Paediatric Scenarios for Medical Students

23/03/11Dr. John Twomey

Department of Paediatrics/ Emergency Department

ETA 5 min…….

Weight• Centile Charts• Broselow Tape• Formula (1-10yrs): Wt (kg) = (age + 4)2• Estimate (0-1 yrs): Newborn = 3.5 kg 6/12 = 7 kg 12/12 = 10 kg• Estimate (>10 yrs): 10 yrs = 30 kg 12 yrs = 40 kg 14 yrs = 50 kg 16 yrs = 60 kg

Energy• 4 J/kg asynchronous shock• Except: - Ventricular Tachycardia with Pulse - Synchronous

cardioversion 0.5-1J/kg, 2J/kg- Supraventricular Tachycardia (SVT) - If No IV access &

shocked – Synchronous cardioversion 1J/kg, 2J/kg

Synchronous cardioversion:• shock given @ “R” of QRS complex; relies on the ability

of the defibrillator to recognise QRS complexes• The shocks may have to be given asynchronously if

synchronous shocks are ineffectual (may => VF or asystolé)

Tube

Estimate (>1)• Internal Diameter (mm) = (Age/4) + 4

• Length (cm) = (Age/2) + 12 (oral) + 15 (nasal)Term Neonate• 3.5 (3.0,4.0)

Preterm Neonate• 3.0 (2.5,3.5)

Fluids• 0.9% NaCl 20 ml/kg (10ml/kg in DKA or Trauma)• >/= 3 boluses (60ml/kg = ¾ of total circulating blood

volume!) = consider RSI• Larger volumes => haemodilution - Albumin??• Use CVP (~cardiac preload) as a guide• Blood – fully cross-matched = 1º type-specific non-cross –matched = 15 min O-negative = 0 min

• NOT dextrose because => hyponatraemia

Adrenaline

• 10 μg/kg IV/IO (0.1ml/kg of 1:10,000); 100 μg/kg (0.1ml/kg of 1:1,000) ETT - Cardiac Arrest

• 10 μg/kg IM (0.01ml/kg of 1:1,000) – Anaphylaxis

• 5ml of 1:1,000 nebulised in O2 – Laryngotracheobronchitis (Croup)

/Anaphylaxis

Glucose

• Dextrose 10% 5ml/kg IV (APLS)

• Except: - Neonates – Dextrose 10% 2ml/kg IV (NRP)

WETFAG• Weight = (Age + 4)2

• Energy = 4 J/kg asynchronous shock

• Tube = (Age/4) + 4 ---- +/- 0.5

• Fluids = 20 mls/kg 0.9% NaCl

• Adrenaline = Adrenaline 10 μg/kg IV/IO (0.1ml/kg of 1:10,000); 100 μg/kg (0.1ml/kg of 1:1,000) ETT

• Glucose = Dextrose 10% 5ml/kg IV

Scenario 1

• You are called to the ED to see a 10 year old boy in respiratory distress with a history of asthma. You have a few minutes to make your calculations. You estimate his weight to be … kg?

Scenario 1

• As you approach the ED, the student nurse swings the door open and screams, “Come in quick!”. As you enter the room you note a young boy, approximate age 10, leaning forward in a tripod position. He is alert but unable to answer questions. He is diaphoretic with audible wheezing. He has signs of respiratory distress. His colour is pale.

Questions?

• What is your general impression of this patient?

• What are your initial management priorities?

Answers

• What is your general impression of this patient?

Severe respiratory distress - increased work of breathing with retractions and tripod position, audible wheezing, pale and diaphoretic skin

Alert, however, it is clear that he is struggling to breathe This patient has potential to progress rapidly into respiratory failure

• What are your initial management priorities?

Address airway and breathing Leave in a position of comfort Pulse oximeter 100% oxygen given by a non-rebreather mask Salbutamol neb

Case Continuation

• After 3 nebulisers the child’s saturations suddenly drop to mid 70s despite supplemental O2 therapy. His respiratory rate increases to 40 bpm. He has very shallow respirations. He becomes increasingly distressed.

