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- 1. Paediatric Resuscitation in Retrieval Medicine
- 7. • A 6 year old has been hit by a car and is unresponsive • List your preparations en route to scene
- 9. Weight estimation in paediatrics: a comparison of the APLS formula and the formula ‘Weight=3(age)+7’ Emerg Med J. 2010 Jul 20. [Epub ahead of print]
- 10. “The APLS formula has clearly become a victim of better nourished children. With a mean underestimate of more than 20% (nearly 40% at age 10 years), its place as a weight estimation tool is questionable.” Weight estimation in paediatrics: a comparison of the APLS formula and the formula ‘Weight=3(age)+7’ Emerg Med J. 2010 Jul 20. [Epub ahead of print]
- 11. • 1-puberty: wt = 3(age) + 7 • < 1: wt = (age in months / 2) + 4 • ETT uncuffed = (age/4) + 4 • length = age/2 + 12 cm (oral) • 2 x UETT - NG / foley • 3 x UETT = length of ETT@lips • 4 x UETT = intercostal catheter • ETT cuffed = (age / 4) + 3 • Fluids = 10-20 ml/kg • adrenaline = 0.1 ml/kg 1:10 000
- 12. • A 5 month old with a history of RTI has a respiratory arrest at home • paramedics have been unable to intubate • the child is asystolic • your bag-mask ventilation is ineffective
- 15. Infant feeding tube • list some uses of this device in paediatric resuscitation
- 16. Infant feeding tube • list some uses of this device in paediatric resuscitation
- 17. • You get a grade IV view on laryngoscopy • List your actions
- 18. Mellick L, Edholm T, Corbett S. Pediatric Laryngoscope Blade Size Selection Using Facial Landmarks Pediatric Emergency Care 2006;22(4);226-9
- 19. Laryngeal mask airways • Size 1 - < 5 kg • Size 1.5 - 5-10 kg • Size 2 - 20-30 kg • Size 3 - 30-50 kg • Size 4 - 50-70 kg • Size 5 - 70-100 kg
- 20. Vascular access
- 24. • A perimortem caesarean delivery is peformed on a woman in traumatic cardiac arrest • A hypotonic, pale, apneoic near-term infant is delivered in the back of an ambulance • List your actions
- 29. • A 2 year old drowning victim receives CPR • ROSC is achieved prior to arrival • The child is combative, agitated, and obtunded • Describe your management
Editor's Notes
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- \nGSA-HEMS retrieval mission database was searched between January 1 2008 and December 31 2009 for all patients aged 15 years and under. Prospectively entered data on mission urgency, age, gender, diagnostic category and interventions were recorded for both pre-hospital and inter-hospital missions.\n\n\n\n\n\n\n\nDuring the study period, there were 208 paediatric cases, representing&#xA0;3.9 percent of the total caseload. There were 126 male paediatric patients and the median age was 12 years (range: under 1 to 15).\n\n\n\n\n\nThere were 141 pre-hospital missions and 66 inter-hospital missions. Eight of the inter-hospital missions began as pre-hospital missions with subsequent diversion of the helicopter to the closest health facility. Fourteen of the pre-hospital cases required&#xA0;an extraction by winch.\n\n\n\n\n\nThe commonest diagnostic category was trauma (160/208 cases = 77%) followed by neurologic (18/208 = 8.6%) then respiratory (16/208 = 7.7%).Intubation was carried out by our team &#xA0;in 22/208 (10.6%) cases. Other interventions included central and peripheral venous access, arterial catherisation, intraosseous needle insertion, thoracostomy, fracture reduction and splintage, ultrasound, sedation and analgesia, noninvasive ventilation, nerve blocks, and blood transfusion.\n\n\n\n\n\n\n\nAlthough representing a small proportion of the total caseload, paediatric cases are commonly managed by our retrieval physicians, averaging &#xA0;two missions per week, and demanding a wide range of critical care interventions. These data should guide the development of standard operating procedures, training, and equipment targeted to paediatric pre-hospital and retrieval medicine.\n\n\n\n\n\n95 = 4.3/100 n2 so n2 = 9500/4.4 = 2159\n\n\n\n\n\n\n\n5387 cases total so 3.9% kids\n\n\n\n
