomyopathies, uh, you can have, um, you know, like they, um, it's often they'll manifest as, uh, like you'll pass out mm-hmm.

In the middle of a basketball game, for example. Right. Those congenital abnormalities can manifest later in life, even as an adult. 

Matt: Mm-hmm. 

Erik: Um, and, and, uh, we don't need to get into the details of being able to identify that on [00:33:00] eek G or Right. 

Matt: Right. 

Erik: There are certain things you can do, but the point is, is there's a lot of different cardiac abnormalities that can manifest at all sorts of different ages.

Mm-hmm. And being able to identify those can be helpful when you're trying to figure out where to go. Yeah. Um, 

Matt: yeah. Most of the time if they have a known issue, like you said mm-hmm. Caregiver, mom or dad are gonna go, this is where, this is the hospital that we go to. 

Erik: Yeah. 

Matt: Right. And you take 'em to that hospital.

Right. 'cause they're not gonna get help at your normal ER. They need to go to a specialist. Right. No. Now if they don't know Right. And they're unstable, well of course always follow your protocols. 

Erik: Yeah. 

Matt: Right. But, uh, you know, then you would go, 'cause we don't know what's going on. We have no idea. 

Erik: Yeah. 

Matt: We're gonna go to the closest facility.

And then they're gonna have to figure out like, oh, this. Kid's got this issue and then, you know, refer them to a specialist. Um, our job is to manage while we have them. 

Erik: Mm-hmm. 

Matt: And transport. To the correct place as we've been saying. 

Erik: So let's briefly circle back to management of the most common. 

Matt: Yes. 

Erik: So you get a kiddo [00:34:00] that you get 911.

Yep. And, uh, O2 SATs are low. Yep. This kiddo's been sick for a while with who knows what virus. Yep. It's a normal kid otherwise, but is sick with respiratory issues. Maybe it's croup. Who knows what it is, right? Yeah. 

Matt: Yeah. 

Erik: Um, how do we manage. Uh, a kiddo that's, that's, um, in crisis. Good. Yeah. Well, I mean, yeah.

Yeah. It's a We're gonna give 'em oxygen. 

Matt: Yeah, yeah, yeah. You're gonna get 'em on some oxygen. Yeah. And you're gonna try to, you know, with any kid, try to keep 'em calm. 

Erik: Mm-hmm. 

Matt: Don't freak out. Think the duck on the water. You're calm on the surface, but your legs are freaking out underneath, right. Yeah, yeah.

Keep 'em calm. Get 'em on oxygen. 'cause whether it's croup, you know, especially if it's epi. Have you ever seen epiglottitis? 

Erik: I've never seen, I've never seen Titus in a kid. I did see it once though, in an adult. 

Matt: Oh, really? 

Erik: I remember it was an unvaccinated, uh, individual from another country who, who was, he was 

Matt: adult.

Like how old? Like twenties, thirties. 

Erik: Uh, he was in his twenties. He was an older guy. 

Matt: Older? 

Erik: I mean. Like it wasn't a kid, it was a, 

Matt: I'll go back to my twenties. 

Erik: Yeah, that's right. It was an adult. Yeah. And [00:35:00] uh, it was a weird 

Matt: Yeah, 

Erik: weird situation. Had some other congenital abnormalities of his, of his airway.

Matt: Yeah, yeah, yeah. 

Erik: Which can com kind of complicated things a little bit. 

Matt: Yeah. You were hoping you didn't have to intubate. 

Erik: Yeah, no, we, we ended up intubating and uh, but it went, went well. 

Matt: Yeah. That's good. 

Erik: But it was, um, it's, uh, whether or not you like vaccines or not, uh, there are certain things that we can protect ourselves from.

That's right. 

Matt: Some of them. Yeah. Yeah. We won't get into that argument or conversation. No, we won't. But yeah. So 

Erik: not much makes parents more irritated. Oh, 

Matt: man. Yeah. They can be on opposite ends of the spectrum too. Some of them want none and. 

Erik: We're all on the same page. We all want our kiddos to be healthy.

Matt: Yes. 

Erik: And, uh, 

Matt: and you have the freedom to choose what's best for your kids. We just ask that you do that intelligently. 

Erik: Yes. 

Matt: And educate yourself 

Erik: A lot of misinformation out there. 