Case Continuation

• His trachea is noted to have deviated to the left and the right side of his chest is hyper-resonant to percussion

• What is the diagnosis?

• What immediate and subsequent interventions are required?

What is the Diagnosis?

• Tension Pneumothorax

What immediate and subsequent interventions are required?

• Needle Thoracocentesis

• Chest drain placement

Tension Pneumothorax PM Film

Asthma• ABC• High-flow O2• β-agonist – Salbutamol inhaler + spacer +/- face mask – 1,000μg

{10 sprays}• Salbutamol Nebuliser 2.5mg (<5 yo); 5 mg (>5 yo) with O2 (flow

rate 4-6 l/min) + Ipratropium Bromide (250μg)• PO Prednisolone (2mg/kg) or IV Hydrocortisone (4mg/kg)• Salbutamol Nebuliser Continuously• IV Salbutamol 15μg/kg over 10 min over 2 years fb infusion of 1-

5μg/kg/min (ECG & K+)• IV Aminophylline 5mg/kg over 20 min fb infusion of 1 mg/kg/hr

(omit ld if received oral theophylline or other methylxanthine in previous 12º)

• IV Magnesium Sulphate 25-40mg/kg over 20 min (max 2g)• Intubation & Mechanical Ventilation – Increasing exhaustion;

progressive deterioration in clinical condition; PCO2 > 8 kPa; PO2 < 8 kPa with FiO2 = 60%

Scenario 2

• You are called by one of the ED nurses that a 3 year old boy is on his way to the ED. He was fine earlier in the day when he went shopping with his mother, but began to act strangely and then became lethargic about 1 hour after their return home. You have time to make your calculations. You estimate his weight to be … kg?

Scenario 2

• In the ED the child is lying on the examination couch, with his eyes closed, and does not react to you entering the room. His breathing is not laboured, and his colour is pink. Initial assessment reveals that his airway is open, respiratory rate is 16 per minute, with slightly shallow respirations, heart rate 104 with strong distal pulses, capillary refill 2 seconds, blood pressure 84/50. He withdraws from painful stimuli, and moans, but does not respond to verbal stimuli, his pupils are 6 mm and briskly reactive, and there are no bruises or evidence of trauma.

Questions?

• What are the BLS treatment priorities?

• What are some possible causes for this altered level of consciousness?

• What test would you do now to guide therapy?

Questions?• What are the BLS treatment priorities? Provide oxygen and support respirations with bag-valve mask ventilation. A respiratory rate of 16

is low for a 3 year old. (normal rage is 24-40 respirations/minute)

• What are some possible causes for this altered level of consciousness?

A – Alcohol/acidosis/ammonia (metabolic disease) E – Epilepsy I – Infection O – Opiates U – Uremia T – Trauma I – Insulin/Hypoglycemia P – Poisoning/Psychogenic S – Shock/Sepsis

• What test would you do now to guide therapy? – Blood glucose

Case Continuation

• Blood Glucose – 1.2 mmol/l

• What other investigations would you consider?

Case Continuation

• Blood Glucose – 1.2 mmol/l

• What other investigations would you consider?

• “Newcastle” Work Up

• Urine toxicology screen is negative

• Blood alcohol level is 115 mg/dl!!!

?

Case Continuation

• Further history reveals that upon returning home the child was thirsty and opened a bottle containing a red liquid. He drank some (thinking it was his favourite rasberry flavoured drink). This turned out to be mouthwash, which contained 25% alcohol

Scenario 3

•  It is January in Limerick. You receive a call that a 2 year old girl is on her way into the ED having been found in a shallow pond. BLS is in progress but no advanced interventions have been performed. The ambulance crew report that a rescuer at the scene said the child may have been lost for 25 minutes. You have a few minutes to make your calculations. You estimate his weight to be … kg?

Questions?

• On arrival the child is apnoeic and pulseless.

• What are the BLS treatment priorities?

Questions?

• What are the BLS treatment priorities? Stop BLS & assess Airway – Patent Breathing – Apnoeic – oral endotracheal

intubation & bag-valve mask ventilation with added 02

Circulation – Pulseless – attach to monitor

Monitor shows this rhythm – what is it?

