preventing perilous pediatric pitfalls · preventing perilous pediatric pitfalls provides six (6)...
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PREVENTING PERILOUS PEDIATRIC PITFALLS PROVIDES SIX (6) HOURS OF CONTINUING EDUCATION CREDIT
May 3, 2019
AGENDA
0830-0930 Heads to Toesies
0930-0940 Break
0940-1040 Achy Breaky Heart
1040-1045 Break
1045-1145 Trial and Tribulations of Terrible Tot Transports I and II
1145-1215 Lunch
1215-1315 Peds Trauma on the Fly
1315-1330 Break
1330-1430 When “Just Go Poopy,” Isn’t the Answer: Pediatric Abdominal Emergencies
1430-1530 Ups and Dows of a Swing Set Trauma
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Head to Toesies
Pediatric Assessment
Teri Campbell
Flight Nurse
University of Chicago Aeromedical Network
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Objectives
• Participants will review physiologic
differences in the pediatric patient
• Participants will discuss assessment
techniques for the pediatric patient
• Participants will list subtle assessment
clues to identify the deteriorating
pediatric patient.
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Physiologic airway differences
• Neonate: obligatory nose breathers
• BIG tongue
• Ooey, gooey
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“Ring around the trachea…”
• Sniffing position
• Shoulder roll
• Anterior / twisting
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Do not INHALE the frog!
• FBO
• Infectious obstruction
• Anaphylaxis
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Airway obstruction
• Nasal flaring
• ↑ inspiratory effort
• Prolonged “I” phase
• “funny sounds”
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Airway “pearls”
• Treat airway FIRST
• Lots of “badness”
• FBO: back blows?
• Position
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PLEASE pull my finger!
• Aerophagia
• Diaphragm
• Aspiration
• OGT
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Work of breathing
• Chest wall compliance
• Muscles of breathing
• Too fast / too slow
• Paradoxical breathing
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I can’t believe I missed it
• Fatigue
• White flag
• Pneumo assessment
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Oh thank goodness she stopped…
• Crying…
• Fighting…
• Snoring/wheezing/funny breathing…
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Respiratory DISTRESS
• ↑ WOB
• Accessory muscle use
• Requires respiratory assistance
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Respiratory Failure
• Inadequate gas exchange
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Circulation
• VS “rough guide”, * clinical assessment
• Pulse more reliable than B/P
• Crash and burn
• Skin parameters
• LOC
• Central lines / cutdowns?
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Why Are You so SHOCKED?
• Hypovolemia: most common
• Small blood volume
• Acidosis
• ↑ RR, ↑ HR
• ↑ contractility / tone
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Given ‘em What They Need
• Only what they need…
• Normovolemia!
• Consequences of flooding
• 20 cc/ kg isotonic
• Blood 10 cc/kg
• Urine output
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Disability
• Agitation
• Goofy
• ↓ LOC vs. 0300!
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Level of Consciousness
• GCS (modified)
• AVPU
• Assess before NMB
• Pupils
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Pain meds / sedation
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Exposure
• Strip ‘em and flip ‘em
• Full head to toe
• Hypothermia
• Normothermia
• Controlled hypothermia
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Head
• BIG occiput
• Fontanelles
• Don’t forget to palpate!
• FLK
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Clavicles and Chest
• Clavicle assessment
• Soft pliable rib cage
• Intra-thoracic injury w/o external signs
• Pneumo / pulmonary contusion
• It’s all in the box!
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Abdomen
• Abdomen begins at the “nickels”
• Underdeveloped abdominal muscles
• Poor protection of abdominal organs
• Blunt trauma
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Abdominal wall bruising
• Seat belt sign
• Significant intra-abdominal injury and vertebral
fracture
• (+) PV= 11.5%, (-) PV = 99.9%
• CT: solid organ injury, free fluid
• Pain / guarding
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Pelvis / Genitalia
• Pelvic fractures less common
• Less hemorrhage
• Single squeeze
• Straddle injuries
• R/O Abuse
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Abuse
• Most under the age of 3
• 1/3 under 6 months
• S & SX can be subtle
• History and mechanism consistent?
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Extemities• Secondary survey! (last)
• Skeletal fractures common
• Incomplete fractures (greenstick)
• Major and minor trauma
• CMS
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Vascular injuries
• Usually associated with ortho injuries
• Pulsatile bleeding, expanding hematoma, absent
pulses, cold limb
• Thrombosis vs. spasm?
