PEDIATRIC AND NEONATAL TRANSPORT RESOURCE

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Bridget Ford
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1 PEDIATRIC AND NEONATAL TRANSPORT RESOURCE

2 PEDIATRIC EMERGENCY CARE GUIDELINES Foley (Fr) NG (Fr) Chest Tube (Fr) Laryngoscopy Blade (Miller) *ET tube internal diam (mm) (cuffed) BP (sys) (mmhg) Resp Rate breaths/min HR avg/min HR Range Age Weight (kg) Preterm < (uncuffed) Term month mos mos yrs yrs yrs yrs yrs yrs yrs yrs yrs PHONE NUMBERS MedCom CHETA 1 RN CHETA 1 RT CHETA 2 RN CHETA 2 RT Mother-Baby Care Line AFCH NICU AFCH PICU AFCH PICU Attending A AFCH PICU Attending B UW University ED Access Center Meriter NICU Tom Brazelton Jamie Limjoco PICU FAX ED FAX MedCom FAX UW ED Pharmacist (from ) UW ED/PICU/NICU Pharmacist (from ) POISION CONTROL LANGUAGE LINE #231019

3 CHETA Infusion Reference Sheet Drug Rates Amount of Drug in 50 ml Syringe Amount in 250 ml OR Standard Conc. D5W, NS or Both Amiodarone 5-15 mcg/kg/min 100 mg 1.2 mg/ml (300mg/250 ml) B Caffeine Loading dose mg/kg Over 30 minutes Undiluted up to 10 mg/ml D5W Only DoBUTAmine 5-20 mcg/kg/min 50 mg OR 100 mg 1000 mg /250 ml (4000 mcg/ml) B + D10 Labetolol mcg/kg/hr 50 mg OR 250 mg 1 mg OR 5 mg/ml B Milrinone mcg/kg/min 5 OR 10 mg 100 OR 200 mcg/ml B Nicardipine mcg/kg/min 5 mg 25 mg/250 ml B Phenylephrine mcg/kg/min 2.5 mg OR 5 mg 10mg OR 20 mg/250 ml B Vasopressin milliunits/kg/min 5 OR 10 OR 25 units 100 units/250 ml B Fosphenytoin mg PE/kg (Loading Dose) 1-3 mg PE/kg/minute (maximum of 150 mg PE/minute) 1.5 to 25 mg PE/mL. B Keppra 20 mg/kg over 15 minutes 15 mg/ml 15 mg/ml Ketamine 5-20 mcg/kg/min 50, 100, OR 250 mg 1 mg OR 2 mg OR 5 mg/ml B Mag Sulfate mg/kg/hr 1 gm 60 mg/ml B For Asthma mg/kg over 20 min (max 2 gms) Drug Rates Amount of Drug in 50 ml Syringe Amount in 250 ml OR Standard Conc. D5W, NS or Both Narcan 10 mcg/kg/ hr, then double dose Q10min to effect 0.2 mg 4 mcg/ml B Pentobarb mg/kg/hr 250 mg 8 mg/ml OR 50 mg/ml with LR rider B Propofol mcg/kg/min 500 mg 10 mg/ml Precedex (Dexmedetomidine) mcg/kg/min 200 mcg 4 mcg/ml B Loading Dose 0.5-1mcg/kg Rocuronium 1 mg/kg/hr then bolus as needed 50 mg OR 250 mg 1 mg OR 5 mg/ml B Terbutaline Loading 2-10 mcg/kg/min over 5-10 min 1 mg 0.02 mg/ml OR 0.1 mg/ml B Maintenance Titrate mcg/ kg/min Sodium Bicarb 1 meq/kg/hour 0.5 meq/ml (neo) OR 1 meq/ml B Hypertonic/3% rmal Saline 2 to 5 ml/kg/dose (over 30 min) Mannitol 0.25 to 1 g/kg/dose (over 20 to 30 minutes)

