Arterial Puncture. Medications: Lidocaine 1% or EMLA (optional)

Transcription

1 Arterial Puncture Supplies: Gloves Alcohol wipes or chlor hexidine Straight needle or butterfly needle Blood gas syringe and/or additional 3 10mL syringe as needed Blood collection tubes as needed Gauze Band aid Chucks Medications: Lidocaine 1% or EMLA (optional) Procedure Description: 1. Choose site for arterial puncture based on palpation (see diagram below). 2. When time permits, place topical anesthetic such as EMLA 30 minutes prior to procedure or inject lidocaine subcutaneously over puncture site. 3. Assemble equipment 4. Wash hands/put on gloves 5. Place patient s palm upward and extend the wrist degrees 6. Clean site with alcohol or chlorhexidine 7. At degree angle puncture skin with needle, bevel up, and advance into artery. 8. Fill up syringes as needed. 9. Place gauze pad over needle insertion site and withdraw needle, hold pressure for 5 minutes 10. Engage needle safety mechanism and dispose of needle 11. Check puncture site for bleeding and apply band aid as needed. FIGURE 9: Arterial anatomy of hand.

2 Trouble shooting: You feel that you are in the correct location, but have no blood return: You are above the artery or underneath: insert needle slightly deeper or slightly more shallow. You are just next to the artery: withdraw needle and try again slightly more medial or lateral after palpation You have good blood return but it stopped: Bevel of needle is against arterial wall: slightly rotate the needle Needle has dislocated outside of the artery: advance the needle or withdraw a little bit or try again Needle has clotted off: remove needle and try again A hematoma is forming around the puncture site: You have punctured through the artery: withdraw needle, apply pressure for 5 minutes and try again. Doppler ultrasound may be helpful for identification of the exact location of the artery. 30 Pediatric Housestaff Emergency Medicine Manual

3 UCSF - CONVULSIVE STATUS EPILEPTICUS UCSF Treatment Guideline for Pediatric Convulsive Status Epilepticus CHILD ARRIVES IN ED SEIZING 0-10 MINUTES: IMPENDING STATUS EPILEPTICUS* Skip this step if pt received 2 doses of any benzodiazepine prior to ED Preferred: Lorazepam: 0.1 mg/kg IV (max 4mg) o Repeat in 5 min if persistent seizure (MAX 2 doses, including pre- ED doses) If no IV access: midazolam 0.5mg/kg IV solution given buccally or 0.2 mg/kg IM (max 10mg) Evaluation based on H&P: ABC s, labs as indicated (consider glucose, CBC, BMP, LFT s, AED levels, tox, cultures) Seizure stopped within 5 min of 2 nd dose of benzodiazepine? NO YES Continue evaluation as indicated Call Pedi Neuro if seizing > 20 min MINUTES: ESTABLISHED STATUS EPILEPTICUS* Fosphenytoin: 30 mg PE/kg IV or IO, run over 10 minutes, or IM (max 150 mg/min) CALL PEDIATRIC NEUROLOGY: Delay neuroimaging until seizure controlled unless concern for emergent intracranial process *Order VPA/levetiracetam or phenobarbital: may take time to get from pharmacy *Consider pyridoxine if INH suspected (1g/g ingested, max 5g initial dose) Seizure stopped after fosphenytoin load? NO MINUTES: REFRACTORY STATUS EPILEPTICUS* *Call PICU to arrange for admission YES Admit to Pediatrics If intubated/unconscious: to PICU for EEG monitoring Child 1 mo- 2 years? Phenobarbital 20 mg/kg IV over 10 min Prepare for intubation If seizure persists: Repeat 20 mg/kg IV over 10 min X1 Child > 2 years? Valproate 20 mg/kg IV over 4 min unless contraindicated* *If known or suspected inborn error or liver disease, use levetiracetam 30 mg/kg IV (max 3 g) over 6 min 6 - Seizure 45 MINUTES: COMA INDUCTION (IN PICU) Midazolam 0.2 mg/kg IV bolus (max 10mg), start infusion at 0.1 mg/kg/hour o Repeat bolus and increase infusion rate by 0.1mg/kg/hr (max 2 mg/kg/hr) every 5 min until seizure cessation on EEG If seizure persists, start pentobarbital (10mg/kg IV bolus, infusion at 1mg/kg/hr) and wean midazolam o Repeat bolus (5mg/kg) q 30 min and increase infusion by 1mg/kg/hr q hr until seizure cessation AND burst- suppression on EEG Continue coma meds X 24 hrs after last seizure, then wean (if recurrent seizures, restart and add topiramate 10mg/kg NG) o Wean: reduce midazolam gtt by 0.05mg/kg/hour q3h; reduce pentobarbital gtt by 1mg/kg/hr q6h PEDIATRIC NEUROLOGY: Kendall Nash, MD May 9, 2011 UCSF Pediatric Neurology Andrea Marmor, MD 176 Seizure stopped? NO Neurology YES Admit to PICU for EEG monitoring