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- preps include triage destination - include!\n2 person, adjuncts, position, OGT \nweight formula\ntube, fluids, drugs\nchest compressions (evidence for thumbs)\n\nOkay so it&#x2019;s a small case series &#x2013; but the results warrant further investigation: 10-20 mcg/kg terlipressin was given to five infants and children who arrested in the paediatric intensive care unit and who had not responded to several doses of adrenaline (epinephrine)\n1\n. Sustained return of spontaneous circulation (ROSC) was achieved in four, and two survived to be discharged home without sequelae and with good neurologic status at 6 and 12 month follow up. Interestingly, the four patients who had ROSC all had septic shock as the cause of their arrest. The two survivors had severe bradycardia and severe bradycarda-asystole as the arrest rhythms, and both received 20 mcg/kg terlipressin.\n\n\nTerlipressin is a synthetic arginine vasopressin analog with a significantly longer duration of effect, which previously showed positive effects when administered to a small group of children unresponsive to prolonged resuscitative efforts\n2\n.\n\n\n1. Pediatric cardiac arrest refractory to advanced life support: Is there a role for terlipressin?\n\n\n\n\nPediatr Crit Care Med. 2010 Jan;11(1):139-41\n\n\n\n\n\n\n2. Beneficial effects of terlipressin in prolonged pediatric cardiopulmonary resuscitation: A case series.\n\n\n\n\nCrit Care Med. 2007 Apr;35(4):1161-4\n\n\n\n\nIt is common for the infant trachea to deviate to the right, with a frequency of 50% at one year, 25% at two years, 15% at three years and 6% at four years (tending not to occur in the over fives), but it may be missed on inspiratory chest films with the head in extension. In a case report from India, authors point out that anaesthetists are often unaware of this normal variant. Since many tracheal tubes are designed with the bevel facing left, the angled tracheal wall may occlude the distal outlet of the tube, necessitating repositioning of the tube higher in the trachea above the bend.\n\n\n\nAnaesth Intensive Care. 2009 Jan;37(1):144-5\n\n\n
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- \n93&#x2009;827 children aged 1&#x2013;16&#xA0;years attending the ED between June 2003 and September 2008.\n\n\nMain outcome measures\n Percentage weight difference between the child's actual weight and the expected weight, the latter determined by &#x2018;Weight(kg)=2(age+4)&#x2019; and by &#x2018;Weight(kg)=3(age)+7&#x2019;, in order to compare these two formulae.\n\n\nResults\n The weights of seriously ill children were recorded in only 20.5% of cases, necessitating a weight estimate in the remainder. The formula &#x2018;Weight=2(age+4)&#x2019; underestimated children's weights by a mean of 33.4% (95% CI 33.2% to 33.6%) over the age range 1&#x2013;16&#xA0;years whereas the formula &#x2018;Weight=3(age)+7&#x2019; provided a mean underestimate of 6.9% (95% CI 6.8% to 7.1%). The formula &#x2018;Weight=3(age)+7&#x2019; remains applicable from 1 to 13&#xA0;years inclusive.\n\n\nConclusions\n Weight estimation is of paramount importance in paediatric resuscitation. This study shows that the current estimation formula provides a significant underestimate of children's weights. When used to calculate drug and fluid dosages, this may lead to the under-resuscitation of a critically ill child. The formula &#x2018;Weight=3(age)+7&#x2019; can be used over a larger age range (from 1&#xA0;year to puberty) and allows a safe and more accurate estimate of the weight of children today.\n\n
- \nSimply estimating by looking has been shown to be poor,\n9&#x2013;12\n although a recent article found parental estimation to be more accurate than either the APLS formula or the Broselow tape. However, it may be difficult and unfair to expect parents to safely state their child's weight during resuscitation, and the study only used clinically stable children, excluding emergency cases.\n13\n The use of growth charts to estimate weights by using the 50th centile has shown better accuracy than the current formula\n14\n but, once again, requires the information to be readily available. Other formulae such as the mid-arm circumference or shoe size-based systems are available but not straightforward\n\n
- 2 x uett = ng/foley\n3 x uett = length @ lips\n4 x uett = icc\n
