Pediatric Restraint


Pediatric restraints are to used only when necessary in situations where the patient is violent or potentially violent and may be a danger to themselves or others.

  • Administer midazolam (Versed) 0.1 mg/kg (max 5 mg) IV/IO or 0.2 mg/kg (max 10 mg) IN/IM
  • When able and safe to do so, place patient on cardiac monitor, continuous pulse oximetry, check blood glucose level, and end-tidal capnography.
  • Administer oxygen

Submersion Injury


  • Remove victim from water and keep patient warm
  • If suspected diving accident or axial load to head, apply C-spine stabilization
  • Ensure adequate airway, breathing, and oxygenation
  • For cardiac arrest, follow appropriate protocol
  • Transport to appropriate trauma center
  • For ice water drowning, transport to pediatric ECMO-capable facility (Cincinnati Children’s Hospital)

Pediatric Toxicological Emergency


  • If narcotic overdose, naloxone 0.1 mg/kg IV/IM/IN/IO (max 2 mg)
  • If toxin remains on patient, wash or brush off as appropriate. Alert medical control if patient will require further decontamination; patient NOT to be brought through regular Triage.
  • For eye exposure, flush the eyes with 0.9% NaCl for at least 15 min
  • If patient has ingested medications or other substance, obtain container(s), and bring with patient to ED

Pediatric Pain Management


  • For children 5-15 y.o with extremity injury or burn

Administer a single dose of either:

  • Fentanyl 1 mcg/kg IV/IO (max 50 mcg for pain) – administer over 3-5 minutes slow IV push to prevent rigid chest
  • Fentanyl 2 mcg/kg intranasal (max 100 mcg for pain) – use the undiluted injectable fentanyl product (100 mcg/2 ml), draw up an extra 0.1 ml of drug solution to prime the atomizer and administer a max of 1 ml per nostril (if giving to larger kid and need to use 100 mcg, you should use the same atomizer for both nostrils)
  • Morphine sulfate 0.1 mg/kg IV/IO or IM (maximum dose 5 mg)
  • If patient experiences a drop in systolic blood pressure to < (2x age in years) + 70, give 20 ml/kg 0.9% NaCl IV push
  • If patient has an allergy to opioids and/or pain not relieved or for subsequent doses, contact medical control

Pediatric Diabetic Reaction


IF blood glucose is < 70 mg/dl:

  • If dysrhythmia present, proceed to appropriate protocol
  • For shock, push 20 ml/kg 0.9%NaCl IV/IO (max 1 L)
  • If glucose ≤70, administer 1 ml/kg D50W IV/IO push; If child ≤3 y.o. or ≤ 15 kg, instead push 2 ml/kg of D25 IV/IO (D25 is made by mixing D50 1:1 with 0.9% NaCl)
  • If no IV, Glucagon 1 mg for ≥6 y.o. or 0.5 mg for children ≤5 y.o.

IF blood glucose is > 400 mg/dl or glucometer reads “HIGH”:

  • Give fluid bolus of 20 ml/Kg not to exceed 1000 ml IV/IO during transport if no evidence of pulmonary edema
  • Place patient on monitor for possibility of dysrhythmia

Pediatric Stridor


  • Keep the patient calm
  • Consider 0.9% NaCl mist via nebulizer
  • Place patient on a cardiac monitor
  • Contact medical control if considering nebulized epinephrine
  • Epinephrine 0.5 ml of 1:1000 solution mixed in 2.5 ml of 0.9% NaCl, nebulized
  • Continue nebulized 0.9% NaCl afterwards may be beneficial

Pediatric Respiratory Distress (Wheezing or Asthma)


  • Assess need for assisted ventilation
  • Allow patient to sit in a position of comfort
  • If wheezing, albuterol 0.5 ml in 2.5 ml 0.9% NaCl nebulized
  • Initiate transport
  • May give 3 albuterol nebulized treatments. May considering adding 1 vial Ipratropium Bromide (0.5% of 0.02%) to the albuterol treatments, or substituting Duoneb.  Contact medical control if additional treatments needed
  • For severe respiratory distress, contact medical control while BVM ventilating. For impending respiratory failure, contact medical control for consideration of epinephrine 1:1000 IM 0.01 ml/kg (max 0.3 ml)
  • For patients ages 3-16 y.o. who are awake, oriented, can take oral medications, have known asthma or reactive airway disease, or history of multiple episodes of wheezing responsive to albuterol, and are NOT currently taking steroids, have a history of cancer, diabetes, or immune deficiency, administer one of the following:

Prednisolone 3 mg/ml liquid

  • Age 3-7 years: 30 mg (10 ml)
  • Age 8-16 years: 60 mg (20 ml)

Prednisone 20 mg tablets

  • Age 3-7 years: 30 mg (1.5 tabs)
  • Age 8-16 years:  60 mg (3 tabs)

Solumedrol IV solution to be administered PO (125 mg/2ml)

  • Age 3-7 years: 30 mg (0.5 ml)
  • Age 8-16 years: 60 mg (1 ml)

Pediatric Respiratory Distress (Obstruction or FBO)


Alert and not choking

    • Begin transport with patient as comfortable as possible
    • If wheezing, albuterol nebulized treatment

Alert and choking

  • <1 y.o., give 5 back slaps and 5 chest thrusts; repeat as necessary
  • >1 y.o., give abdominal thrusts (Heimlich maneuver)
  • Unconscious
  • Begin CPR/BVM
  • With laryngoscope, look for foreign body and remove with Magill forceps
  • If no foreign body, intubate
  • If still no chest rise, consider pushing tube in right mainstem or needle cric
  • Contact medical command and transport to the closest appropriate facility

Pediatric PVST


  • Obtain 12 lead ECG

If STABLE patient:

  • Vagal maneuvers
  • Contact medical control
  • Adenosine 0.1 mg/kg IV rapid push (maximum first dose 6 mg); may repeat with dose doubled (maximum second dose 12 mg)
  • Only on the conscious patient and the order of a medical control physician, administer midazolam 0.1 mg/kg (max 5 mg) IV/IO or other medications as directed by medical control) and deliver synchronized cardioversion 0.5 J/kg
  • If unsuccessful, repeat synchronized cardioversion at 1 J/kg
  • If unsuccessful, repeat synchronized cardioversion at 2 J/kg
  • Round the joules up

If UNSTABLE patient:

  • Contact medical control
  • Midazolam 0.1 mg/kg (max 5 mg) IV/IO
  • Synchronized cardioversion 0.5 J/kg.
  • If unsuccessful, repeat synchronized cardioversion at 1 J/kg
  • If unsuccessful, repeat synchronized cardioversion at 2 J/kg
  • Round the joules up

Pediatric Bradycardia


  • If symptomatic give oxygen, use BVM as needed, and recheck pulse rate
  • If HR <60, BVM and chest compressions
  • Epinephrine 1:10,000 IV/IO at 0.1 ml/kg or 1:1000 at 0.1 ml/kg via ETT (max dose 2 ml)
  • Contact medical control
  • Repeat epinephrine every 5 minutes
  • After epinephrine, consider 1 dose of atropine, 0.02 mg/kg (min 0.1 mg, max 1.0 mg) IV/
  • IO (ETT = 0.04 mg/kg)
  • If hypotensive, 0.9% NaCl 20 ml/kg IV