Wheezing is a frequent EMS pediatric encounter. First-line treatment for acute asthma episodes includes bronchodilators, such as the beta-agonist albuterol, and the anticholinergic ipratropium. Other therapy may include corticosteroids, IV magnesium sulfate, and epinephrine (nebulized or IM injection) (Table 54.1). Continuous positive airway pressure (CPAP) should be administered for severe respiratory distress of any cause. Bag-valve-mask ventilation should be utilized in children with respiratory failure [9,10]. It is very difficult to manage ventilation in asthmatic patients who are intubated; therefore, intubation should only occur when high-quality BVM ventilation fails [7,10,11].

Other respiratory processes such as bronchiolitis, pneumonia, and airway foreign bodies can cause wheezing. Bronchiolitis is associated with a large amount of mucus production and airway edema, and neonates are at risk of apnea. The airway should be maintained by suctioning the nose and/or mouth when excessive secretions are present [12]. Bronchodilators may be ineffective in bronchiolitis but albuterol should be administered to all children in respiratory distress with signs of bronchospasm [13–15]. Nebulized epinephrine should be administered if the above treatments fail.

Pneumonia usually presents with fever and cough, associated with dyspnea, tachypnea, chest pain, and/or vomiting. Prehospital interventions include oxygen and ventilatory support by the least invasive means. IV access should be obtained if the patient’s status warrants treatment of dehydration with IV fluids. Suspected foreign body airway obstruction is managed according to AHA/ILCOR guidelines.

Laryngotracheobronchitis, or croup, causes a characteristic barking cough and can present with stridor. Nebulized epinephrine should be administered to all children in respiratory distress with signs of stridor and can be repeated with unlimited frequency for ongoing distress [16,17]. Patients who receive nebulized epinephrine should be transported to a receiving facility for continued observation [18].

While key history and physical exam findings can lead the provider to the correct treatment guideline, a key principle should be to treat respiratory distress first, by ensuring an open airway and providing supplemental oxygen, and then consider the differential diagnosis.

Controversies over airway management

The current literature highlights shortcomings associated with prehospital pediatric ETI. Few studies show improved outcomes, and several studies describe worsened outcomes. ETI and intubation medications may inadvertently interact with other physiological processes key to resuscitation. Adverse events and errors are frequent. Significant system-level barriers limit training and clinical experiences for prehospital providers and students, and ETI is a complex procedure, requiring a significant amount of training to learn and maintain proficiency. Fortunately, few situations necessitate prehospital ETI.

One review documented that ETI was attempted in only 0.7% of all calls for children less than 15 years of age. Paramedics were unable to intubate 18% of these patients [19]. A review from a largely rural state documented that fewer than half of the state’s paramedics attempt at least one pediatric intubation per year; only 2% of providers attempted any pediatric intubation during the 5-year study period [20].

A large prospective controlled trial comparing BVM ventilation to ETI in pediatric medical and trauma patients under 13 years of age demonstrated no survival or neurological outcome benefits in the ETI group [10]. The ETI group had longer scene and total prehospital times. In a review of the National Pediatric Trauma Registry, mortality and abnormal functional outcome scores were more likely in children who were intubated in the prehospital setting versus the hospital setting, controlling for injury severity scores. Observed versus expected rate of mortality was higher for patients intubated in the prehospital setting across all injury severities [21].

Supraglottic airway devices have not been studied in pediatric patients in the prehospital setting; however, use by prehospital providers on pediatric high-fidelity simulators has been studied [22–26]. Of the available devices, the laryngeal mask airway is available in a range of sizes that allows its use in all ages, including neonates. The King airway device (Kingsystems, Noblesville, IN) is limited in pediatric use due to available sizes. The smallest size is recommended for patients as small as 3 feet tall or 12 kg, making them unavailable for patients under the age of approximately 2 years.

One key fact remains: proficiency in pediatric BVM ventilation is mandatory for all prehospital providers [27]. The method of airway support used in the system should be based on the skill level of the providers, equipment and medications available, ongoing training and experience, transport times, and medical oversight.

Apparent life-threatening events

Apparent life-threatening events (ALTE) may present as a call to 9-1-1 from a frantic parent stating that his or her child has stopped breathing or turned blue. The child may have already recovered to baseline status. An ALTE is defined as “an episode that is frightening to the observer and that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging. In some cases, the observer fears that the infant has died [28].”

Apparent life-threatening event is a diagnosis usually reserved for infants up to age 12 months. ALTE has a reported incidence of 1–9 infants per 1,000 live births, but accounts for 7.5% of infant EMS encounters [29], 2% of hospitalized children, and 0.7% of infant ED visits [30]. ALTE is more common in younger infants less than 3 months [31]. The literature reports mortality associated with ALTE as being anywhere between <1% and 6% [28].

Greater than 80% of these patients will recover quickly and be well-appearing at the time of evaluation, with no signs of distress. Nearly all will have normal vital signs [29]. The on-scene evaluation for children with ALTE should include close examination of the patient and surroundings for evidence of occult trauma, and a blood glucose measurement. Despite the patient’s well appearance, all those with a chief complaint consistent with ALTE should be transported to the hospital. At least 75% of patients presenting to the ED with ALTE are admitted to hospital [32]. Thirteen percent may need significant intervention during hospitalization [33]. It is prudent to recommend contact with direct medical oversight for caregivers who are refusing medical care and/or transport.

The differential diagnosis of ALTE is broad, encompassing gastrointestinal, respiratory, neurological, cardiac, and metabolic disorders. Serious illness causing an ALTE is difficult to exclude during a brief EMS evaluation. Of the very serious causes of ALTE, child abuse has been found in as many as 11% of cases, metabolic disease in 1.5%, ingestion of drugs or toxins in 1.5%, meningitis in 0.5–1%, and cardiac problems in 0.8% [30,32,34]. One study noted that a call to 9-1-1 for ALTE was associated with an almost five times greater odds of abusive head trauma being diagnosed as the cause of the ALTE [35], clearly emphasizing the high index of suspicion EMS providers must have when responding to these calls.

Long-term prognosis for infants with ALTE is generally very good. Recurrence of ALTE has been reported as being as high as 24% [30]. ALTE has not been shown to be a risk factor for subsequent sudden infant death syndrome (SIDS) [34].

Seizures and seizure mimics

Seizures account for 10% of pediatric calls to 9-1-1 [2]. They often are associated with anxiety on the part of the family and bystanders. The EMS physician should be concerned about the cause of the seizure as well as field treatment; however, providers should not diagnose the cause of the seizure before initiating appropriate therapy and transport [36]. The management of seizure is covered in Volume 1, Chapter 20 and Table 54.1.

For actively seizing patients, a blood glucose level should be measured. A blood glucose of <45 mg/dL in neonates or <60 mg/dL in infants, children, and adolescents should be treated with IV dextrose or IM glucagon (see Table 54.1

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Respiratory distress Seizures Infectious and communicable diseases Bites, stings, and envenomations End-of-life issues Leadership and team building