4 PEDIATRIC MEDICATIONS FOR RSI Medication Indication/Use Dose tes Pre-Meds Atropine Any child < mg/kg IV May admin IM in a Excessive oral secretions Min dose 0.1mg dose of 0.04mg/kg if no IV is available Max dose 0.5mg children, 1.0mg for adolescents Ketamine Hypotension, Asthma (Avoid with penetrating eye inj, preexisting seizure disorder) 1-2 mg/kg IV OR 4-6 mg/kg IM Use with Midazolam 0.1 mg/kg IV (max 2mg) Sedation Propofol Fentanyl (Avoid in pts with shock, myocardial dysfunction, CHD, hypotension) May need to provide dosage up to mcg/kg 1-3 mg/kg IV 2-5 mcg/kg IV (titrate to effect in maximum increments of 100 mcg) Use with Midazolam 0.1 mg/kg IV (max 2mg) Midazolam mg/kg IV Paralytics Rocuronium Ensure pt can be ventilated with BVM prior to administration mg/kg IV NEONATAL MEDICATIONS FOR RSI Medication Indication/Use Dose tes Pre-Meds Atropine All term or near-term neonates (>35wks) mg/kg IV OR mg/kg IM (NICU will go less than 0.1 mg) Sedation Fentanyl Midazolam For infants >35 wks, admin in addition to Fentanyl 1-2 mcg/kg IV slowly Repeat once if needed mg/kg IV Repeat once if needed Paralytics *Consult with MC 7

5 THE DKA 2 BAG (BAG A/BAG B) TECHNIQUE Start insulin infusion at 0.1 Units/kg/hr Add 50 gms/100ml (2 amps) of D50 to a 1L bag of D5 0.9NS (or D5 0.9NS with 20 KCl {if MD orders KCl}) = D NS. Start 1.5x maintenance using the Two-Bag technique If the patient s glucose is: Patient s glucose is Give this % of 0.9%NS (Bag A) AND Give this % of D %NS (Bag B) > < (and call Med Control) Check Glucose at least Q1hour and Neuro checks If RN/Med Control has concern for poss decreasing K, request OSH for 10 meq KCL/100ml NS (K-rider) Do NOT administer bicarb Consider 2nd IV for hourly lab draws Continue assessment, per CHETA protocol, with a focus on Cerebral Edema, specifically: Headache Recurrence of vomiting Changes in neurological status Inappropriate lowering of heart rate Abnormal respiratory pattern Rising blood pressure Decreasing serum Na on labs despite decreasing serum glucose If you suspect cerebral edema, notify the Medical Control immediately. Then perform the following: Reduce the IV infusion rate to normal maintenance Administer Mannitol 1 gm/kg IV or 3% saline 3-5 ml/kg IV Elevate HOB to 30 degrees Begin PPV with 100% Oxygen, and prepare for an advanced airway NEONATAL HYPOGLYCEMIA (<40) 2ml/kg of D10, repeat x1, then increase rate to next tier (60-80, ) Recheck glucose in 30 min and q 30 min until stable INTRANASAL DOSES Administer all meds in doses of ml/nare, max 1ml. Call Med Control for under 1 year old Versed mg/kg Q5-10 min Fentanyl mg/kg Q20-30 min Narcan mg/kg repeat Q 2 to 3 minutes if needed Flumazenil 40 mcg/kg (maximum dose of 200 mcg) 8 9

