All posts with tag: "resusc"

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You are seeing a 5 year old child with known adrenal insufficiency with fluid and pressor-resistant hypotension. You wish to give stress-dose steroids. 

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You are told that you will be receiving a 12 month old child in full arrest. CPR is in progress by the paramedics. Your EMS agency does not have pre-hospital providers intubate children. Which of the following is true as you prepare your equipment and medications?

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A 16 year old girl arrives to the ED by ambulance and promptly delivers a 34 weeks by dates neonate. The infant is unresponsive, apneic, and you cannot palpate a pulse. After initial steps of drying, warming, and stimulating, the baby is still apneic with a heart rate < 100. You initiate positive pressure ventilation for 15 seconds but still do not hear the heart rate rising. Which of the following is not a part of the MR SOPA ventilation corrective steps recommended to try next?

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(Click the link to comment and to vote - voting not working through email, sorry!) You are managing a 1yo patient with submersion injury who has respiratory distress and falling O2 saturation. You begin bag-valve-mask ventilation as you prepare to intubate the patient, using a 450mL self-inflating bag with oxygen at 10 L/minute, bagging at a rate of 20 breaths/minute. You note that the patient is not improving and there is poor chest rise, so you insert a correctly sized and placed nasopharyngeal airway. The patient is still not improving and has poor chest rise - after repositioning, which is the best intervention? [yop_poll id="178"]

(Click the link to comment and to vote - voting not working through email, sorry!) EMS is bringing you a 10yo patient that has been actively seizing for 20 minutes. They are unable to obtain IV access. [yop_poll id="177"]

(Click the link to comment and to vote - voting not working through email, sorry!) A 2yo girl is brought in by ambulance after a seizure lasting 1 minute. She has had 2 days of fever, vomiting, and diarrhea. Her temperature is 39.1, HR 202, BP 129/61. Despite antipyretics, calming down, and volume resuscitation, she remained febrile and tachycardic. On exam, a midline neck mass is palpable, and the mother gives a history of several months of sweating and poor weight gain. A lab test confirms her diagnosis. [yop_poll id="164"]

(Click the link to comment and to vote - voting not working through email, sorry!) A 3 week old infant that is positive for RSV has had several prolonged episodes of apnea requiring BVM ventilation. The decision is made to intubate the baby. It is a difficult intubation, although the tube is finally observed to pass through the cords on video laryngoscopy. A 3.5 uncuffed tube has been placed and taped at 12cm at the lip. After several positive pressure breaths on 100% FiO2, the pulse oximetry has fallen to 85% and fails to rise. The ETCO2 waveform is normal and reading 46 mm Hg. Heart rate is 170, BP is 62/30. On auscultation breath sounds are decreased on the left side. Trachea is midline. [yop_poll id="160"]

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(Click the link to comment and to vote - voting not working through email, sorry!) For which of the following pediatric patients is it most important to have the clinician with the most experience in advanced airway management and endotracheal intubation perform rapid sequence medication-assisted intubation? [yop_poll id="125"]

(Click the link to comment and to vote - voting not working through email, sorry!) A new edition of ATLS (10th edition) was recently released. Which of the following is not a recommendation of the 10^thedition of ATLS regarding the trauma patient in shock? [yop_poll id="75"]

(Click the link to comment and to vote - voting not working through email, sorry!) A previously healthy 5 year old boy with PMH of ADHD presents with 9 days of lethargy, fever, vomiting, diarrhea, and weight loss. He recently was diagnosed with strep pharyngitis and treated with amoxicillin for 3 days. His vital signs are: temp 39 C, HR 140, RR 24, BP 154/99, O2 sat 99% on room air. His exam is significant for agitation and restlessness, and tachycardia with bounding pulses and a hyperdynamic PMI. His mother feels that his anterior neck looks swollen. [yop_poll id="23"]

You are caring for a 6yo oncology patient presenting in septic shock. Although he is oxygenating and ventilating well at this time, you plan to intubate him to reduce his metabolic work. The most important pre- treatment before rapid sequence intubation (RSI) is: (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="13"]

A 12yo girl presents to the ED in December with fever for 4 days, malaise, and pain in the right thigh gradually leading to her having difficulty walking. There is no history of trauma, although she did play a lot of basketball 1 week ago. She is alert and oriented. Physical exam of her leg is unremarkable except for diffuse pain. She has no rash nor joint swelling or erythema. Her vital signs are: temp 39.1, HR 165, RR 22, BP 85/44. Labs show an elevated WBC count with a bandemia, a BUN of 20 with a creatinine of 2.2, and mildly elevated transaminases with a bilirubin of 2.4. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="9"]