Ventricular Fibrillation

• Bizarre, irregular, random waveform

• No clearly identifiable QRS complexes or P waves

• Wandering baseline

Case Continuation

• What do you do next?

Case Continuation

• What do you do next? Shockable Rhythm Algorithm

Shockable Rhythm AlgorithmVF/PLVT

DC shock4 J/kg

2 min CPRCheck monitor

IntubateHigh flow O2IV/ IO access

DC shock4 J/kg

2 min CPRCheck monitor

IntubateIV/ IO access

Adrenaline10 mcg/kg IV or IO

then DC shock4 J/kg

2 min CPRCheck monitor

2 min CPRCheck monitor

Amiodarone5 mg/kg IV

then DC shock4 J/kg

Adrenaline10 mcg/kg IV or IO

then DC shock4 J/kg

2 min CPRCheck monitor

DC shock4 J/kg

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Case Continuation

• After repeated asynchronous shocks – child remains in Ventricular Fibrillation

Eh, What’s Up Doc?

Case Continuation

• This child was found in a shallow pond in Winter. Her initial temperature was 27°C. She needs active rewarming to >32°C before a decision can be made to stop resuscitative efforts

• How can this be done?

Active Rewarming

• External Rewarming (T> 30°C) Remove cold, wet clothing Supply warm blankets Infrared radiant lamp Heated blanket Warm air system• Core Rewarming (T< 30°C) Warm IV fluids (39°C) Warm ventilator gases (42°C) Gastric/bladder lavage with 0.9% NaCl (42°C) Peritoneal/pleural/pericardial lavage Extracorporeal blood rewarming

NB Rewarming Shock -↓ PVR >> ↑Temp => ↓BP

Case Continuation

• Her temperature was gradually increased to 35°C and a further DC shock of 4 J/kg brought her rhythm back to normal sinus rhythm

Scenario 4

• A 1 year old male infant was admitted to a peripheral unit with shortness of breath and poor feeding. He was found to have his first episode of supraventricular tachycardia. This was treated correctly with adenosine but reverted and needed several doses. After appropriate discussion with the Regional Cardiac Centre, flecainide was given orally. You are the retrieval doctor about to receive hand over of this patient from the registrar on call in the peripheral unit. You have a few minutes to make some calculations. The baby’s weight is 10 kg.

Scenario 4

• The infant is just about to be transferred to the Cardiac Unit when he suddenly stops breathing and is pulseless. You discover that 10 times the correct dose of flecainide was given!

Questions?

• What do you do?

Sure YOU might feel better but it won’t really be of any help to the

child!!

Questions?

• What do you do? Commence BLS Airway – Patent Breathing – Apnoeic – oral endotracheal

intubation & bag-valve mask ventilation with added 02

Circulation – Pulseless – attach to monitor

Monitor shows this rhythm – what is it?

Ventricular Tachycardia

• Wide complex (>/= 0.08 sec)

• No P-wave or if present not associated with QRS

Case Continuation

• What do you do next? Shockable Rhythm Algorithm

Shockable Rhythm AlgorithmVF/PLVT

DC shock4 J/kg

2 min CPRCheck monitor

IntubateHigh flow O2IV/ IO access

DC shock4 J/kg

2 min CPRCheck monitor

IntubateIV/ IO access

Adrenaline10 mcg/kg IV or IO

then DC shock4 J/kg

2 min CPRCheck monitor

2 min CPRCheck monitor

Amiodarone5 mg/kg IV

then DC shock4 J/kg

Adrenaline10 mcg/kg IV or IO

then DC shock4 J/kg

2 min CPRCheck monitor

DC shock4 J/kg

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Case Continuation

• The child is in pulseless ventricular tachycardia which reverts to sinus rhythm after the 1st shock of 4 J/kg. A palpable pulse is achieved.

THE AUTHOR WISHES TO ASSURE ALLCONCERNED THAT NO NURSE WAS

HARMED IN THIS SCENARIO!

Scenario 5

• You are called to the Medical Ward to attend a 6 week old child. This baby girl was admitted 2 days previously with bronchiolitis. She suddenly became apnoeic and the nurse suctioned her airway. During suction she became pale and floppy. You have a few minutes to make some calculations. You estimate her weight to be 5 kg.

