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

For APLS I’m referencing the 5th edition from that awful paper binder thing they give you.

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
  • if not any better then change something and repeat the 5 breaths
  • once the chest is moving and HR<60 then start CPR.
  • 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
  • plastic bags and under a heater for less than 29/40 or <1000g before drying (sounds like a cooking recipe doesn’t it…)

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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What makes the paeds airway different?

  • narrow nostrils
  • large tongue
  • possible loose baby teeth
  • floor easily compressible and pushed into the oral cavity
  • horseshoe shaped epiglottis projecting posterior
  • high anterior larynx (this is the main reason for the straight blade as per APLS)
  • massive occiput in the litluns can over flex the neck
  • easy to squish the trachea with hyperextension

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Signs of raised ICP in kids?

  • abnormal oculocephalic – normal is for eye to move in the opposite direction of the head movement
  • decorticate, decerebrate
  • pupils
  • breathing patterns
  • Cushsing’s

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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 do you distinguish sinus tach from SVT in babies?

  • sinus usually <200, SVT rate usually >220
  • p waves often not seen in either but if seen in SVT then usually negative in II, III and aVF (retrograde)
  • beat to beat variation in sinus and often response to fluids
  • a condition causing shock is usually present in sinus tachycardia (eg gastro, sepsis)
  • note in babies they have often been in SVT for quite some time and only present when there are signs of shock and poor feeding

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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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How do we give and how much fluids?

  • for shock in general it’s 20ml/kg of something salty
  • for trauma and DKA it’s 10ml/kg
  • as per APLS as a rough rule
    • if dehydrated no shock = 5% dehydration
    • if shock = 10% dehydration
  • If a 20kg child is 10% (10ml/100g) dehydrated then they should have:
    • 10%*20kg = 2000mls replaced over 24 hrs = 2000/24 = 83ml/hr to rehydrate
    • you will need to add maintenance to that rate
  • for maintenance
    • first 10kg = 100ml/kg/day (or 4ml/kg/hr)
    • second 10kg = 50ml/kg/day (or 2ml/kg/hr)
    • subsequent kg = 20 ml/kg/day (or 1ml/kg/hr)

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