Matt: That's what I was gonna Yeah. Educate yourself not on YouTube. 

Erik: Yeah. 

Matt: Like listen to actual 

Erik: Dr. Google. 

Matt: Yeah. Or yeah, Dr. Billy Bob, who's not really a doctor.

Uh, anyway, but, um, and, and to be honest. Not [00:36:00] all doctors and, and you and I, I think, agree on this. Like, there's doctors that just believe things that it's like, that's not, you know, but people like, well, he's a doctor. Yeah. And it's like, well, you're not open to other options of things. 

Erik: Yeah. 

Matt: Like, I mean, we could go back to COVID and you got doctors fighting about this and fighting about that.

Nobody agrees on, you know, 

Erik: I had, I had a doc, a friend of mine, show me a letter from their pediatrician saying that if you don't agree with him on these things, then don't come back. 

Matt: Just the fact that he would give me that, I wouldn't go back. 

Erik: Yeah, I know. Me too. Yeah. But what frustrated me on that, uh, regardless of what the issue might be, is there's a way to communicate and educate.

Matt: Right, 

Erik: exactly. Exactly. At least, at least have a full understanding of both perspectives. Yes. So we can have some discourse. 

Matt: Yes. 

Erik: There may be an opportunity to learn something new, right. Whether you're the doctor or the patient. There's always more to learn with literature, 

Matt: right? 

Erik: I think it's 

Matt: like parents that shove antibiotics down their kids' throats.

They're like, stop doing that. 

Erik: Yeah, 

Matt: but they're sick. They need, no, they don't let their immune system fight it. They're not [00:37:00] dying. You know, the fever's good. Like let 'em have a fever within reason. Yeah. Right. Keep 'em hydrated. Give them Tylenol, give them Motrin, keep their fever down. But that's how you build up your immune system.

If you're throwing antibiotics at your kid, you know, two, three times a year, they're not gonna have any immune system or very weak one. 

Erik: In, in some ways, having a fever is like having oxygen supplementation because it actually changes the oxygen dissociation curve. 

Matt: Right. 

Erik: So the fever's actually really helpful.

Yes. When you're sick. 

Matt: Yes. 

Erik: Treating a fever, 

Matt: it's the way the 

Erik: body is supposed 

Matt: to work, 

Erik: may not be as helpful as you might. Think it is, right? Uh, yeah. I I, but 

Matt: nobody wants to see their kids suffer. 

Erik: No. 

Matt: Well, a little Jimmy or, you know, whatever doesn't feel okay, I get it. But that's part of life, you know, let 'em fight through it, keep 'em comfortable.

Yep. But 

Erik: well, the treatment for respiratory emergency in a kiddo, whether it's albuterol, epinephrine, or oxygen or whatever. Yeah. Uh, most of the time it's gonna be either hypoxia we're dealing with mm-hmm. Or perfusion. Right. So, yeah. Let's talk about perfusion. Obviously if you have low blood volume right.

You can't perfuse the [00:38:00] organs, you may need fluids. 

Matt: Yes. 

Erik: And so obviously a BLS provider may not be able to provide that. 

Matt: Right. 

Erik: Um, but uh, at least we can get 'em to a place where they can get fluids. 

Matt: Right. Or call for help. Call for an ALS unit. Call for a helicopter. Yes. And if you're the only BLS unit in your area, get moving.

Erik: Right. 

Matt: You know, get moving to that hospital and do the best you can. 

Erik: Yep. 

Matt: Keep 'em on oxygen. 

Erik: Yep. 

Matt: You know? Um, but yeah, if you can't give fluids, you can't give fluids. You 

Erik: can't. That's right. Yeah. So those are the two common things mm-hmm. That we can manage. Um, we, we should talk briefly though, 'cause it's so important and it's such an, a common cause of an emergency in kids sepsis, is identifying sepsis.

We talked about this a little earlier. 

Matt: Yeah. 

Erik: I know, uh, cs, the surges criteria, kind of maybe some of the more common ones. 

Matt: Mm-hmm. 

Erik: It was designed for the hospital, not the pre-hospital world. Mm-hmm. But we use it anyway. 

Matt: Yeah. 

Erik: So high heart rate. Mm-hmm. I think over 90. Respiratory rate over 20. Yeah. And a fever that's three of the four 

Matt: that, or a known source of infection because they [00:39:00] don't, with the known 

Erik: source 

Matt: of attention.

