Paediatric Emergency Prompt Cards Introduced July 2016 Prompt cards are designed to be used by any member of the resus team If you have any comments or suggestions, please contact helen.collyer-merritt@sash.nhs.uk or julie.brimble@sash.nhs.uk
Contents Page Paediatric advanced life support 3 Emergency drugs 4 Newborn life support 5 Anaphylaxis 6 SVT 7 VT 8 Bradycardia 9 Status epilepticus 10 Hyperkalaemia 11 Croup 12 Bronchiolitis 13 Acute wheeze 14 DKA 15 Bacterial meningitis 16 Meningococcal disease 17-18 Intraosseous (IO) insertion 19 Burns 20 Intranasal diamorphine 21 Trauma 22 2
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Anaphylaxis 6
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Minimum dose 100 micrograms Maximum dose 600 micrograms. Dose can be repeated after 5 mins 0.05-2 micrograms/kg/min IV 9
Midazolam: 0.5mg/kg Diazepam: 0.5mg/kg Lorazepam: 0.1mg/kg Phenytoin: 20mg/kg over 20 mins Phenobarbitone: 20mg/kg over 5 mins (if child already on phenytoin) 0.4ml/kg 10
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Croup Treatment Dexamethasone PO 150 micrograms/kg for all children +/- repeat dose at 12 hours If symptoms persist Nebulised budesonide 2mg can be given instead of dexamethasone. They are equally effective. For severe croup Also give nebulised adrenaline 400 micrograms/kg (0.4ml/kg of 1:1000 ) Give oxygen if sats <95% on air 12
Bronchiolitis Management - Oxygen therapy for sats persistently below 92% - CPAP if impending respiratory failure - Upper airway suctioning if child presents with apnoea. Consider in children with respiratory distress or feeding difficulties because of upper airway secretions - Fluids via nasogastric/orogastric tube in children who are not tolerating enough by mouth. If unable to tolerate this or impending respiratory failure, give IV isotonic saline - Consider chest physiotherapy in children with relevant comorbidities eg spinal muscular atropy, severe tracheomalacea DO NOT: X Routinely perform a CXR unless ITU admission considered (Changes on a CXR may mimic pneumonia and should not be used to determine the need for antibiotics) X Routinely take bloods or carry out blood gas testing (capillary blood gas testing can be considered in children with severe worsening respiratory distress or suspected impending respiratory failure) X Use the following drugs to treat bronchiolitis: antibiotics, hypertonic saline, nebulised adrenaline, salbutamol, montelukast, ipratropium bromide, corticosteroids Risk factors for more severe bronchiolitis 1) Chronic lung disease 2) Haemodynamically significant congenital heart disease 3) Less than 3 months old 4) Premature (particularly <32 weeks) 5) Neuromuscular disorders 6) Immunodeficiency When to admit? 1) Apnoea (observed or reported) 2) Persistent sats < 92% on air 3) Persisting severe respiratory distress eg grunting, marked chest recession, RR >70 4) Inadequate oral intake (50-75% of usual volume, taking into account risk factors and clinical judgement) 5) Take risk factors and social factors into account When to discharge? 1) Clinically stable 2) Taking adequate oral fluids 3) Maintained SpO2 > 92% on air for 4 hours, including a period of sleep 13
Algorithm: Management of acute wheezing in children 14
DKA Use the calculator below found on the computer desktops (60kg child is given as an example here) Use 0.9% sodium chloride with 20 mmol potassium chloride in 500ml until blood glucose levels are less than 14mmol/l. All fluids should contain 40mmol/l potassium chloride apart from the initial bolus and if there is evidence of renal failure. 15
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Repeated scoring is recommended to document changes in the severity of the illness. 18
Intraosseous (IO) insertion Before applying the power of the drill, push the needle through the skin until it hits bone. If one black mark (5mm) is not seen, the needle is too short. If in pain from rapid infusion, give 2% lidocaine 0.5mg/kg slow infusion. 19
Burns ATLS ABCDE assessment Call anaesthetics if airway issue or potential for airway issue Is transfer likely? Start documentation on the LSEBN transfer document Estimate percentage burn Use the body map. Exclude simple erythema Fluid resuscitation Start IV fluids if >10% surface area burn 4ml x kg x % of plasmolyte Give half over first 8 hours. Give next half over 16 hours. Fluid resuscitation is calculated from the time of burn so a catch up bolus may be required. Analgesia Clean soot with saline or water Deroof blisters that are larger than the patient s little finger nail Take photos after deroofing Get consent Cover with clingfilm while awaiting burns service advice Keep the patient warm with a Bair hugger/warm fluids Remove jewellery/watches Refer via www.trips.nhs.uk For patients not requiring ITU, call QVH on 5025 and ask for peanut ward If complex ie. Airway issue, trauma or medical co-morbidity, call Chelsea and Westminister Children s Burns Unit on 020 3315 3706 or 3707 If no beds, call National Burns Bed Bureau 01384 679036 20
Intranasal diamorphine Indications: For traumatic injuries including burns. Can also be used for suturing. Prior to prescribing, document: Weight Baseline observations Pain score Contraindications: Children <10kg Airway or respiratory problem Administration of other opiates prior Known allergy to opiods Children with head injury/neurological problem Cardiovascular or respiratory compromise Reduced level of consciousness Blocked nose both sides or epistaxis Dose: 0.1mg/kg All children receive this dose in a volume of 0.2ml 21
Trauma Additional notes to be used alongside the trauma proforma booklet C-spine Cervical collars are no longer recommended in children Manual inline stabilisation is recommended. Blocks and tape are still recommended. Log roll to 20 angle only IV access alternatives Intraosseous External jugular Seldinger femoral Cut down CABC approach Manage catastrophic bleeding first eg. Direct pressure, tourniquets, haemostatic dressings, pelvic binders and splints Tranexamic acid 15mg/kg (max 1g) initial bolus dose over 10 mins to be given within 3 hours of injury. Then 2mg/kg per hour for at least 8 hours or until bleeding stops. Suggested dilution 500mg in 500ml, N.saline or 5% glucose Fluid/blood Give IV boluses of 10mg/kg (blood if bleeding and available) to maintain perfusion. Transfuse 1:1:1 Analgesia Intranasal diamorphine (see previous page) IV morphine 0.1-0.2mg/kg (under 1 year: 80 micrograms/kg) IV fentanyl (Titrate increments of 0.5 microgram/kg) 22