- 2 person, adjuncts, position, OGT \nweight formula\ntube, fluids, drugs\nchest compressions (evidence for thumbs)\n\nOkay so it&#x2019;s a small case series &#x2013; but the results warrant further investigation: 10-20 mcg/kg terlipressin was given to five infants and children who arrested in the paediatric intensive care unit and who had not responded to several doses of adrenaline (epinephrine)\n1\n. Sustained return of spontaneous circulation (ROSC) was achieved in four, and two survived to be discharged home without sequelae and with good neurologic status at 6 and 12 month follow up. Interestingly, the four patients who had ROSC all had septic shock as the cause of their arrest. The two survivors had severe bradycardia and severe bradycarda-asystole as the arrest rhythms, and both received 20 mcg/kg terlipressin.\n\n\nTerlipressin is a synthetic arginine vasopressin analog with a significantly longer duration of effect, which previously showed positive effects when administered to a small group of children unresponsive to prolonged resuscitative efforts\n2\n.\n\n\n1. Pediatric cardiac arrest refractory to advanced life support: Is there a role for terlipressin?\n\n\n\n\nPediatr Crit Care Med. 2010 Jan;11(1):139-41\n\n\n\n\n\n\n2. Beneficial effects of terlipressin in prolonged pediatric cardiopulmonary resuscitation: A case series.\n\n\n\n\nCrit Care Med. 2007 Apr;35(4):1161-4\n\n\n\n\nIt is common for the infant trachea to deviate to the right, with a frequency of 50% at one year, 25% at two years, 15% at three years and 6% at four years (tending not to occur in the over fives), but it may be missed on inspiratory chest films with the head in extension. In a case report from India, authors point out that anaesthetists are often unaware of this normal variant. Since many tracheal tubes are designed with the bevel facing left, the angled tracheal wall may occlude the distal outlet of the tube, necessitating repositioning of the tube higher in the trachea above the bend.\n\n\n\nAnaesth Intensive Care. 2009 Jan;37(1):144-5\n\n\n
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- position, ELM, HELP, blade, LMA\n\nsize 1 <5kg; size 1\n1\n/\n2 \n5-10kg; size 2 10-20kg; size 2\n1\n/\n2\n20-30kg; size 3 30-50kg; size 4 50- 70kg; size 5 70-100kg; size 6 >100kg\n\n
- Blade lengths considered too short (blade lengths >10 mm proximal to the angle of the mandible) were more likely to be associated with more than 1 attempt at intubation. Only 57.1% (12/21; 95% confidence interval [CI], 36.5 &#x2013; 75.5) of the intubations using the shorter blade were performed on the first attempt as \ncompared with 89.7% (26/29; 95% CI, 73.6 &#x2013; 96.4) of the intubations using the recommended length or 85.7% (6/7; 95% CI, 48.7 &#x2013; 97.4) of the intubations using blades extending longer than 10 mm past the angle of the mandible. Conclusions: The distance from the upper incisor teeth to the angle of the jaw seems to be an excellent clinical landmark for laryn- goscope blade length selection for pediatric intubations. When the blade (excluding the handle insertion block) is placed at the upper midline incisor teeth and the tip is located within 1 cm proximal or distal to the angle of the mandible, oral tracheal intubations are more consistently accomplished on the first attempt. Our obser- vations suggest that facial landmarks can be used to estimate an appropriate laryngoscope blade length for oral endotracheal intuba- tion in children.\n
- position, ELM, HELP, blade, LMA\n\nsize 1 <5kg; size 1\n1\n/\n2 \n5-10kg; size 2 10-20kg; size 2\n1\n/\n2\n20-30kg; size 3 30-50kg; size 4 50- 70kg; size 5 70-100kg; size 6 >100kg\n\n
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- \n\nBest position for RIJV cannulation in kids\n\n\n\n\n\n\nMarch 1, 2010 by \n\nCliff\n\n &#xA0;\n\n(Edit)\n\n Filed under \n\nAll Updates\n\n, \n\nResus Room\n\n, \n\nSick Kids\n\n, \n\nUltrasound\n\n\n\n\n\n\n\nLeave a Comment\n\n\n\n\n\n\nIn a study of anaesthetised infants and children, the right internal jugular vein as assessed by ultrasonography was measured with the head in the neutral position, and then at 40 degrees and 80 degrees of rotation to the contralateral side. The 40 degree position resulted in an increase in IJV diameter but with less overlap with the carotid artery than the 80 degree position. The authors conclude that rotating the head 40 degrees to the left results in the best balance of increased IJV diameter versus overlap with the carotid.\n\n\nEffects of head rotation on the right internal jugular vein in infants and young children\n\n\n\n\nAnaesthesia Volume 65, Issue 3, Pages 272-276\n\n\n\n\n\nSmall infant IJV cannulation tip\n\n\n\n\n\n\nOctober 17, 2009 by \n\nCliff\n\n &#xA0;\n\n(Edit)\n\n Filed under \n\nAll Updates\n\n, \n\nResus Room\n\n, \n\nSick Kids\n\n\n\n\n\n\n\nLeave a Comment\n\n\n\n\n\n\nSimple taping using Transpore tape of the skin over the internal jugular vein insertion point increased IJV cross sectional area and AP diameter, and shortened to time to successful cannulation in this RCT on 28 infants and neonates undergoing cardiac surgery. Also, the degree of IJV collapse during advancement of the needle was less in the taped group.