6 EZ-IO LIDOCAINE DOSING Use 2% preservative free/epi free IV Lidocaine 0.5 mg/kg (max 40 mg), may repeat dose of 0.25 mg/kg (max 20 mg) Prime EZ-IO extension tubing with Lidocaine (total volume 1 ml); (if less than 1ml, use T-connecter extension) Slowly infuse over 120 seconds Allow to dwell in space for 60 seconds Then, flush with 2-10 ml NS PARKLAND FORMULA FOR BURNS 4 ml/kg/% of Burn {to be given over 24 hours (from time of burn)} PLUS Maintenance Fluid 1st half of total in first 8 hours 2nd half in next 16 hours IV FLUID MAINTENANCE RATES PICU/Peds 4 ml/kg for first 10 kg 2 ml/kg for kg 1 ml/kg per kg over 20 kg NICU Day 1 = ml/kg/24 hours Day 2-3 = ml/kg/24 hrs Day 4-5 = ml/kg/24 hrs > Day 5 = ml/kg/24 hrs CHETA ANTIBIOTIC TIMES/CONCENTRATION Antibiotic Over Concentration Acyclovir 60 min Ampicillin 30 min max 30 mg/ml Azithromycin 60 min CefaZOLIN 60 min Conc of 20 mg/ml CefePIME 30 min CefoTAXIME 30 min 10 to 40 mg/ml CefTAZIdime 30 min CefTRIAXone 30 min CeFUROXime 30 min Ciprofloxacin 60 min Clindamycin 60 min Fluconazole 120 min (max 200mg/hr) Gentamicin 60 min max <10 mg/ml Metronidazole 60 min Oxacillin 30 min for Pediatrics; 60 min for Neonates Tobramycin 60 min Unasyn (Amp/Sulbactam) 30 min Vancomycin minimum 60 min for Peds; max 10 mg/min for Neonate Zosyn (Pip/Tazo) 30 min 10 11

7 NICU Specifics ETT depth based on weight: weight in kg +6 Term = size 1 blade Pre-Term = size 0 blade Extreme prematurity = size 00 blade Tube Size Weight Gestational Age 2.5 <1000g <28 wks g wks g wks 4 >3000g >38 wks Surfactant 2.5 ml/kg via ETT Poractant (May repeat 1.25 ml/kg Q12 hours x 2, max total 5 ml/kg) Give in small aliquots via ETT followed by bagged or ventilator breaths Umbilical Catheters 3.5fr pt <1200g 5.0fr pt >1200g UAC Length equals 3x birth weight x s length of shoulder to umbilicus measurement Catheter tip should be between T6-T9 On X-ray, UAC goes caudally into the iliac arteries then head cranially in the aorta, left side of body (unless R-sided aortic looping) Tape catheter in upwards pattern to form an A, duoderm down first and then Tegaderm UVC (HIGH LYING) Length equals 1.5x birth weight +6 2/3 length of shoulder to umbilicus measurement Catheter tip should be cm above the diaphragm, T8-T9, right side of body (unless abdominal situs inversus) Tape catheter in downwards pattern to form a V, duoderm down first and then Tegaderm O2 Sat Goals Patient Gest Age O2 Sat Goals Less than 37 weeks 90-94% Greater than 37 weeks > 95% Hyperbilirubinemia For infants <35wks (use post menstrual age) and <7 days Initiate Phototherapy Exchange Transfusion Gest Age (week) Total Serum Bili (mg/dl) Total Serum Bili (mg/dl) <28 0/7 5 to 6 11 to /7 29 6/7 6 to 8 12 to /7 31 6/7 8 to /7 33 6/7 10 to /7 34 6/7 12 to