Scenario 5

• On your arrival the nurse is bagging the child and there is no spontaneous respiratory effort. The baby is pulseless. There is an IV cannula in situ in the dorsum of her left hand.

Questions?

• What are the BLS treatment priorities?

Questions?

• What are the BLS treatment priorities? Stop bagging the baby & assess Airway – Patent Breathing – No spontaneous respiratory effort –

oral endotracheal intubation & bag-valve mask ventilation with added 02

Circulation – Pulseless – chest compressions (15:2) - attach to monitor

Monitor shows this rhythm - what is it?

Asystolé

• Commonest arrest rhythm in children

• Hypoxia => acidosis => progressive bradycardia => asystolé

• Almost a straight line with occasional P-waves

• ? Artifact – loose wire/disconnected electrode

• ↑ gain on the ECG monitor

Case Continuation

• What do you do next?

Case Continuation

• What do you do next? Non-Shockable Rhythm Algorithm

Non-shockable Rhythm Algorithm

Asystole &PEA

Ventilate withhigh

concentration O2

Continue CPRIntubate

IV/ IO access

Adrenaline 10mcg/kg IV or

IO

4 minutes CPRCheck monitor

every 2 minutes

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What causes Asystolé?

Causes of Asystolé?

4 Hs:• Hypoxia• Hypovolaemia• Hyper/hypokalaemia/Metabolic D/O• Hypothermia

4 Ts:• Tension Pneumothorax• Cardiac Tamponade• Toxic Substances• Thromboembolic Phenomena

What caused this infant to become asystolic?

What caused this infant to become asystolic?

• Apnoeic attack => hypoxia => suctioning => vagal stimulation => asystolé

Case Continuation

• The baby responded to the second round of adrenaline

Scenario 6

• You are on your way to the resuscitation area in the ED to review a 2 year old girl who has been brought in in a collapsed state. She has a history of pyrexia and lethargy for the preceding 24 hours. You have a few minutes to do some calculations. You estimate her weight to be …kg

Scenario 6

• On arrival to the ED you notice that she is grey and hypotonic. As you expose her torso you notice that she has a purpuric rash on her chest and abdomen. She is attached to a monitor which shows a sinus rhythm but she is apnoeic, pulseless and unresponsive

What could this rhythm be?

PEA (EMD)

• Recognisable complexes on ECG monitor

• No pulse or other signs of circulation

Case Continuation

• What do you do next? Non-Shockable Rhythm Algorithm

Non-shockable Rhythm Algorithm

Asystole &PEA

Ventilate withhigh

concentration O2

Continue CPRIntubate

IV/ IO access

Adrenaline 10mcg/kg IV or

IO

4 minutes CPRCheck monitor

every 2 minutes

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Questions?

• What other treatments should be initiated in this scenario?

Questions?

• What other treatments should be initiated in this scenario?

IV fluid bolus(es)IV Broad Spectrum Antibiotics

Scenario 7

• A 17 month old girl is brought into the ED by ambulance. She was eating a packet of “mini-eggs” in the kitchen with her father when the telephone rang. He went out to answer it. Ten minutes later he looked for her and found that she had managed to unlock the back door and had fallen in the garden. You are on you way to see her. You have time to do some calculations. You estimate her weight to be …kg

Scenario 7

• As you reach the ED paramedics are performing bag-valve-mask ventilation on the child but they are struggling to move the chest. They tell you that she had vomited at the scene and that there were “mini eggs” in the vomitus. She is apnoeic but conscious.

Questions?

• How will you initially manage this child?

Questions?