• Spasm ↓ 3 hours
• ↑ 6 hours R/O thrombosis or transection
• Prolonged ischemia
• Compartment syndrome
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Just Remember
• When kids give you “pucker”
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Head to Toesies
Pediatric Assessment
Teri Campbell
Flight Nurse
University of Chicago Aeromedical Network
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CONGENTIAL HEART DEFECTS
Teri Campbell RN, BSN, CEN, CFRNKelley Holdren RN, BSN, CFRNUniversity of Chicago Aeromedical Network
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NOT our objectives…
• Bedside diagnosis
• Multiple variations
• Surgical repairs
Our REAL objectives…
• Suspect CHD
• Broad classifications
• A → B
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• 2 simple truths
• Right side = low pressure
• Left side = high pressure
• High pressure →
• Low pressure
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• ASD• VSD• A-V Canal• PDA
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• Size DOES matter
• High pressures (LA)→RA→RV
• RV hypertropy, ↑ PA pressures, pulmonary
HTN, CHF
• Pulmonary valve replacement (?)
• Symptoms?
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• Size DOES matter
• Pin hole → absence of septum
• Fun factoid: VSD size
• Large defect→ big RV → ↑ PA pressures
(from ↑ volume)
• CHF
• ↓ CO
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• Sometimes…
• Turbulent blood flow (pulmonary valve)
• Smaller = louder
• New murmur ?
• Physio changes at 2-4 weeks of age
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• Similar to other acyanotic defects
• LA and LV → RA and RV
• Left to Right shunt
• Big RV→ ↑PA pressures → CHF
• LV needs 2-3 X workload
• ↑ work of heart/lungs
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• Open connection between the PA and Ao
• Closes within 10 days of birth
• Size DOES matter
• Preductal O2 sats (Right hand)
• Postductal O2 sats (feet)
• Indomethacin /Ibuprophen
• PGE
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• “Won’t eat, just not acting right”
• Assessment: ↑RR, NAD, pink, dehydrated?, dry vs. wet lungs ? CHF
• Sweat during feeding
• Failure to thrive
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• ABCs
• IVF bolus : 10cc/kg (titrated)
• Treat CHF (lasix, digoxin,)
• ↓ O2 and glucose requirements
• THESE ARE THE EASY ONES!
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• Tetrology of Fallot
• Truncus Arteriosis
• Total Anomalous Pulmonary Venous Return
• Ebsteins
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• VSD
• RV hypertrophy
• Pulmonary stenosis: PS
• Overriding aorta
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• Variable cyanosis (r/t degree of PS)
• Pink kiddo = minimal PS
• L → R ventricular shunt
• Blue kiddo = moderate / severe PS
• R → L ventricular shunt
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• Spasm of the pulmonary valve
• ↓ blood flow to the PA (cyanosis)
• Calm baby: knee to chest position
• ↑ SVR to ↓ R → L shunt at VSD
• ↑ blood to lungs and ↓ to LE
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• ↑ irritable, r/t hypoxia
• Hard to bag when hacked off!
• ↑ hypoxia → ↓ LOC
• Easier to bag with ↓ LOC
• SEDATE! (caution w/ Versed).
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• One large vessel (truncus)
• Single valve : PA / Ao are one
• VSD
• May have PDA
• Mixing is mandatory!
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• Usually presents within 1st week of life
• Murmur
• Hypoxia (as low as 60’s)
• CHF symptoms
• Hepatomegaly
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• All 4 pulmonary veins dump into RA
• ASD
• R → L shunt (across ASD)
• LA and LV are filled only
with shunted blood (ASD)
• Hemodynamically crap!
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• * SAS from birth• Murmur
• Severe respiratory distress r/t ↓ CO
• ↓ pulses
• ↑ capillary refill: mottled, blue, cold
• SPO2: less than 60
• Hypotensive
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• Often mistaken for RDS/ Pneumonia/Sepsis
• ECHO confirms diagnosis
• Risk for pneumothorax r/t (US)
• BVM VT!
