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Advanced Life Support in Pediatric IR
C James, M Moore, S Schexnayder,
T Hill, J Johnston, J Green,
L Braswell
Conflict of Interest Disclosure : None
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Advanced Life Support in Pediatric IR
• Purpose: Review life support scenarios in one Pediatric IR practice.
• Methods: – Scenarios requiring urgent interventions during or
within one week of a Pediatric IR procedure were identified.
– 20 events were reviewed and compared to current pediatric life support algorithms (PALS).
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Advanced Life Support in Pediatric IR
• Static Poster, October 2012:
Pediatric Interventional Radiology Symposium
• Simulation added: IR Lab “Mock Codes” – Initiated December 2012
– Coordinator: Leah E. Braswell, M.D.
Arkansas Children’s Hospital
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Scenario 1
• Teenager passed out at school
• Unresponsive, no breathing, no pulse
• Next steps?
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Scenario 1
• Teenager passed out at school
• Unresponsive, no breathing, no pulse
• Next step: CPR begun: ? order
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Scenario 1
• Teenager passed out at school
• Unresponsive, no breathing, no pulse
• Next steps:
– CPR begun: COMPRESSIONS first
– Emergency response activated/AED retrieved
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Asystole
8
next steps?
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Asystole (PALS)
• Start CPR: compressions first, airway/breaths – 30:2 compression-ventilation ratio (single rescuer)
• Oxygen, monitor/defibrillator:
• Epinephrine every 3-5 min – IO/IV: 0.01 mg/kg (0.1 mL/kg of 1:10,000)
– CPR 2 min, shockable rhythm?:
• Ventricular Fibrillation: – Shock: 2J/kg, CPR 2 min, shock: 4J/kg
• Amiodarone: IO/IV: 5 mg/kg (up to 2 doses)
PALS book
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Sudden cardiac arrest
• In-hospital
– Arrhythmia
• Out-of-hospital
– Arrhythmia
– Trauma
– Drowning
– SIDS
PALS book
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Reversible Causes Cardiac Arrest in Children
• H’s
– hypovolemia, hypoxia, hydrogen ion (acidosis)
– hypoglycemia, hypo-/hyperkalemia, hypothermia
• T’s
– tension pneumothorax, tamponade, toxins
– thrombosis (pulmonary)
– thrombosis (coronary)
PALS book
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Secondary Assessment
• Focused history: PALS “SAMPLE” mnemonic
– Signs and symptoms
– Allergies
– Medications
– Past medical history (Scenario 1: OHT as infant)
– Last meal
– Events
PALS book
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Scenario 2
• Sclerotherapy procedure
– 8 month old infant
– extensive buttock/abdominal wall macrocystic lymphatic malformation
– 10 ml 3% sotradecol injected
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Sinus Tachycardia: P waves present, R-R variable
next steps?
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Sinus Tachycardia: identify/treat cause
• Assess patient: – Ventilation: intubated, stable
– Pulse > 200 for over 6 minutes
– Perfusion: BP drop
• Anesthesia staff: – Called for staff back-up
– Vasopressor medication administered
• IR staff: – Sclerotherapy stopped
– Sclerosed contents aspirated
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Sinus Tachycardia (PALS)
• Normal heart rate (3 months to 2 years age): – 100-190 beats per minute
• Common causes of Sinus Tachycardia: – exercise, pain, anxiety, fever
– tissue hypoxia, hypovolemia, shock, metabolic stress, anemia
– toxins/poisons/drugs
PALS book
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Sinus Tachycardia
• Common causes:
– Exercise, pain, anxiety, fever,
– tissue hypoxia, hypovolemia, shock, metabolic stress, injury, anemia
– Toxins/poisons/drugs: (Scenario 2: SCLEROSANT)
• Search for and treat cause:
– Sclerotherapy discontinued
PALS book
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Scenario 3
• 7 day old infant with osteomyelitis requiring PICC
• Single dose IV Versed/Ketamine:
– Drop in pulse oximetry and apnea
• Next steps?
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Oversedation
• Airway repositioned, bag/mask ventilation, 100% O2
• Hypoventilation persisted
• Next step?
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Oversedation
• Airway repositioned, bag/mask ventilation, 100% O2
• Hypoventilation persisted
• Next step:
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Oversedation
• Flumazenil dose given
– 0.01 mg/kg IV
• Spontaneous ventilation returned
• Observe patient for 2 hours S/P reversal agent to assess for recurrent oversedation
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Sedation reversal agent: Flumazenil
• Benzodiazepine receptor agonist
• IV flumazenil (0.01 mg/kg)
– can repeat up to 1 mg
• Observe patient for 2 hours* given shorter half life of reversal agent:
– flumazenil half life: 40-80 min
– versed half life: 1-2.5 hours (up to 7 hours for premature infants)*
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Scenario 4 • Central venous guidewire measurement near
completion of PICC placement
• HR abruptly increases
– Normal pulse oximetry
– Normal BP
• Next steps?
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“Mock Code” ACH IR Lab
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“Mock Code” ACH IR Lab
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SVT: P waves absent, rhythm uniform
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Scenario 4: SVT
• Central venous guidewire measurement near completion of PICC placement
• HR > 220
• Next steps?