That's one thing that I get all the time is. I'll, I'll be looking at a report and we'll be teaching CEs and somebody's like, well, what if they don't have a fever? Mm-hmm. And all the time I'll be reviewing reports and the heart rate's, you know, 115 and they're at 96% room air SATs and their blood pressure's fine.

Erik: Mm-hmm. 

Matt: But they, and they don't have, well they didn't have a fever. It's like, yeah. But they're in nursing home resident. 

Erik: Yeah, that's, 

Matt: and they've got chronic UTIs, right? So maybe they're so they don't have to have a fever. Maybe they just took Tylenol control. 

Erik: They don't have to 

Matt: be Right. They do not have to have a fever.

Erik: It's just two. You only need two of them. That's 

Matt: right. 

Erik: And the fourth one we can't even measure. So it's kind of a bad thing. But you know, they're not gonna check a white blood cell count. 

Matt: Correct. Not pre-hospital. 

Erik: So, you're right, Matt, if not having a, a fever doesn't mean they don't have sepsis. Right. And that's not the way that the SIRS was designed.

SIRS was designed to catch everybody. 

Matt: Yes. 

Erik: And so you're gonna catch people who don't really have sepsis. Right. So we make an effort to never miss anybody. 

Matt: Right. 

Erik: Nationally though, we miss about three quarters of septic shock patients because [00:40:00] we've misdiagnosed them. 

Matt: We're taking it for granted. I think I really do.

How so? Because I think we see these patients that look okay. 

Erik: Yeah. 

Matt: Their heart rate's a little bit high. Yeah. They're breathing 24, 25 times a minute. But I mean, they look okay and their heart rate's 110. Well, that's not that high of a heart rate. And they don't realize like they're septic. Yeah. They're meeting the sepsis.

And again, maybe they're not. 

Erik: Yeah. 

Matt: But let's sound the alarm so that if they are, we're getting them the appropriate treatment. Yeah. And sometimes we're gonna miss. So what happens, right? You give them an IV with some fluids mm-hmm. If that's what your protocol is, yeah. They, they're, that's not gonna hurt them.

Erik: And keep, keep your eyes open. Don't we sometimes want to just anchor on the one diagnosis of sepsis or maybe the one diagnosis of whatever it might be. Yeah. Right. Asthma or hypo hypoxia or whatever it might be. Uh, there are things that can cause that. Um, just like these kids we're talking about, this kiddo is sick.

They're crumping, they're, they're falling off the cliff. Yep. It's probably hypoxia or perfusion, but it might not be. 

Matt: Right. 

Erik: [00:41:00] So, um, we have assessed our kiddo. Mm-hmm. And man, we gave maybe, maybe you gave a little bit of fluid and it didn't help, or Right. Or maybe you're doing your physical exam and the, the lungs are wet and it's.

Poor cap refill, volume overloaded, who knows? For whatever reason you're thinking to yourself, okay, well this may actually be cardiac. 

Matt: Mm-hmm. 

Erik: For whatever reason, whatever the context might be. Mm-hmm. So how do we manage these kids? 

Matt: Oxygen first. 

Erik: Oxygen first. Absolutely. 

Matt: Some oxygen. And I mean, it depends on, you know, what are my vitals look like?

Yeah. Do I need to slow the heart rate down at all? Mm-hmm. Do I need to speed it up? Maybe. Or do I need to, like I need to just get to a, a facility that can appropriately treat this kid. 

Erik: That's right. 

Matt: There's lots of different variables. 

Erik: Mm-hmm. 

Matt: Um, to how we're gonna manage. 

Erik: Yeah, 

Matt: these kids, I don't know what.

Erik: Yeah. Well I think for me, in the er I think you said it, you said it Well, I mean, I'm going, I'm gonna put on oxygen. 'cause uh, most of these kids are gonna need that. Um, some of them don't though. Um, some of these ductal dependent and weird [00:42:00] lesions just have a low, um, SPO 2 because there's a lot of shunting of blood from, uh, which they 

Matt: would probably know that.

Erik: They probably know that. That's right. Yes. 