4 MOCK CODE: PNEUMONIA WITH RESPIRATORY FAILURE AND VENTRICULAR TACHYCARDIA OBJECTIVES: After participating in this mock code, participants will be able to 1. Initiate appropriate supportive therapy for respiratory failure 2. Anticipate respiratory arrest in a child with respiratory failure 3. Recognize ventricular tachycardia 4. Apply the treatment algorithms for wide-complex tachycardia 5. Operate the defibrillator to perform defibrillation Introduction: 4 year old girl with respiratory distress. Initial assessment: pale, sick appearing child, significant distress Assess - CAB Circulation: tachycardia, warm, diminished pulses, cap refill 3s Airway: patent, no stridor Breathing: marked increased work of breathing with tachypnea and deep retractions, R-sided crackles Disability: lethargic, moans when stimulated Expose the child Categorize: respiratory distress, possible shock (be prepared for: respiratory failure) Action: 1. Call for help! Rapid Response or Code Team 2. Get the child on a heart rate monitor with pulse oximetry & blood pressure (cycle q 1-3 min) 3. Oxygen Continue assessment: Hx as above, immunized. No known sick contacts. Weight: 30kg. One 24 G IV in place Vital signs: HR 160 BP 90/60 RR 48 O 2 Sat 82% T o F Categorize: Respiratory failure (be prepared for: cardiopulmonary arrest) Action: 1. Give more oxygen: remember, regular nasal cannula provides only up to ~40% 2. Establish additional IV access, bolus with 20 cc/kg 3. Order chest X-ray, obtain ABG, CBC, blood cultures 4. Ensure adequate antibiotics have been administered, otherwise order these Continue assessment: Breathing much slower with deep retractions, becoming more obtunded, pale, pulses weak but present Vitals: HR: wide complex tachyarhhythmia BP 70/40 RR 10 O 2 Sat 75% with poor wave form, CR 4 sec Categorize: Respiratory arrest and ventricular tachycardia with pulses and poor perfusion Additional History: Wt = 30 kg. Ex 32-wk, hx mild CLD, not on oxygen since infancy. Healthy, one episode RSV in infancy. No hx RAD. No meds, NKDA, vaccinated. URI sx and fever for 2 days, today incr WOB, fever, emesis, lethargic. Family brings her to ED where she appears ill. Action: 1. Call code 2. Get the code cart & defibrillator 3. Start bag-mask ventilation 4. Secure access 5. Get ready for endotracheal intubation 6. PALS algorithm for pediatric tachycardia with pulses and poor perfusion, possible V-tach: a. Cardiovert (0.5-1 J/kg), if cardioversion not effective: repeat with 2 J/kg b. Give Amiodarone 5 mg/kg IV over min (or IO) 7. Call cardiology 8. Remember H s and T s: get labs (electrolytes, ABG, tox screen), check temperature, give volume, give sodium bicarbonate (1-2 meq/kg), Magnesium sulfate early on if the rhythm looks like Torsades 9. Anticipate what may come next: pulseless v-tach/v-fib: draw up epinephrine, ready to start chest compressions, finger (literally) on the pulse! Case description: This was a child with bacterial community acquired pneumonia. We see a case this sick several times a year, although luckily the deterioration to respiratory failure and cardiopulmonary arrest typically happens a little slower and intubation takes place in an ICU. It is very important that you give adequate oxygen supplementation early. Regular face mask or nasal cannula only provides up to 40% F i O 2, whereas a non-rebreather with oxygen reservoir can provide close to 100%. Children with severe pneumonia should always be intubated by an experienced provider. De-recruitment of lungs during intubation attempts can make it more and more difficult to bag-mask ventilate in-between attempts, and hemodynamic instability in this situation occurs commonly. Since this child had a wide-complex tachycardia with pulses and poor perfusion, the initial therapy is synchronized cardioversion.