• How will you initially manage this child?Clear airway with suction or removal under

direct visionFBAO Protocol

Management of a Choking Child

Assess

IneffectiveCough

EffectiveCough

Unconscious

5 BackBlows

Assess &repeat

Conscious

OpenAirway

5 RescueBreaths

CPR 15:2Check for

FB

5Chest/abdo

Thrusts

EncourageCoughing

Support &Assess

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Ineffective Cough & Conscious

Infants (<1)• Back Blows (x5) and

Chest Thrusts (x5) (1/second)

Ineffective Cough & Conscious

Children (1-14)• Back Blows (x5)

and Abdominal Thrusts (x5) (1/second) (Heimlich Manoeuvre)

Case Continuation

• The child expectorates a large piece of chocolate and has a further vomit. She begins to breath normally once again and is positioned in the recovery position

The Recovery Position

Scenario 8

• A 2.5 year old boy became pyrexial and vomited once 6 hours before admission. He was seen by his GP prior to admission and was noted to have a sore throat. The GP prescribed penicillin but his Mum had not yet obtained his medication as the local chemist was shut. He now will not drink. You are going to see him in the ED but have a few minutes for some calculations. You estimate his weight to be…kg

Scenario 8

• When you see him you note that his respiratory rate is 40 with marked recession. His pulse rate is 160 with normal capillary refill. He is very pale. He has a soft inspiratory stridor with no cough and he is drooling profusely from his mouth. His Mum believes that vaccines have not been adequately tested and can do more harm than good

Questions?

• How will you initially manage this child?

Questions?

• How will you initially manage this child? DON’T: Inspect the airway Attempt to insert an IV cannula Lie the patient down Send for lateral neck x-ray DO: Give High-flow O2 Call Anaesthetist/ENT

Case Continuation

• Minutes later his respiratory rate falls to 10 gasps/minute. He loses consciousness and the stridor disappears

• What do you do next?

Case Continuation

• What do you do next?Bag-and-mask ventilation with high flow

O2Attempt orotracheal intubationNeedle cricothyroidotomy and transcricoid

ventilationIV/OI access (AFTER AIRWAY

MANAGEMENT)IV Broad Spectrum Antibiotics

Cricothyroidotomy Cannulae

• Different sizes12 gauge – adult14 gauge – child18 gauge – infant

OR

• IV Cannula

Surgical Airway – Needle Cricothyroidotomy

• A last resort!• Cricothyroidotomy

cannula-over-needle/IV cannula + 5ml syringe

• Identify cricothyroid membrane

Surgical Airway – Needle Cricothyroidotomy

• 45º angle caudally, aspirate as the needle is advanced

• Advance cannula over needle & withdraw the needle

• Y-connector to oxygen flowmeter

• Flow rate = child’s age (yrs)

• Ventilate – “1 second on; 4 seconds off”

• Secure

Transcricoid Ventilation

• Cannot ventilate with self-inflating bag (P= 4.5kPa) but can ventilate with oxygen flow meter (P= 400kPa);

O2 rate = 1l/min/year of age• Cannot expire through the cannula;

expiration must occur through the upper airway => complete UA obstruction => ↓ gas flow to 1-2l/min => some oxygenation but very little ventilation

Surgical Airway – Surgical Cricothyroidotomy

• Only in >12 yoa• Vertical incision in skin &

press the lateral edges of the incision outwards to minimise bleeding

• Transverse incision through cricothyroid membrane

• Insert scalpel and twist through 90º

• Insert appropriately sized ETT/tracheostomy

• Secure• Check position

Scenario 9

• A 7 year old girl is brought into the ED by her mother who has noticed that she has become sleepy and has laboured breathing. 24 hours previously, she had been seen at another hospital with abdominal pain. A diagnosis of constipation was made. You are on your way to see her. You have some time to do some calculations. You estimate her weight to be …kg

Scenario 9

• When you arrive you notice that she has a respiratory rate of 40. Her pulse rate is 160 with a poor volume. Her capillary refill time is 5 seconds. She responds to her mother’s voice by briefly opening her eyes.

• What do her vital signs indicate?

• How are you going to manage her?

Questions?