Matt: Mom's, when they probably 

Erik: know that. And you're gonna hear weird murmurs. I mean, there's a lot of medical things that we don't really need to know in the pre-hospital environment, but, um, I think the, the minimum, give them the oxygen. If you have the capability to get a heart rhythm, get a heart rhythm somehow.

Oh, for sure. 

Matt: Yeah. If you're ALS get 

Erik: a, if you can, yeah, a EKG and then IV access. If you can get it, get it. If you need an io, get an io. Do what you need to do. Um, because if you do go into cardiac arrest, which can happen to these kids, they crump fast. Whether it's because their heart rate got so low or because, uh, they, they went into a pulseless rhythm.

The most common ones, if you do, it's gonna be PEA or asystole. 

Matt: Yep. I'm just like a trauma. 

Erik: That's right. And, um, 

Matt: where's your preferred, uh, IO site for a pediatric patient? 

Erik: Uh, to me it's the femur. 

Matt: Yeah, 

Erik: yeah. Distal femur. 

Matt: Yeah. 

Erik: That's, 

Matt: if that, if distal femur is not in your protocols, go talk to your medical director.

It should be. 

Erik: That's, that's right. [00:43:00] Yeah. Yeah. But getting IV access is good. And you get the, you may, you may even be able to, to get the, uh, the umbilical vein too. Yeah. Veins, protocols, 

Matt: little kids. It's little, tiny little, 

Erik: but getting, getting access could be huge. Especially if you go into cardiac arrest 

Matt: for sure.

Yeah. If your kid's really crumping. 

Erik: Yeah. 

Matt: Yeah. If this kid's really going down the hill down. Yeah. Yeah. You gotta, if you have that capability, if you're ALS, if you're BLS, you need to get moving. 

Erik: Yep. 

Matt: You need to get moving or you need to get help. 

Erik: Yep. Yeah. And we, and we covered that with transport, getting them transported to the right facility.

Yep. That's, that's huge. Um, the other, I think, I think, you know, in terms of red flags and things that we'd want to treat, um. If you're, if you're in that situation where you're thinking maybe it is cardiac 

Matt: mm-hmm. 

Erik: Um, we're trying to prevent the kid going into cardiac arrest. Right. Getting some fluid on board could be huge.

Sure. Getting the oxygen on board is huge. Yep. And we can try to help assist the compensation of that kid. 

Matt: That's right. 

Erik: To prevent, 

Matt: you're basically just kind of putting a bandaid it. 

Erik: Right. 

Matt: Giving it [00:44:00] some time to get 'em to the facility so that they can fix that underlying issue. 

Erik: Yes. 

Matt: Yeah, for sure. 

Erik: Um, the last thing I think, um, one of the other things that's important I think to remember, um, is the, the path I pathogenesis, I've heard that term before.

It's like the what, what is the process of the disease that happens? Mm-hmm. Mm-hmm. It starts with respiratory distress. Poor feeding kiddos don't like to breathe. If they're, if they're all socked up for whatever reason Right. They're gonna have trouble feeding. So they're not gonna be feeding. 

Right. 

They don't have the reserves of nutrition to be able to compensate long term.

Right. So eventually they're just gonna get tired. Worker of breathing. 

Uh, then eventually, um, you get to that point where the heart now mm-hmm. The heart can't compensate anymore. Right. And now what started off as a respiratory issue has just become cardio a cardiac issue. Right,

so you go further down.

Far enough down the sepsis or the respiratory route. You're now in the, the, the common pathway of a cavitating pump. 

Matt: Mm-hmm. 

Erik: If you have a [00:45:00] cardiac abnormality, you're not gonna be able to compensate very long. No. You're gonna crop faster. 

Matt: Right. 

Erik: So I think that's, that's a big clue to us as providers is, um, man, Joey's been sick for three days.

He just keeps getting worse. Now he's not acting right. Yeah. As opposed to, I just got home from the hospital, I just had my baby. Everything seemed to be going fine, but today he stopped feeding and now he's all blue. 

Matt: Danger, danger. 

Erik: Right. I mean, that's the two totally different pictures. 

Matt: Right. Right. 

Erik: But, um, a lot of what you said is so true, Matt is identifying the emergency and knowing that we can't fix some of these things.

Matt: Right. 

Erik: And they gotta get to the right facility. 

Matt: Did you see the AHA change their guidelines on pediatric. Yeah. Compressions. 