A 36-week infant is born precipitously NSVD to a 17yo G2P1 mother in the ED after the mother presented with the chief complaint of intermittent abdominal pain. Apgars are 8 and 9 at 1 and 5 minutes, with -1 for color at both times and -1 for reflex irritability at 1 minute. The O2 sat in the left upper extremity is 82% at 5 minutes. The baby is crying intermittently, is not pale or plethoric, and is in no respiratory distress. Lung sounds are equal and clear bilaterally, and cardiac exam is normal. The next best intervention is: A. Intubate and mechanically ventilate B. Suction and apply 100% O2 C. Suction and apply nasal canula O2 at 5 L/min D. Transilluminate the chest to r/o pneumothorax E. Continue to observe the infant Check back in a few days for my answer and others' comments Also, if you're interested in the Peds ID Question of the Week, you can find it here

A 20kg child sustains a 15% body surface area burn. The best answer for the rate of IV fluids that should be administered over the first 8 hours is: A. 60 cc/hr B. 75 cc/hr C. 120 cc/hr D. 135 cc/hr E. 150 cc/hr

A 12yo boy with very high risk ALL, recent chemotherapy 4 days prior, presents to the ED with fever and lethargy. Temperature is 39C, HR 180, RR 24, BP 80/50.  The patient is lethargic, has no nuchal rigidity, lungs are clear to auscultation, heart is tachycardic but regular rate and rhythm, abdominal exam is benign, and there is no rash. Pulses are bounding, there is flash capillary refill, skin is warm and dry. After adequate fluid resuscitation, cultures, and empiric antibiotics, the patient remains hypotensive. The next best treatment is: A. Dopamine IV at 5 mcg/kg/min B. Epinephrine IV at 0.1 mcg/kg/min C. Norepinephrine IV at 0.1 mcg/kg/min D. Dobutamine IV at 5 mcg/kg/min E. Hydrocortisone 1 mg/kg IV

Classic teaching is to estimate the nasopharyngeal airway (NPA) size as the length from the patient's nares to tragus of the ear, and the oropharyngeal airway (OPA) from the maxillary incisors to the angle of the mandible. However, a few recent studies found that (nares to tragus minus 10mm) more accurately predicted the correct size NPA in children: Johnson et. al. and Nemeth et. al.

Everyone knows it’s nearly impossible to memorize all the formulas and doses relative to pediatric emergency medicine. That’s why 2 pediatric emergency medicine physicians created http://pocketpem.com/ when they were PEM fellows. Log on for a plethora of PEM info; maybe even bookmark the page on your phone. PEMsource also has several quick references that can be printed out / laminated and attached to your badge, or added to the files on your phone – check out resuscitation formulas and sizing, ECGs, labs, and medications.

So many helpful tips and tricks can be found on twitter! Of course, for kids, adjust IV catheter size and amount of fluid infused.

From Haliloglu M, Bilgen S, Uzture N, Koner O. Simple method for determining the size of the ProSeal laryngeal mask airway in children: a prospective observational study. Braz J Anesthesiol 2017; 67(1):15-20. The child's ear is a good estimate of the LMA size.

Part of the new AAP BRUE algorithm’s definition of low-risk BRUE (Brief Resolved Unexplained Event) is that the event duration was < 1 minute. I always ask the caretaker to walk me through what happened step by step, using “and then what” prompting. I have had parents that told me the event lasted 2 minutes whose step-by-step description varied from “I picked her up, called for my husband to call 911, and blew in her face and she started coming around” (probably < 1 minute) to “I picked her up, ran to my neighbor’s house, she was still blue, we laid her on the couch, my neighbor gave mouth-to-mouth, and I called 911” (probably > 1 minute). Another trick I use is to say, “OK let’s say it starts when I say “now”, let me know when you think it stopped… now,” while timing with a stopwatch (available on your phone) – when your baby’s not breathing, 15 seconds can seem like 5 minutes; this helps get a more realistic estimate.

When resuscitating neonates vascular access is often a challenge. While IV and IO attempts are ongoing, the ability to obtain a small amount of blood for point-of-care testing of, for example, glucose, hemoglobin, electrolytes, and venous blood gas, can be valuable. One method is the "blind stick", attempting to hit a venous plexus in the upper volar forearm blindly. Note: this method should only be used in emergent resuscitation conditions, as complications such as hematoma formation can occur.

The Coach at PEMPlaybook.org has a great podcast on using the VBG in situations where we used to try to get an ABG (which was never fun to do in small children). From the podcast: the rule of 4’s: (note ABG values are always higher): VBG pH is 0.04 lower than ABG pH VBG pCO2 is 4 lower than ABG pCO2 VBG pO2 is approximately 40 lower than ABG pO2 The bottom line is that for most of our clinical concerns, we can use VBG to assess pH and pCO2, and O2 sat to assess oxygenation. VBG may be less reliable in shocky or hypercapneic patients (but end-tidal CO2 will be useful in hypercapneic patients). When do we really need an ABG? When we want to calculate the Aa gradient, looking for e.g. VQ mismatch, shunt, or a diffusion problem.