\n\n\nThe skin over the right IJV (RIJV) was lifted up with several pieces of tape in the cephalad and caudad directions. The skin cephalic to the RIJV was stretched cephalad, whereas the skin caudal to the RIJV was stretched caudad. The other ends of the tape were attached to the metal edge of the operating table.\n\n\nA Novel Skin-Traction Method Is Effective for Real-Time Ultrasound-Guided Internal Jugular Vein Catheterization in Infants and Neonates Weighing Less Than 5 Kilograms\n\n\n\n\nAnesth Analg. 2009 Sep;109(3):754-9\n\n\n\n\nAn ultrasound study of 80 children from 5 pre-determined age groups showed that the femoral veins increased their diameter in the frog-leg compared with straight-leg positions. Left and right femoral veins were the same size. There was significant overlap of the femoral arteries and veins which increased with distance distal to the inguinal ligament.\n\n\nThe Anatomic Relationship between the Common Femoral Artery and Common Femoral Vein in Frog Leg Position Versus Straight Leg Position in Pediatric Patients.\n\n\n\n\nAcad Emerg Med. 2009 Jul;16(7):579-84\n\n\n
- \n\n\nwarm & dry, adjuncts, BVM, position (towel), ETT, scope, lines\n3:1\n\n\nLMA for newborn resuscitation\n\n\n\n\n\n\nMarch 18, 2010 by \n\nCliff\n\n &#xA0;\n\n(Edit)\n\n Filed under \n\nAll Updates\n\n, \n\nResus Room\n\n, \n\nSick Kids\n\n\n\n\n\n\n\nLeave a Comment\n\n\n\n\n\n\nAn observational study of near term infants (34 weeks gestation to 36 weeks and 6 days) born in an Italian centre over a 5 year period showed that nearly 10% of near-term infants needed positive pressure ventilation at birth, confirming that this group of patients is more vulnerable than term infants. Most were able to be managed with either bag-mask ventilation (BMV) or with a size 1 laryngeal mask airway (LMA). Of the 86 infants requiring PPV, 36 (41.8%) were managed by LMA, 34 (39.5%) by BMV and 16 (18.6%) by tracheal intubation. Why not slap a tiny LMA on your neonatal resuscitation cart &#x2013; it could come in handy!\n\n\n\n\n\n\n\nDelivery room resuscitation of near-term infants: role of the laryngeal mask airway\n\n\n\n\nResuscitation. 2010 Mar;81(3):327-30\n\n\n
- NLS\n\nn three randomised controlled trials encompassing 767 infants with hypoxic-ischaemic encephalopathy, induced moderate hypothermia for 72 hours significantly reduced the combined rate of death and severe disability, with a number needed to treat of nine (95% CI 5 to 25). Hypothermia increased survival with normal neurological function, with a number needed to treat of eight (95% CI 5 to 17), and in survivors reduced the rates of severe disability and cerebral palsy. The studies used different cooling methods and different target temperatures (33-34 deg C vs 34-35 deg C), suggesting the method of cooling itself is not important as long as therapeutic hypothermia is achieved.\n\n\nNeurological outcomes at 18 months of age after moderate hypothermia for perinatal hypoxic ischaemic encephalopathy: synthesis and meta-analysis of trial data\n\n\n\n\nBMJ. 2010 Feb 9;340:c363\n\n\n\n
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- \nIn a prospective randomised controlled multi-centre trial, cuffed tracheal tubes were compared with uncuffed tubes in 2246 children aged from birth to five years undergoing general anaesthesia. There was no significant difference in post-extubation stridor but the need for tube exchange was 2.1% in the cuffed and 30.8% in the uncuffed groups (P<0.0001).\n\n\nFrom the resuscitation point of view, there remain few if any arguments for using an uncuffed tube.\n\n\nProspective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children\n\n\n\n\n\n\nBr J Anaesth. 2009 Dec;103(6):867-73\n\n\n\n\n\nCricoid pressure squashes kids&#x2019; airways\n\n\n\n\n\n\nMarch 1, 2010 by \n\nCliff\n\n &#xA0;\n\n(Edit)\n\n Filed under \n\nAll Updates\n\n, \n\nResus Room\n\n, \n\nSick Kids\n\n\n\n\n\n\n\nLeave a Comment\n\n\n\n\n\n\nA bronchoscopic study of anaesthetised infants and children receiving cricoid pressure revealed the procedure to distort the airway or occlude it by more than 50% with as little as 5N of force in under 1s and between 15 and 25N in teenagers. Therefore forces well below the recommended value of 30 N will cause significant compression/distortion of the airway in a child\n\n\n\n\n\n\n\nEffect of cricoid force on airway calibre in children: a bronchoscopic assessment\n\n\n\n\nBr J Anaesth. 2010 Jan;104(1):71-4\n\n\n
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