What are your pediatrics protocols?

[platon20]

I know a paramedic in Alaska that ran into the following situation:

7 day old newborn with fevers up to 102. Mild URI symptoms.

The paramedic did an LP and gave one dose of ceftriaxone while en route to the hospital.

Have any of you done LPs on a newborn before?
What is your protocol for giving antibiotics to pediatrics patients?

 

[VFlutter]

I know a paramedic in Alaska that ran into the following situation:

7 day old newborn with fevers up to 102. Mild URI symptoms.

The paramedic did an LP and gave one dose of ceftriaxone while en route to the hospital.

Have any of you done LPs on a newborn before?
What is your protocol for giving antibiotics to pediatrics patients?

LP as in Lumbar Puncture? Seriously?

 

[platon20]

LP as in Lumbar Puncture? Seriously?

Yes, lumbar puncture. I was surprised too. Apparently there are some jurisdictions where paramedics can do LPs.

 

[NomadicMedic]

Where? I'd Like to see those protocols.

 

[CodeBru1984]

Where? I'd Like to see those protocols.

I searched the EMS protocols for the state of Alaska, and I wasn't able to locate anything that referenced Paramedics preforming LPs in the field. If you can find this in their protocols, I too would like to see them.

 

[VFlutter]

Some info about pediatric LPs and antibiotics...

-Antibiotics do not appear to cause changes in cerebrospinal fluid (CSF) white blood cell, protein, or glucose levels which are compatible with impeding diagnostic utility.

-Additionally, CSF gram stain findings are not significantly changed by early antibiotic use, as these studies have been found to be diagnostic in most patients even if lumbar puncture (LP) is delayed by up to 3 days.

-CSF cultures may be positive even after a single dose of antibiotics, although the yield decreases with more fastidious organisms such as meningococcus.

-In 86% of patients with bacterial meningitis, the causative organism may be isolated pre-antibiotic administration via blood culture.

https://umem.org/pearl_view.php?p=1506

I see no reason why you would need to preform a LP in the prehospital setting

 

[platon20]

This guy said his EMS director had approved all of his paramedics to do LPs after they had done a certain number in a hospital -- he works out of Fairbanks. I'm not sure what the state laws are on this but he made it sound like its up to the EMS director -- if the EMS director says its OK to do brain surgery in the field, then I guess its OK.

Doing an LP is not a hard thing -- I've done a couple as part of my hospital-based training for paramedic 15 years ago. You guys make it sound like its open heart surgery or something. I've never done one in the field obviously, but I dont think it is as big of a deal as you guys seem to think it is.

As for the utility of doing LPs in the field, apparently the EMS director only approves it for certain transport times longer than a pre-defined interval. I'm not sure what that interval is though. I've talked to pediatricians about this before and I think most of them would prefer the LP to be done within a few hours of giving antibiotics.

So what do you think of this paramed's protocol for abx? I would have chosen a different one, but what would you guys use in this situation?

 

[WTEngel]

Some info about pediatric LPs and antibiotics...

-Antibiotics do not appear to cause changes in cerebrospinal fluid (CSF) white blood cell, protein, or glucose levels which are compatible with impeding diagnostic utility.

-Additionally, CSF gram stain findings are not significantly changed by early antibiotic use, as these studies have been found to be diagnostic in most patients even if lumbar puncture (LP) is delayed by up to 3 days.

-CSF cultures may be positive even after a single dose of antibiotics, although the yield decreases with more fastidious organisms such as meningococcus.

-In 86% of patients with bacterial meningitis, the causative organism may be isolated pre-antibiotic administration via blood culture.

https://umem.org/pearl_view.php?p=1506

I see no reason why you would need to preform a LP in the prehospital setting

^ What he said.

I call BS on a field LP, unless performed by a provider level clinician (i.e. not a paramedic). Even then, it seems like it is taking great risk for little benefit. As Chase pointed out, cultures can still be obtained in the relatively immediate time frame post ABX administration, and I think a good history in the neonate would be every bit as beneficial when screening for meningitis risk.

