Tasty Morsels of EM 110 – #FRCEM Paediatric resus

4 Aug

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here

(Featured Image, Truckee Meadows Community College, on Flickr, CC License)

This is even less comprehensive than the usual post as most of this is hammered into our heads on the alphabet courses so i’ve tried to highlight the bits i get stuck on

Paeds BLS and ALS from the resus council

How should we estimate weight?

This is not without controversy

Resus Council says this from 2011

The formula taught on Resuscitation Council (UK) and European Resuscitation Council courses for estimating the weight of a child has not changed.

(Age + 4) x 2

This simple formula is taught because it is easy to remember and apply in an emergency setting. It is a useful first calculation, allowing treatment to be given quickly.

APLS 5th edition has this

  • 0-12 months
    • (0.5 x age in months) + 4
  • 1-5 years
    • (2 x age in years) + 8
  • 6-12 years
    • (3 x age in years) + 7

There’s a great critique of these at St Emlyns

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Basic Neonatal Resus

From Resus Council

  • warm, dry stimulate
  • assess heart rate with a stethoscope, possibly with the umbilicus for a pulse
  • if gasping, not breathing then 5 rescue breaths
  • normal pre ductal (right arm) sats
    • 2 mins – 60%
    • 3 mins – 70%
    • 4 mins – 80%
    • 5mins – 85%
    • 10 mins – 90%
  • in the well infant 1 min delay in cord clamping
  • begin with air in term infants
  • 3:1 ratio

APGAR

  • done at 1 and 5
  • scored 0, 1, 2
  • Appearance
  • Pulse
  • Grimace
  • Activity
  • Respiration

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Highlight some differences in the paediatric algorithm from the adult one

  • BLS incorporates 5 rescue breaths prior to chest compressions
  • ratio is 15:2
  • <1  year encircling
  • in infants pads may be better AP
  • 0.1ml/kg 1:10000 adrenaline (10mcg/kg)
  • 4J/kg
  • cuffed tubes can be used in all but neonates
    • size (older than a year) = (age/4) + 4
    • of note this is for uncuffed tubes, cuffed tubes have slightly different calc…
  • amiodarone after 3rd and 5th shock
    • 5mg/kg each time
  • fluid boluses are 20ml/kg
  • resus council says either 32-34 or maintaining normothermia are reasonable in ROSC

WETFlAG (1-10 years)

(from resus council)

  • Weight =  (Age +4) x 2
  • Energy = 4J/kg
  • Tube = (Age/4) + 4
  • Fluids =  20ml/kg
  • Adrenaline = 0.1ml/kg 1:10000
  • Glucose = 2ml/kg 10% dextrose

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Choking

  • ineffective v effective coughing
  • if effective just encourage coughing
  • if ineffective and conscious
    • 5 back blows
    • 5 thrusts (chest for infant, abdo for >1 year)
  • if ineffective and unconscious
    • open airway
    • rescue breaths
    • CPR

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How should we manage SVT?

  • in infants, often > 220 bpm
  • vagal maneuvers can still be used in kids with shock
  • if you can get access faster than a defib then adenosine 100mcg/kg then 200, then 300
  • for defib it’s a sync shock at 1 J/kg then 2 J/kg

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How should we manage status?

from APLS 5th and NICE agrees

  • remember the algorithm in APLS has you waiting 5 mins before drugs
  • drugs are lorazepam 0.1mg/kg preferred or if no access (midaz buccal or diazepam rectal)
  • remember to include the pre hospital buccal or rectal doses when you’re repeating a benzo
  • repeat at 10 mins after the first dose
  • give phenytoin at 20 mins after first drug (phenytoin 20mg/kg or phenobarbitone 20mg/kg if already on phenytoin)
  • if still seizing at 40 mins post first drug then RSI

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