5 MOCK CODE: STATUS EPILEPTICUS OBJECTIVES After participating in this mock code, participants will be able to: 1. Choose first-line medications for management of status epilepticus. 2. Practice emergent IO access. 3. Anticipate/manage respiratory compromise as a result of seizures and benzodiazepine treatment. Introduction: 2 year old with seizures Additional history: Wt = 20kg. Kristoff is a 2 yo who has had AGE sx (emesis, loose stool, fever) for 1 d. Sib with AGE. This AM, was in his room when mom found him having GTC. Initial assessment: generalized tonic-clonic seizure EMS arrived in 5 min, sz had stopped. No meds given. En route, had 2 nd short sz. No PHMx, no meds, NKDA Assess - CAB Circulation: warm, cap refill brisk Airway: patent, + oral secretions Breathing: rapid & shallow Disability: generalized tonic-clonic seizure, no eye deviation Expose the child! Categorize: Generalized tonic-clonic seizure (be prepared for: respiratory failure) Action: 1. Call for help 2. Open airway (position, suction if secretions are present) and apply oxygen 3. Make sure the child is on a monitor with pulse oximetry and blood pressure (cycle q 5 min) 4. Seizure precautions: never leave this child unattended, bedrails up, pillows to prevent injury, roll the child on side Continue assessment: Weight: 20 kg No access Vital signs: HR 130 RR 46 BP 100/65 T F Sat 91% Categorize: Febrile status epilepticus Action: 1. Call for help: RRT, Neurology 2. Obtain access IV or IO 3. Check labs: glucose, electrolytes, CBC, tox screen 4. Stop the seizures: Ativan IV, (buccal or IM midazolam if no IV access) 5. Repeat in 5 minutes if still seizing 6. Consider other antiepileptic therapies if no effect of the above and glucose is normal: Fosphenytoin (30 mg PE/kg IV or IO run over 10 min) Phenobarbital (20 mg/kg IV over 10 min) Continue assessment: Seizure stops. She becomes apneic and desaturates to the 50% range. Categorize: Respiratory failure Action: 1. Call Code 2. Bag-mask ventilate Adequate seal? (mask should cover nose and mouth) Adequate pressure? Enough=what makes the chest wall rise 3. Get ready for intubation: remember that once you give a paralytic agent, you won t be able to assess for seizure activity anymore. Make sure you give additional AEDs if child still seizing prior to intubation and get an EEG ASAP. Case description: This child had febrile status epilepticus complicated by apnea and profound desaturation. Respiratory compromise is not uncommon with seizures, sometimes because of inadequate effort directly as a result of the seizures and sometimes due to hypoventilation secondary to benzodiazepines or other AEDs administered. Always think about the etiology: Even though this seizure is associated with a fever, check a glucose and sodium level and think about other risk factors (VP shunt, recent trauma, bleeding diathesis?). In any seizing child, stopping the seizures is a high priority, and sometimes it takes a lot of drugs. Remember to think about the consequences: all anti-epileptic medications can cause respiratory depression and most will cause hypotension at high/repeated doses. Be prepared to take over the airway and monitor the blood pressure frequently.