I am not saying an LP should not be done in the clinical setting when there is a high index of suspicion for meningitis, but in the field, I see nothing but trouble...especially for the paramedic who might possibly have the opportunity to do 1 or 2 a year, max.

 

[WTEngel]

This guy said his EMS director had approved all of his paramedics to do LPs after they had done a certain number in a hospital -- he works out of Fairbanks. I'm not sure what the state laws are on this but he made it sound like its up to the EMS director -- if the EMS director says its OK to do brain surgery in the field, then I guess its OK.

Doing an LP is not a hard thing -- I've done a couple as part of my hospital-based training for paramedic 15 years ago. You guys make it sound like its open heart surgery or something. I've never done one in the field obviously, but I dont think it is as big of a deal as you guys seem to think it is.

As for the utility of doing LPs in the field, apparently the EMS director only approves it for certain transport times longer than a pre-defined interval. I'm not sure what that interval is though. I've talked to pediatricians about this before and I think most of them would prefer the LP to be done within a few hours of giving antibiotics.

So what do you think of this paramed's protocol for abx? I would have chosen a different one, but what would you guys use in this situation?

Yep, sticking a needle into the subarachnoid space of the lumbar spine sounds like a perfectly benign procedure. I see no reason why we don't allow parents to go ahead and do it for their children, if they suspect meningitis.

/sarcasm

While it might not be "brain surgery" it is a skill that I have seen plenty of physicians struggle with, unless they are pediatric specialists, and even then most primary care pediatricians are not going to do one...they will defer to the ED or ICU peds specialist to perform the procedure.

What if it is unsuccessful? Why even risk it, and have to stick the child twice? Additionally, taking the time to do this procedure in the field is ridiculous. Your time would be better spent closing distance with the hospital you are transporting to. Please don't tell me they performed the procedure in a moving vehicle...

 

[abckidsmom]

Yep, sticking a needle into the subarachnoid space of the lumbar spine sounds like a perfectly benign procedure. I see no reason why we don't allow parents to go ahead and do it for their children, if they suspect meningitis.

/sarcasm

While it might not be "brain surgery" it is a skill that I have seen plenty of physicians struggle with, unless they are pediatric specialists, and even then most primary care pediatricians are not going to do one...they will defer to the ED or ICU peds specialist to perform the procedure.

What if it is unsuccessful? Why even risk it, and have to stick the child twice? Additionally, taking the time to do this procedure in the field is ridiculous. Your time would be better spent closing distance with the hospital you are transporting to. Please don't tell me they performed the procedure in a moving vehicle...

Not to mention it's typically at least a 3 person job. We tend to have fewer people than that.

I would not allow an LP by any level provider in the field for my child. Tooth chance of contamination, of the culture, of the CSF, of the anything.

 

[JPINFV]

Anyone else get this image of an ambulance driving down the road and the paramedic calls up to his partner, "Hey, John, slow down, I need to get this LP done!"

 

[abckidsmom]

Anyone else get this image of an ambulance driving down the road and the paramedic calls up to his partner, "Hey, John, slow down, I need to get this LP done!"

My image was the baby on a hand hewn table in a cabin with a pump at the sink. I'm sure both of us are off from this incident, assuming it was real life.

 

[platon20]

Yep, sticking a needle into the subarachnoid space of the lumbar spine sounds like a perfectly benign procedure. I see no reason why we don't allow parents to go ahead and do it for their children, if they suspect meningitis.

LP is a much more benign procedure than a chest tube. Hell I would argue it is a much more benign procedure than intubation, especially in pediatrics patients who are much more likely to experience intubation-related laryngospasm.

