A SERIES OF PAEDIATRIC TOPICS DR DANIEL WATSON

Transcription

1 A SERIES OF PAEDIATRIC TOPICS DR DANIEL WATSON March 2014

2 Who am I? MBChB Otago 1996 FACEM 2004 Staff specialist Wellington ED ~ 55k presentations PA ~ 20% paediatric APLS instructor Locum work NT Australia (Alice Springs ED / Tennent Creek) including RFDS retrieval

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4 Case 1 2 year old vs coffee table Isolated injury no loss of consciousness Active and well Not keen to lie still

5 Treatment options? Wrap the child and close wound +/- local anaesthesia (either injected or topical) Refer the child to a secondary or tertiary centre Do nothing Procedural sedation with Ketamine

6 Ketamine Produces a cataleptic-like state in which the patient is dissociated from the surrounding environment by direct action on the cortex and limbic system. Noncompetitive NMDA receptor antagonist that blocks glutamate. Low (subanesthetic) doses produce analgesia, and modulate central sensitization, hyperalgesia and opioid tolerance.

7 Developed 1962 as PCP derivative FDA approval 1970, used in Vietnam War Widely used for anaesthesia where advanced anaesthetic skills or equipment not available Little use in developed countries as concerns re unpleasant hallucinations Over last decade increasing use in Australasian emergency departments primarily as a procedural sedation agent for children

8 Ketamine - Benefits Reduced distress and future doctor phobia Improved conditions for procedure ie the child lies still (mostly) Vastly improved parental satisfaction Informed consent and parental presence throughout procedure mandatory

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10 What do I notice? Dissociation within 60 seconds IV or 2-3 minutes IM Tachycardia (usually ~ 20 bpm increase) Salivation Sharp intake of breath or wide open eyes during painful procedure stop if distress Vomiting post procedure ~ 10%

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12 Isn t it dangerous? Green et al. Predictors of Airway and Respiratory Adverse Events With Ketamine Sedation in the Emergency Department: An Individual Patient Data Meta-analysis of 8282 Children. Annals of Emergency Medicine. 2009;52:

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15 What about emergence delerium? Treston et al. What is the nature of emergence phenomenon when using intravenous or intramuscular ketamine for paediatric procedural sedation? Emergency Medicine Australasia. 2009; 2: Prospective study 745 children. Titrated IV 691 cases. IM 54 cases. 12.5% cried on waking 2.1% classified as emergence delerium No formal definition for emergence delerium Of verbal children 46.9% experienced pleasant visual hallucinations No increase in nightmares

16 Telephone follow-up

17 Aggitation and emesis by age Green et al. Predictors of Emesis and Recovery Agitation With Emergency Department Ketamine Sedation: An Individual-Patient Data Meta-Analysis of 8282 Children. Annals of Emergency Medicine. 2009;54:

18 What does this mean for me? Ketamine sedation is safe and well tolerated You need: Basic airway skills A resuscitation room Supplemental O 2 via BVM Suction Airway adjuncts SpO 2 monitoring Two operators a sedator and a proceduralist Recommend 0.5mg/kg IV boluses but 3-4mg/kg IM alternative Be ready to give supplemental O 2 and do basic airway manoeuvres explain the possible need for O 2 to parent(s) in advance. Assisted breaths are almost never required.

19 Ideal for: Children 2-8 (conservatively!) Minor laceration repair, foreign body removal, fracture reduction Supplement with local anaesthetic immediately on dissociation Keep the caregiver present at all times Explain clearly to the child what will happen Imagine you are Superman and you can fly Daddy might look funny and have two heads Think about your favourite movie or computer game

20 Case 2 A 23 month old riding their scooter falls off

21 You see them 2 hours later with the following clinical findings... Forehead haematoma Momentary loss of consciousness 2-3 seconds Single vomit 20 minutes post injury Father says is acting normally What do you do?

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23 PATTERNS OF ACUTE HEAD INJURY Pattern of neurological deterioration and the Pressure-Volume curve 2 GCS points Neurol status I N J U R y ICP Time Lesion volume + CSF ± oedema

24 CT all children with minor trauma? ~ 1:1500 increased malignancy in 1 year old ~ 1:5000 increased malignancy in 5 year old Ionising radiation to brain may affect adult cognitive ability Likely to require retrieval team transfer May require sedation or intubation If we can avoid an unnecessary CT we should!

25 Apply a decision rule... CATCH CANADIAN ASSESSMENT OF TOMOGRAPHY FOR CHILDHOOD HEAD INJURY CHALICE CHILDREN S HEAD INJURY ALGORITHM FOR THE PREDICTION OF IMPORTANT CLINICAL EVENTS PECARN PEDIATRIC EMERGENCY CARE APPLIED RESEARCH NETWORK

26 But we don t have one of these

27 Or one of these...

28 Which one do I use... CATCH Now prospectively validated Quite simple Doesn t specifically separate infants from older children (3866 children but only 277 < 2 years) 4 or 7 item rules only the 7 item rule performs well Would mean CT for any child who had fallen > 1m or 5 stairs and any motor vehicle related injury or any fall from a bike with no helmet Not ideal...

29 CHALICE Large sample children 0-16 years 98% sensitive for clinically significant head injury Derivation only never validated Specifically mentions NAI Somewhat complex Did not perform so well when applied to an Australian population more than 2X increase in CT scans with no change in outcome Better than CATCH but not quite there

30 PECARN Designed to identify those children who do not need CT children (10718 < 2 years) Separate rule for < 2 and 2-18 year olds < 2 year old rule includes parental assessment No over-reliance on vomiting for < 2 year olds Does not mandate CT scanning Prospectively validated! Sounds promising...

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33 Caveats Observation vs transfer for CT vs transfer to neurosurgical centre will depend on your geographical / clinical setting Consult for all children who cannot be discharged A clinical decision rule still requires common sense! No suspicion of NAI Competent supervision Access to phone and transport Good written discharge advice

34 Case 3 A 3 year old has been playing with Lego a small piece is missing...

35 How do you get it out? Suction Glue on a stick Adson hook Kissing method O 2 to contralateral nare...or use a paper clip!

36 Always vasoconstrict co-phenylcaine (section 29) adrenaline / lignocaine via atomiser You may or may not need sedation (ketamine ~ 0.5mg/kg iv usually sufficient)

37 Questions

38 Summary Ketamine is a safe alternative to wrap and hold Minor head injuries use a decision rule and ensure it can be applied to your local environment Nasal foreign bodies you don t need expensive equipment (but remember to vasoconstrict!)