Two tips for intubating the obese patient:

1. Position the patient: build a sizeable ramp to position the patient such that his/her ears are at the level of the sternal notch, and his/her face is parallel to the ceiling
2. Position yourself: keep your back straight, your left elbow in, and lift (don't crank). If you're having difficulty summoning enough muscle, try straightening your left arm at the elbow to make use of your stronger upper arm muscles, rather than just your forearm.

Two great resources: Obese Difficult Airway Airway Jedi Step by Step (scroll down to the "How you lift matters" section)

It is commonly taught that a patient’s palmar hand represents approximately 1% of his/her body surface area (BSA), a useful tool when estimating the BSA of burns. But does one use the palm including or excluding the fingers? Adult studies support that the palmar hand including fingers actually represents about 0.8% BSA. Despite this widespread teaching, there are surprisingly few pediatric studies. Pediatric studies support the palmar hand without fingers to = 0.5% BSA, and with fingers close to 1% BSA. What is considered pediatric for using this estimation method? One original study included children to age 13 years, and another to age 17 years; puberty may be a useful cutoff age. How well the palm estimates BSA may also vary by gender, race, and degree of obesity. Ref: Thom D, Burns 2017 Feb; 43(1):127-136.

It's July, so good time to review the basics. For pediatric resuscitations of any type, the mnemonic ABCDEFG is great - Airway, Breathing, Circulation, Don't Ever Forget Glucose. Children have lower reserves and become hypoglycemic more easily than adults when stressed. This mnemonic also came from a fantastic quick review of pediatric congenital heart disease presentations from the awesome folks at emergencymedicinecases.com

Having trouble with bag valve mask ventilation? Don't forget to use adjunctive airways - nasopharyngeal for conscious patients, oropharyngeal for unconscious. Reuben Strayer's great video here advocates placing 2 nasal airways and an oral airway, then bagging over those, for the difficult to bag patient. You can also place an ETT adaptor (pull the adaptor off the tube) into a nasal airway and bag the nasal airway directly - see more information here. Don't forget, nasal airways are measured from the nostril to the tragus of the ear, and oral airways are measured from the center of the mouth to the angle of the jaw.

Thanks to Tim Horeczko pemplaybook.org for tube-tape-tap mnemonic  

You're seeing a 5 day old with a fever of 39. Attempts to get IV access have been unsuccessful. The child is alert and not toxic appearing, but you'd like to get empiric antibiotics started within the first hour of evaluation. What are your options other than drilling with an IO or embarking on a potentially long sweaty frustrating attempt at a central line in a neonate? An ultrasound-guided peripheral line is one possibility if you have the skills. Another vascular access method to keep in mind is the umbilical venous line - the umbilical vein can stay patent up to 7-10 days of life! Soak the dry cord in saline soaked gauze to soften it, use a scalpel to cut straight across at 1-2cm from the base, look for the single large vein, insert a pre-flushed catheter with gentle pressure into the vein while pulling back on a syringe until you see a flash of blood. For more info: https://blogs.brown.edu/emergency-medicine-residency/emergent-umbilical-venous-catheter-uvc-placement/ The "Fast-cath" technique advocates using a 14 gauge angiocath http://www.emsworld.com/article/10852257/paramedic-umbilical-vein-catheterization-for-newborns Find resources for born out of asepsis babies on our algorithms page, including how to make umbilical venous catheter mini kits to keep in your ED. http://pemsource.org/algorithms/boa-newly-born/

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Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!

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Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!

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A full term infant born out of asepsis (BOA) at home is brought in by ambulance to your PED. No neonatologist or pediatrician is in house. The baby's venous blood gas shows a pH of 6.9, PCO2 80. The baby has inadequate respirations. Which do you decide to do?

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(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 29 day old afebrile former 35 weeker brought in by ambulance. The patient was given a few sips of "gripe water" for runny nose, appeared to choke and gasp for air, turned blue briefly, then recovered. The entire episode was about a minute. There was no tone change. The baby has no birth complications. The baby's vital signs and physical exam are normal in the ED, pulse ox is 100% on room air, RSV testing is negative. What would be your management? [poll id="33"]

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! It's the day after Thanksgiving, and your patient just ate a bunch of leftovers before getting into an automobile accident. You are intubating, and hoping the patient doesn't aspirate during the procedure. A medical student asks whether he should apply cricoid pressure for you. [poll id="31"]

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 19 year old with a history of illicit drug use brought in with sudden onset cardiac arrest. He received bystander CPR immediately after the arrest, and is in a ventricular fibrillation rhythm that has persisted despite 5 shocks, epinephrine, and amiodarone following the ACLS algorithm. [poll id="30"]

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 3 year old with 2nd lifetime episode of SVT. The patient has no other prior PMH, was not on any medications, was healthy prior, and does not have WPW. After 2 doses of properly administered adenosine, the patient is still in SVT. She is alert, not toxic, has good perfusion, and is not hypotensive. [poll id="29"]