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SVT
• Ice pack to face (vagal stimulation)
• Dose of IV adenosine calculated (0.1 mg/kg)
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SVT
• Vagal maneuvers: – Infant: ice pack to face (Scenario 4)
– Older child: blow through obstructed straw, carotid massage
• Dose of IV adenosine calculated
– 0.1 mg/kg
– Plan: rapid bolus 2 syringe technique
• Pediatric Cardiology informed
PALS book
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SVT: if vagal maneuvers unsuccessful
• Adenosine: rapid bolus 2 syringe technique – 1st dose: 0.1 mg/kg
– 2nd dose: 0.2 mg/kg
• If unstable: Synchronized cardioversion – 0.5-1 J/kg, if not effective , increase to 2 J/kg
PALS book
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Scenario 6
• 2 days S/P IR Cecostomy tube placement
• Fever, tachycardia, abdominal distention
• Urine output below 0.5 ml/kg over past 12 hours
• Next steps?
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Cecostomy tube sinogram: no leak, patient tender
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Peritonitis/Septic shock
• Pediatric Surgery consulted
• IV fluid bolus and increased IVF maintenance
• Strict I’s and O’s
• 7 days broad spectrum IV antibiotics
*IVF bolus warranted much earlier in retrospect
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Septic shock (PALS)
• Oxygen, support ventilation, monitor vital signs, establish vascular access
• Aggressive isotonic bolus fluid administration in first hour
• Frequent re-assessment of perfusion
• Vasoactive agents if septic shock is fluid refractory
PALS book
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Scenario 5
• 8 y/o girl autism/severe movement disorder • 3 days S/P IR G-tube placement: • Morning rounds:
– Tachycardia – Low urine output (below 0.5 ml/kg/hour) – IVF rate increase recommended to Pediatric team
• Afternoon: – Fluoroscopic contrast check – G-tube malpositioned – Tube repositioned by IR
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Hypovolemic shock
• Evening: patient decline – Poor perfusion
– Cardiopulmonary arrest
– IVF bolus warranted much earlier in retrospect
– Patient expired 1 week after ICU care
• Hospital wide “Root Cause” analysis
• Change in IR G-tube placement order sets/team responsibilities
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Hypovolemic shock (PALS)
• Children receiving appropriate volume of fluid within the first hour of resuscitation have best chance at survival
• Infuse 20 ml/kg boluses of isotonic crystalloid rapidly to treat hypovolemic shock due to dehydration; deliver each over 5-20 minutes
• Not uncommon to require 3-5 fluid boluses in first hour
PALS book
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Scenario 7
• 10 y/o S/P MVA with facial fractures and subdural hematoma
• In OR for subdural hematoma decompression
– Anesthesia noted tachycardia/hypotension
– Pulled back drapes: massive nasal/oral cavity bleeding
– Vitals unrecordable: CPR begun
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Hemorrhagic shock
• IV fluid resuscitation
• Nasal packing
• Common carotid artery ligated (temporary)
• Packed RBC’s: 9 units received in OR
• Inotropic support:
– Epinephrine/norepinephrine IV drips
• To IR Lab for angiography
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Carotid Cavernous Fistula: urgent embolization
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Hemorrhagic Shock (PALS)
• Moderate/severe hypotensive hemorrhagic shock correlates with 30% loss of blood volume (about 25 ml/kg).
• Transfusion indication:
– Poor response to IVF boluses (poor perfusion despite 40-60ml/kg of crystalloid)
– Known significant blood loss
PALS book
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Scenario 8
• 1 month-old with pneumonia and para-pneumonic pleural effusion
• IR chest tube placement • 7 hours later:
– Increased work of breathing/desaturations – Low chest tube output despite post-procedural dose
of alteplase
• PICU transfer, chest radiograph ordered
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Tension pneumothorax S/P IR chest tube
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Tension pneumothorax
• Chest tube: stopcock was open; tube clogged
• Tube resistance resolved with manual flush (gush of fluid, then air)
• If unable to clear tube and severely distressed: – needle thoracostomy
– 2nd intercostal space mid-clavicular line
• IR bedside rounding: monitor tube output, stopcock alignment, and tube patency
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Sudden deterioration intubated patient (PALS)/*Chest tube
• DOPE Mnemonic:
– Displacement of the tube
– Obstruction of the tube (Scenario 8: tube clogged)
– Pneumothorax
– Equipment failure
PALS book
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IR Lab: Simulated “Mock Codes”
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Simulated: IR Lab “Mock Codes”
ACH “PULSE center” IR scenarios/video
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PICU attending supervision
Post simulation team debriefing
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Conclusion
• Most interventions followed PALS guidelines • IV fluid administration was delayed in septic and
hypovolemic shock after IR bowel tube placement.
• Knowledge of life support scenarios and required
urgent interventions are pertinent in Pediatric IR practice.
• Simulated IR Lab “Mock Codes” helpful
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Advanced Life Support in Pediatric IR
• Reference:
• Pediatric Advanced Life Support
– Provider Manual
– 2011 American Heart Association
• The “PULSE center”
– Arkansas Children’s Hospital
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Thanks