So should be we be removing privileges for intubation for peds patients?

it is a skill that I have seen plenty of physicians struggle with,

Yeah and I've seen physicians struggle to intubate as well, or even to get an IV. So what? Does that mean paramedics shouldnt be allowed to do it?

unless they are pediatric specialists, and even then most primary care pediatricians are not going to do one...they will defer to the ED or ICU peds specialist to perform the procedure.

Ummm.... 3rd year med students do LPs on kids ALL THE TIME. Again, this is not some incredibly complex skill.

What if it is unsuccessful? Why even risk it, and have to stick the child twice? Additionally, taking the time to do this procedure in the field is ridiculous.

If it doesnt work, then let the ED doc give another try. I've seen many LPs in the hospital and it is somewhat common for them to have to stick twice, or adjust the needle. This is not some catastrophic complication.

Your time would be better spent closing distance with the hospital you are transporting to. Please don't tell me they performed the procedure in a moving vehicle...

I dont know if they did it in a moving vehicle or not. But I will say this. It is much harder to INTUBATE a child in a moving vehicle than it would be to do an LP.

 

[platon20]

Not to mention it's typically at least a 3 person job. We tend to have fewer people than that.

I would not allow an LP by any level provider in the field for my child. Tooth chance of contamination, of the culture, of the CSF, of the anything.

3 person job? No way, 2 people max. One to hold the baby in flexed position, the other does the tap.

I'll say this again -- 3rd year med students with zero procedure/clinical experience do LPs all the time. A paramedic is certainly going to be better at it than a med student would be.

 

[JPINFV]

I'll say this again -- 3rd year med students with zero procedure/clinical experience do LPs all the time. A paramedic is certainly going to be better at it than a med student would be.

3rd year medical students are doing it in a teaching environment where they've generally seen an LP at least once and are being supervised and guided while doing it. It's an apples to oranges comparison in so many different ways.

 

[WTEngel]

I worked at a large pediatric teaching hospital, and I have seen plenty of PGY-3s doing LPs. I have seen plenty miss too.

Not to mention, you are comparing 3rd year residents on pediatrics rotations to a field paramedic on a 911 call. Not an apples to apples comparison. In fact it is more like comparing rocket ships to half eaten apples.

I am not saying that the likelihood of failure should constitute what skills we should and should not be allowed to do, but the frequency with which we get to practice those skills should definitely be a factor of significant consideration.

Again, I have seen PGY-3s miss multiple LP attempts, and they are in an environment where they may get to practice 2-3 per shift! I can't reliably speculate on the frequency with which your friend gets the opportunity to perform LPs, but I would be EXTREMELY surprised if it was enough to be even close to proficient at it.

As far as intubation goes, if you can show me one study that demonstrates better pre-hospital outcomes in pediatric patients managed with advanced airways vs. BVM/non invasive ventilatory support, then I will agree with you that there is significant importance for EMS to maintain pediatric intubation as a mainstream skill. Until then, it is my belief that the ardent support that most EMS providers exhibit for advanced airway skills is really anecdotal, and has more to do with them wanting to perform a procedure than it does with actual patient outcomes.

 

[WTEngel]

I thought you said 3rd year residents earlier, not 3rd year med students. Sorry for the mistake.

Either way, even though 3rd year med students are less experienced than 3rd year residents by far, it is still not apples to apples to compare them to a paramedic not practicing in a supervised clinical environment.

 

[DesertMedic66]

So should be we be removing privileges for intubation for peds patients?

Come down to a certain county in SoCal and peds do not get intubated in the prehospital setting.

 

[WTEngel]

Last point...in regards to your actual question.

When I was at Children's in Dallas, amp + gent were the empirical ABX therapy of choice in our NICU for neonatal sepsis protocol. This was assuming there were no other extenuating factors in the patient's hx.

In some cases, if it was later onset, ceftriaxone would be used, as it is unlikely that any of the typical microbial players are involved, and the neonate has an infection acquired from a source other than the mother's birth canal.

 

[Aidey]

Back on topic, there is no way in hell a 911 paramedic in Fairbanks, Alaska is doing LPs.