Erik: Yeah. Yeah. We 

Matt: were kind of talking 

Erik: about, yeah, I was talking because it used to be two choices, right? Yeah. 

Matt: You had thumbs wrap around with the thumbs. 

Erik: Yeah. 

Matt: Or you could do two fingers, like on the side, like you would do with your hands on an adult.

Well, they took the two fingers 

Erik: or a mini, uh, Stryker, um, Lucas device, like 

Matt: Yeah, yeah, right. A, a tiny [00:46:00] mini. Yeah. They called it. Yeah. Not a Lucas device. Uh, but, uh, yeah, so they took the two fingers out. They said that the depth wasn't hitting two inches, I believe is the, the reason they said typically it's not enough.

So the two thumbs on like a baby? Yep. Or one hand. Obviously, if you're dealing with maybe a kid, which is. 

Erik: Yeah, 

Matt: applicable. You know, you do have that kid that crashes on you. It's important to know, like, oh, you can actually use one hand if you're doing compressions on a 5-year-old. God forbid. 

Erik: It's, it's, it's nice when things make sense.

Matt: Yes. 

Erik: That doesn't always happen. 

Matt: That does not always happen. 

Erik: We mentioned the Lucas device. The AHA also said that's debunked too. I, I don't agree with that. 

Matt: Well, we won't talk about dual sequential or vector change. 

Erik: No, no, no. 

Matt: We won't talk about any of that. 

Erik: Um, as far as management goes, don't forget to check a blood sugar.

Matt: Yes. 

Erik: Uh, there are some other GI causes and other sorts of, uh, 

Matt: just do a good exam. 

Erik: Yeah. 

Matt: Right. Is your kid, what's the temperature of your kid? Yep. Yep. 

Erik: Temperature's another big one. 

Matt: Yep. 

Erik: So, uh, I think that's, I think we've, we've hit all of the common things for cardiac [00:47:00] emergencies. Mm-hmm. We've talked about the different common causes and then, uh, really what it boils down to is a good history, I think, for mom.

Yeah. Or from parent. 

Matt: Yeah. 

Erik: And then, uh, get 'em to the right facility. 

Matt: Yes. 

Erik: And not to, don't forget to put oxygen on these kids. 

Matt: Yeah. And depending on, you know, you might. I mean, they have pediatric nasal cannulas end tidal readings too. You know, especially with sepsis can be huge. 

Erik: Yeah. 

Matt: But non-rebreather have mom blow by on the little kids.

Mm-hmm. You know, that's a good job for mom to do. 

Erik: Yep. 

Matt: Um, but you have Superlo Airways for kids. You may have to intubate if you're ALS provider. Yeah. What's your, kind of, your, is your cutoff to intubate a kid the same as an adult? Ooh. Or do you have different criteria? I'm kind of dropping this on you.

Good? 

Erik: No, no. Good question. I just had a patient recently brought in to me, mom brought in a lifeless, unresponsive, I think it was a five yearold girl. 

Matt: Mm. 

Erik: Limping mom's arms dropped her on the bed in front of me. 

Matt: Hmm. 

Erik: No idea what was going on. 

Matt: Yeah. 

Erik: And so obviously [00:48:00] we, we got some vitals trying. So where do you start?

We trying to figure out She's breathing. 

Matt: Yeah. 

Erik: And she's got pulses. 

Matt: She great. ABCs? 

Erik: Yeah. 

Matt: Yeah. Okay. She's breathing. 

Erik: Got pulses. And I thinking, uh, you know, right now it could be a million things kid have, didn't have any medical history. 

Matt: Start high and you start. Digging in, talking to mom while you're checking her out, getting a heart rate, getting a respiratory rate, listening, the lung sound.

What's the story, mom? Yeah, 

Erik: so I told my nurses while I'm assessing this kiddo who's breathing with pulses, but unresponsive, uh, to 

Matt: verbal painful, like, is she moving at all with nothing? 

Erik: GCS of 3. 

Matt: Wow. Just, okay. 

Erik: Um, and, uh, I was concerned, obviously, obviously stressful situation. Sure. Especially with the facility I was working at the time. 

Matt: Yeah. 

Erik: I was the only doctor in the building. 

Matt: Yeah. 

Erik: And, um, I told the nurses, I said, okay, draw up. I, I I want you to get my rock and my ketamine. I want you to get the, the meds all ready to go. 