8 Seizures Often present with subtle symptoms: apnea, lip smacking, tongue thrusting, eye deviation, pedaling, cyanotic spells, autonomic dysfunction Treatments Correct electrolyte disturbances, Anticonvulsants Phenobarbital Loading dose: 20 mg/kg, Maintenance dose: 3-5 mg/kg/day Fosphenytoin Loading dose: mg PE/kg, Maintenance dose: 4-8 mg/kg/day Keppra Loading dose: 20 mg/kg Neonatal Thermoregulation Air temp of isolette should be set based on the babies age and weight (see chart on Isolette) When not in use isolette should be kept at 34.0 During transport constant skin temp monitoring is required via probe Verify that skin and axillary temps are correlating prior to departure. Q15min axillary temps until baby has a temp of , as long as the patient is in that target range and the axillary temp is correlating well then q1 hour axillary temps required Pts being passively cooled (or will be cooled), set isolette temp as low as it can go (17.0) and q 15 minute core (rectal or esophageal) temps required (Esophageal temp probe placement is normal OG/NG measurement minus 2 cm). Make note of when (if) pt reaches 33.5 as this is imperative for cooling protocol. MR SOPA If PPV not working: M Mask, right size and fit R Reposition, neck and/or Mask S Suction se and Mouth O Open Mouth while Ventilating P Increase Pressure if Chest Rise A Consider Alternate Airway, Intubate, or LMA Delivery Temperature Control 32+1 to 37 Weeks < 32 Weeks 1 Knitted cap 1 Knitted hat Heat Lamp (If available) Heat Lamp (If available) Radiant Warmer at 100% Radiant Warmer at 100% Room Temp Goal 75 F Room Temp Goal 75 F Warm Blankets (4-5) Warm Blankets (4-5) If < 97.7/36.5, Use transwarmer under one blanket Preemie Bag If temp < 97.7/36.5, Use transwarmer under one blanket IF < 27 weeks, must use transwarmer under one blanket (Keep on for transport) If Stable, Cond Time Cord Clamping (30-60 Seconds) 14 15

9 Birth 30 sec 60 sec Term gestation? Breathing or crying? Good tone? Warm, clear airway if necessary, dry, stimulate HR below 100, gasping, or apnea? Yes PPV, SPO2 monitoring Yes, stay with mother Labored breathing or persistent cyanosis? Yes Clear airway SPO2 monitoring Consider CPAP Routine Care Provide warmth Clear airway if necessary Dry Ongoing evaluation Targeted Pre-ductal SPO2 After Birth 1 min 60 65% 2 min 65 70% FLIGHT INFO Intercom Control System/Radio Use Start with VOX, RX, and ICS dials between 10 and 2 o clock Toggle Up = Listen Toggle Down = Channel Muted Com 1 Dial = Controls Who We Talk To Com 1 & 2 = Air Traffic Control (ATC) FM 1 = Dane County EMS Channel B/MARC 2 (Mutual Aid Radio Channel) FM2 = Med Flight/CHETA Dispatch On Med Pair 8/Med Pair 10 FM3 = thing FM4 = Satellite Radio VOX = Voice Activated Sensitivity Left is live-always on Right is Decreased Sensitivity- Yell to Activate HR below 100? Yes 3 min 70 75% 4 min 75 80% 5 min 80 85% 10 min 85 95% Challenge, ACTION, and Response: Don t Just ANSWER; Look, Touch, Check, then Answer Pilot asks: You reply: Take ventilation corrective steps Post-resucitation care Litter, Patient, and Equipment Secure? Doors Closed and Secure? Yes/ Yes/ HR below 60? Yes N.R.P. Algorithm Seat Belts On and Secure? Visors and Chin Straps? Personal Electronic Devices Off? On and Secure/ Down and Fastened Yes/ Take ventilation corrective steps Intubate if no chest rise! Consider intubation Chest compressions Coordinate with PPV HR below 60? Then you ask the Pilot: Cautions and Warnings Engine Instruments Both Engines 2 to Fly Sterile Cockpit Consider: Hypovolemia Pneumothorax Yes IV Epinephrine talking until reach altitude or cleared from pilot 17

10 CHILD RESTRAINTS Car Seat: Safeguard: PediMate: Peds Backboard: Kg or 16.75" shoulder height Kg Kg Infant to 34 Kg (or 47" long) 18 19

11 ES

ENDOTRACHEAL INTUBATION POLICY

ENDOTRACHEAL INTUBATION POLICY POLICY Indications: Ineffective ventilation with mask and t-piece, or mask and bag technique Inability to maintain a patent airway Need or anticipation of need for prolonged ventilation Need for endotracheal