6 Pediatric Cardiac Arrest Algorithm 6 Pediatric Housestaff Emergency Medicine Manual

7 Pediatric Tachycardia with a Pulse & Poor Perfusion Algorithm 8 Pediatric Housestaff Emergency Medicine Manual

8 Intra Osseous Line Placement Supplies: Gloves Chlorehexidine 16 or 18 gauge IO needle Small sandbag or towel (placed behind knee for support) 10cc saline flush with T connector Extra 10 cc syringe (for blood sampling) Tape Gauze Medications: Lidocaine 1% with 25 or 27 gauge needle (optional) Video: Procedure Description: Analgesia: When time permits, inject 1% lidocaine subcutaneously and over the periosteum Procedure: 1. Identify insertion sites based on visualization and palpation 2. Assemble equipment 3. Wash hands and put on gloves 4. Support leg (place sandbag or towel behind knee). Do not place hand behind knee for support! 5. Clean site with chlorhexidine 6. Insert needle through skin and subcutaneous tissue, advance through the bone with a rotary, twisting motion. Maintain angle perpendicular to the long axis of the bone or slightly caudal to avoid the growth plate. 7. Release pressure when bony resistance ceases and remove stylet 8. Aspirate marrow OR confirm placement by ready infusion of 5 10mL crystalloid into marrow cavity. Ensure that no soft tissue swelling results. 9. Attach T piece connector 10. Inject indicated medications OR use pressure bag for rapid infusion 11. Pack gauze around IO needle to stabilize and tape into place. FIGURE: Anterior surface of proximal tibia (preferred IO site for all ages)

9 ENRICHMENT AIRWAY ADJUNCTS The tongue is the most common cause of airway obstruction in an unconscious person. Keeping the tongue from blocking the air passage is a high priority. Oropharyngeal (oral) airways (OPAs) and nasopharyngeal (nasal) airways (NPAs) can help you accomplish this task. OPAs are inserted into the mouth and are used only on unconscious, unresponsive victims with no gag reflex (Figure 1). If placed improperly, it can depress the tongue into the back of the throat, further blocking the airway. Once you have positioned the device, use a resuscitation mask or bag-valve-mask resuscitator (BVM) to ventilate a nonbreathing victim. OPAs should not be used if the victim has suffered oral trauma, such as broken teeth, or has recently undergone oral surgery. NPAs are inserted into the nose and may be used on a conscious, responsive victim or an unconscious victim (Figure 2). Unlike the oral airway, the nasal airway does not cause the victim to gag. NPAs should not be used on victims with suspected head trauma or skull fracture. 1 Follow local protocols for the use of OPAs and NPAs. 2 Administering Emergency Oxygen Online Resources 2011 The American National Red Cross 1

10 SKILL SHEET INSERTING AN ORAL AIRWAY Notes: Always follow standard precautions when providing care. Before inserting an OPA, be sure the victim is unresponsive; has no oral trauma, such as broken teeth; and has not had recent oral surgery. Use an appropriately sized OPA for the victim. If the victim gags, remove the OPA immediately. SELECT THE PROPER SIZE Measure the OPA from the victim s earlobe to the corner of the mouth. OPEN THE VICTIM S MOUTH Use the cross-finger technique to open the victim s mouth. INSERT THE OPA For an adult: Grasp the victim s lower jaw and tongue and lift upward. Insert the OPA with the curved end along the roof of the mouth. As the tip approaches the back of the mouth, rotate it one-half turn (180 degrees). Slide the OPA into the back of the throat. Continued on next page 2 Administering Emergency Oxygen Online Resources 2011 The American National Red Cross

11 SKILL SHEET Continued For a child or an infant: Use a tongue blade or a tongue depressor and insert with the tip of the device pointing toward the back of the tongue and throat in the position it will rest in after insertion. OR Insert the OPA sideways and then rotate it 90 degrees. ENSURE CORRECT PLACEMENT The flange should rest on the victim s lips. Note: If the victim vomits, remove and suction the airway, ensuring all debris is removed from the airway. Thoroughly clean the device and reinsert the OPA only if the victim is still unconscious and does not have a gag reflex. Administering Emergency Oxygen Online Resources 2011 The American National Red Cross 3

12 SKILL SHEET INSERTING A NASAL AIRWAY Notes: Always follow standard precautions when providing care. NPAs should not be used on a victim with suspected head trauma or a suspected skull fracture. Use an appropriately sized NPA for the victim. SELECT THE PROPER SIZE Measure the NPA from the victim s earlobe to the tip of the nostril. Ensure that the diameter of the NPA is not larger than the nostril. LUBRICATE THE NPA Use a water-soluble lubricant prior to insertion. INSERT THE NPA With the bevel toward the septum (center of the nose), advance the NPA gently, straight in, following the floor of the nose. If resistance is felt, do not force. If you are experiencing problems, try the other nostril. ENSURE CORRECT PLACEMENT The flange should rest on the victim s nostril. 4 Administering Emergency Oxygen Online Resources 2011 The American National Red Cross