Matt: Can't control it. 

Erik: Uh, I want to, um, let's get IV access. Mm-hmm. Let's, you know. We're doing that while I'm assessing the kid.

Matt: Mm-hmm. 

Erik: [00:49:00] Before they got the IV, before, um, they finished drawing up the medications. I, because of the history and what mom was describing to me and me listening, I realize this was probably a seizure. Mm-hmm. I know we're talking about seizures today. 

Matt: No. 

Erik: Um, uh, but if, and that was the most likely, 

Matt: it's an input, but it's about assessment.

Erik: Right. But I'm thinking, okay, we may need to stabilize the airway. 

Matt: Yeah. 

Erik: We may need to 

Matt: have it ready to go. 

Erik: Right. Everything ready? 

Matt: Um, vitals. Were all good. 

Erik: Vitals. Were okay? 

Matt: Okay. Blood sugar, that's 

Erik: another clue. Blood sugar was fine? 

Matt: Yeah. 

Erik: Um, everything seemed to be pointing towards seizures and Oh, okay. I was waiting.

If, if I could just see in a couple minutes any trajectory of improvement, any metal status change. It's just gonna confirm to me that it's more likely that this could be a postictal state. Right, right, right. Well, the kids started to move around a little bit. Uh, look around a little bit. GCS was still in the tanks, but it was still better.

Matt: It was improving. 

Erik: It was improving. Yeah. So I saw that trajectory of improvement. And I'm [00:50:00] watching the vitals like a hawk. My nurses are ready to intubate. Yeah. I'm like, well, hold off a second. Let's wait. Yeah. And, and they continue to improve. 30 minutes later, kids sitting up talking to mom. It was a seizure.

Matt: Yeah. 

Erik: But initially, when you go to those emergencies and you just don't know what's going on. 

Matt: No idea. 

Erik: I wanna encourage everybody listening to this. Is there something you can do? You can listen. God gave you two ears and one mouth. Listen. Put the kiddo on oxygen. Mm-hmm. Gather information as fast as you can.

The things that kill, kill fastest. You may need to stabilize an airway, you may need to intubate so you can have time to do things to save that life. 

Matt: Mm-hmm. 

Erik: But, but do do the things that you can do now. Gather as much information as quickly as you can. Yeah. Keep a calm head. 

Matt: Yeah. 

Erik: Um, and then eventually things over time, and I love to say this time can be a great diagnostician.

Matt: Yes, 

Erik: time can really clarify things. Yes, freaking out and just acting off the cuff help really cause problems. But [00:51:00] I would not fault of maybe an ALS provider, a crew. Intubating somebody for, for whatever reason that kiddo started vomiting. I don't care if it's postictal or what. Oh 

Matt: yeah. He's 

Erik: getting, I'm stabilizing the airway because I don't want them to aspirate a hundred percent and it creates other problems.

I'm gonna intubate. Yes. They can always extubate later. 

Matt: Yes. 

Erik: So all that to say with cardiac abnormalities, these can be scary kids. Mm-hmm. Get a full picture and no, it's not the most common thing. 

Matt: Nope. 

Erik: Hypoxia, perfusion, far more common. 

Matt: Yep. 

Erik: Um, and then down the road, one of the rare things. It could be cardiac.

Mm-hmm. Let's make sure we get 'em to the right facility. 

Matt: That's right. Yep. And use those resources. Use Mom again when they have a known congenital issue. Mom is probably gonna be the expert on what's going on. They're gonna give you all the information you're gonna need to know. 

Erik: Yeah. 

Matt: You know, so, 

Erik: and if you're wanting to dig deeper into any of these topics, watch one of our other courses.

Matt: Yep. 

Erik: Um, 

Matt: we had a, a Dr. Ewing on, we talked a lot [00:52:00] about crashing kids. Lots of good information on that one. So, 

Erik: lots of good stuff. 

Matt: Yep. These are rare calls. Thankfully. They're, but they're scary. But if you're educated and you know what to do, then you just go through your steps and you, you handle them as they come.

Erik: Yep. 

Matt: That's all you can do. Well, well, it was a good topic. See you the next one. 

Erik: Be safe out there.

Narrator: Thank you for listening to EMS, the Erik and Matt Show.