Resuscitation of a child following a near-drowning

     Paramedics save lives, the saying goes, and EMTs save paramedics. That's glib and debatable, but it's certainly true that the role of the EMT-Basic is a vital one, and that there's relatively little out there in the way of information and tools to help him do it better. This new column, which will appear several times a year, is a resource for EMT-Basics. It will cover everything from reviews of basic skills to assisting ALS providers with more advanced interventions in a way designed to enhance understanding and develop a more complete provider. As always, we welcome your comments; send thoughts, feedback and ideas for future columns to nancy.perry@cygnusb2b.com.

     Pediatric emergencies typically pose challenges for prehospital providers. These incidents can be emotional and require careful communication with both the patient and the parents or caregivers. EMS providers fortunately do not deal with pediatric emergencies every day, so maintaining familiarity with procedures, medications and documentation requires frequent training.

Scenario
     At approximately 1825 hours, Rescue 24 responds to a child not breathing. Upon arrival, the crew finds a child of approximately 2 lying on the floor, being attended to by family members. The child is pulseless, apneic and cyanotic. Family members relate that the child was found at the bottom of the pool and had been missing for approximately six minutes.

     Crew members immediately initiate chest compressions, begin ventilating the patient and apply the cardiac monitor. Upon assessing the patient's heart rhythm on the monitor, they determine it's not one that needs to be defibrillated. The advanced provider inserts an endotracheal tube (4 mm) and auscultates for breath and epigastric sounds. Once proper tube placement is verified, a continuous end-tidal CO₂ detector and pulse oximetry (SpO₂) are applied. The endotracheal tube is then secured, and its placement noted. In addition, the advanced provider initiates an intraosseous infusion into the patient's left lower extremity. The patient is placed on a long spine board and cervically immobilized.

     En route to the hospital, the cardiac monitor displays a bradycardic rate of 40 beats per minute, but no palpable pulse is present (pulseless electrical activity, or PEA). The advanced provider administers .12 mg epinephrine via the intraosseous route and assesses the patient. Approximately one minute later, the patient's heart rate increases to 120 beats per minute, and pulses are felt at the carotid and femoral regions. Although the patient is not breathing spontaneously, a blood pressure reading of 78/42 mmHg is obtained. Upon arrival at the hospital, the patient is transferred to the emergency department team while being ventilated.

     Managing the Airway
     The above case presentation was pretty straightforward; however, let's discuss some of the tools used by the advanced provider.

     First, the quick assessment of the ABCs is critical for every unresponsive patient. Upon realizing that this patient was pulseless and apneic, the crew began immediate chest compressions with aggressive airway management. Ensuring appropriate airway management is essential during resuscitation. Terrible complications can result from an inadequate airway or ventilation in a child. Many child arrests are respiratory in nature--not heart-related, as they are in adults. Every child must be ventilated adequately, so rescuers should provide bag-valve mask breathing with added oxygen as a basic element of care.

     Advanced providers can intubate some children. Upon inserting the endotracheal tube here, a crew member auscultated the lung fields and epigastrium. Why auscultate the epigastrium? The goal when intubating a patient is to insert the tube into the trachea. This method of airway management will provide 100% oxygenation when an oxygen source is applied, provides a route for tracheobronchial suctioning, and protects the lungs from aspiration. If the endotracheal tube is inserted into the stomach, then when ventilating, gurgling sounds may be heard over the epigastrium. If these aren't detected immediately, the inappropriate tube placement will result in a catastrophic outcome. It is critical to listen to the lungs and the epigastric area immediately upon insertion of the tube.

     In addition, the advanced provider may attach (if available) an end-tidal CO₂ (ETCO₂) detector. This will detect levels of exhaled carbon dioxide (CO₂). If the CO₂ levels drop, this will alert the provider that there might be something wrong with the tube--maybe it's become dislodged or obstructed.

     Endotracheal tubes come in a variety of sizes (2.5 mm-9.0 mm) and may be cuffed or uncuffed at the distal end. How do you choose the right size for your patient? There are several approaches that the advanced provider is taught to use when selecting the appropriate tube size. First, they may use the following formula:

     (Age in years +16)/4

     For example, if the child is 2 years old, then 2 +16 = 18, and 18/4 = 4.5 mm.

     The provider may also use the Broselow system. This consists of a bag, color-coded pouches and color-coded tape. The color-coded tape is used to measure the length of the patient from head to toe. The color identified at the feet will correspond to the appropriate tools needed for resuscitation. The advanced provider then gathers the same colored pouch from the Broselow bag. Within this pouch is the appropriate size tube.

Vascular Access
     Intravascular access is also an important component of resuscitation. Although intravenous (within the vein) access is the most common way of achieving it, a vein may not be readily accessible during a resuscitation event in a child. Some protocols allow the option of choosing an intraosseous (IO) route for the administration of medications and/or fluids. The intraosseous route is commonly used when resuscitating a child.

     In the IO method, an intraosseous needle is inserted into the bone marrow through the tibia. This route has been shown to be effective due to the vasculature and absorption rate of the marrow. IOs are used by some prehospital agencies for rapid vascular access in adult patients as well.

PEA
     The patient here presented with a heart rate of 40 beats per minute; however, no pulses were present. This presentation is referred to as pulseless electrical activity. PEA is identified when there is a recordable rhythm on the heart monitor, but no pulse is present.

     Typically, when a rhythm is displayed on the ECG monitor, the patient has a pulse. In PEA, the patient's electrical system is carrying a signal, but the pump mechanism of the heart is not working. The most likely causes of PEA are hypoxia, hypovolemia, tension pneumothorax, pulmonary embolism, myocardial infarction and severe poisoning. At any point, and with good treatment, the pump function may return. Therefore, it is critical to continuously assess and reassess your patients and try to anticipate the next treatment modality. As a basic provider, this can only be accomplished by working closely with advanced providers and becoming familiar with the ALS equipment used by your service.

Orlando J. Dominguez, Jr., MBA, FF/EMT-P, is chief of EMS and public information officer for Brevard County Fire Rescue in Rockledge, FL, as well as an EMS program educator for Health First Training Center in Melbourne.