• What do her vital signs indicate? Increased respiratory rate; increased heart rate

with poor volume; increased capillary refill time; responding to voice => compensated => decompensated shock

>/= 10 % dehydration• How are you going to manage her? Airway – patent Breathing – high flow O2 by face mask Circulation IV access; Bloods – FBC, U&E, VBG,

glucose; IV fluid bolus 10ml/kg

Case Continuation

• pH 7.03; Blood glucose 34mmol/lFluids = (Maintenance)2 + Deficit/ 48°Insulin 0.1 IU/kg/hr

Diabetic Ketoacidosis (DKA)Relative/absolute lack of insulin => inability to metaboliseglucose => hyperglycaemia, osmotic diuresis, dehydration,fat breakdown => ketones & metabolic acidosis,compensatory hyperventilation (respiratory alkalosis) =>comaCF:• Wt loss• Abdominal pain• Vomiting• Polyuria• Polydipsia• Moderate=>severely dehydrated• Kussmaul Respiration• Ketotic breath

Management of DKA• ABC• High-flow O2• IV access x2• Bloods – U&E, glucose, FBC, VBG, blood culture (if clinically indicated)• Urine – Glucose, Ketones, C&S• 10ml/kg 0.9% NaCl bolus• Fluids – {(Maintenance)x2 + Deficit}/48 – 0.9% NaCl (BM> 15 mmol/l)

=>0.45% NaCl + 5% Dex (BM 8-15 mmol/l) => 0.45% NaCl + 10% Dex (BM < 8 mmol/l)

• Add KCl 20mmol/500mls once PU• Insulin – 0.1IU/kg/hr• NaHCO3 – avoid unless pH <7.1 despite replacement of intravascular

volume & appropriate insulin & fluid therapy for several hours• 1º vital signs, BMs, Neuro-obs, UO & fluid balance• 2-4º U&E, VBG, serum glucose• Watch for complications

Complications of DKA

• Cerebral Oedema – head ache, recurrence of vomiting, ↓GCS, ↓HR, ↑BP

• Cardiac Arrhythmias - 2º to electrolyte disturbances

• Pulmonary Oedema

• Acute Renal Failure

Scenario 10

• A 4 year old boy presents with a generalised convulsion. He has received rectal diazepam from the paramedics in the ambulance and on arrival is not convulsing but is responsive only to painful stimuli. You are on your way to see him (It does seem strange that you’re never actually in the ED when these patients present!!) You have some time to do some calculations. You estimate her weight to be …kg

Scenario 10

• When you arrive he starts to seize again and he becomes apnoeic. His pulse, which was initially 170 bpm, subsequently falls after apnoea. You cannot determine his blood pressure. He is now unresponsive. His temperature is 39.8°C.

• What do his vital signs indicate?

• How are you going to manage him?

Scenario 10

• What do his vital signs indicate?Apnoea => bradycardia which could =>

asystolé

• How are you going to manage him?

• Airway & Breathing – AVPU score is U => need for RSI

• Circulation – IV access; Check Blood glucose; Status Epilepticus Protocol

“Status Epilepticus” AlgorithmTime IV access No IV access

5 min Lorazepam 0.1mg/kg (max. 2mg) IV/IO

Diazepam 0.5mg/kg PR OR Midazolam 0.5mg/kg buccal

10 min Lorazepam 0.1mg/kg (max. 2mg) IV/IO

Paraldehyde

400mg/kg (max 10g) PR

CALL FOR SENIOR HELP

20 min Phenytoin (Phenobarbitone if already on Phenytoin) 18mg/kg (max. 1g) IV over 30 min +

Pyridoxine 100mg IV (if <3yoa with unexplained afebrile status)

40 min Phenobarbitone 20mg/kg IV (max. 800mg) over 20 min

REFRACTORY STATUS EPILEPTICUS

Refractory Status Epilepticus

Still seizing after 60 min:• RSI

• Midazolam infusion IV (0.15mg/kg ld fb 1-10μg/kg/min)OR• Phenobarbitone 5mg/kg boluses IV every 15 min x 3OR• Thiopental (Thiopentone) 4mg/kg IV/IO

NB • Fosphenytoin: 75mg of fosphenytoin ~ 50mg phenytoin• Fluid restrict to 60% maintenance

Case Continuation

• He responds only when IV phenytoin is commenced

• What about the fever?

Case Continuation

• What about the fever?2° to first seizure

orProlonged Febrile Convulsion – look for

cause

Further reading (viewing)!