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• Abnormal tricuspid valve
• 2 leaflets are displaced down into the RV
• 3rd leaf is long and stuck to the RV wall
• Small RV
• Retrograde of blood in RA
• Maintain ASD
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• Size does matter
• Symptoms r/t size of ASD
• Cyanosis, ↓ sats (70s)
• Murmur
• WPW and SVT common
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• Hypoxic / cyanotic / ↓ SPO2
• CHF
• Murmurs are likely
• Metabolic acidosis
• TAPVR: ↓ B/P / perfusion
• Ebsteins: arrhythmias
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• 100% O2 (get better)
• Keep O2 sats ↑ 75
• Sedate (?) TOF
• Treat CHF (lasix)
• Volume and Inotropes as needed (TAPVR)
• Arrhythmias: try ice first
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• Transposition of the Great Arteries
• Tricuspid Atresia
• Pulmonary Atresia
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• Parallel circulation
• Ao attached to the RV
• PA attached to the LV
• R side →blue blood→body
• L side→red blood→to the lungs
• ASD,VSD or PDA
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• Variable cyanosis (depends on amt of mixing)
• ↑ RR w/o distress (initially)
• Murmur (?)
• 2-4 weeks of life → CHF
• Pre-ductal O2 sat lower (R hand)
• Post-ductal O2 sat higher (toes)
arms
legs
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• Tricuspid valve fails to develop
• No communication between RA and RV
• Hypoplastic RV
• Hypertrophy of RA/RV
• ASD mandatory
• PDA, VSD optional
• Pulmonic valve stenosis
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• Cyanotic (worse with PDA closure)
• Murmur (?)
• Sats will be low (60’s)
• Ride sided heart failure
• Left sided heart failure
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• Atretic pulmonary valve (doesn’t work/ present)
• RV → PA? (ain’t happenin’)
• RV hypertrophy / hypoplastic
• R → L shunt through ASD
• May have a VSD
• PDA mandatory
• 30-60% abnormal coronaries
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• May or may not have a murmur
• R sided / L sided heart failure
• Cyanosis: rapidly deteriorates with PDA closing
• Crash hard, crash fast
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• Murmur (?)
• Cyanosis
• Low SPO2
• Tachypnea
• Tachycardia
• R sided / L sided failure
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• O2, 100%
• Keep O2 sats 75% or ↑
• *PGE to maintain PDA
• Goal: increase pulmonary blood flow
• No signs of systemic shock
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• Coarctation of the Aorta
• Aortic Stenosis
• Interrupted Aortic Arch
• Hypoplastic Left Heart Syndrome
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• Symptoms r/t where coarctation occurs
• Narrowing of the aorta
• Worse with closing ductus
• ↓ blood flow to descending Ao : ↓ pulses in LE
• Different B/P : ↑ / ↓ (4)
• ↓ UO
• Bicuspid Ao valve
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• Narrowing below/above/at aortic valve
• Bicuspid vs tricuspid valve
• LV hypertrophy/failure
• Mild stenosis: not treated
• Progressive stenosis
• Sudden cardiac arrest
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• Absence or discontinuation of the aortic arch
• Most occur between L carotid and L subclavian
• VSD and PDA mandatory
• Pink R arm and face
• Blue, everything else!
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• Mitral atresia / stenosis
• Small LV (token LV)
• Aortic atresia /stenosis
• Coarctation of Ao is common
• ASD / PDA mandatory
• Need PGE
• ACTIVELY TRYING TO DIE
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• RAPIDLY deteriorating
• Severe cyanosis/hypoxia
• Cardiogenic shock
• Cold, ashen/blue, dead looking kid
• Mimics septic shock
• Murmur (?)
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• ETT is a given!
• FIO2 21% !
• O2 sats 75-85%
• PGE !
• Sedation (for us and them)
• Volume and inotropes
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• Pink kids: give them O2 and a pacifier
• Blue kids (not crashing)
• O2 (sats over 75%)
• PGE
• Treat CHF
• Blue kids (CRASHING)
• O2 ?? (they get worse fast)
• PGE
• Volume / inotropes
• Known defect /repair
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CONGENTIAL HEART DEFECTS
Teri Campbell: [email protected] Holdren: [email protected] of Chicago Aeromedical Network
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Trials And Tribulations Of
Terrible Tot Transports And
Their Take-Away Tidbits
Teri Campbell RN, BSN, CEN, CFRN
University of Chicago Aeromedical Network
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5/3/2019 Template copyright 2005 www.brainybetty.com 2
Objectives…(we don’t need no
stinkin objectives)
• Participants will discuss high risk scenarios in which
assessment and clinical clues can be missed
• Participants will review problem solving techniques for the
rapidly deteriorating pediatric patient
• Participants will discuss unsuspected patient care and
transport safety related issues
• Participants will contribute to case study review and
problem solving discussions
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Now… For Our REAL Objectives
• Participants will forgive all offensive and
unprofessional humor
• Participants will laugh heartily and write
EXCELLENT speaker evaluations
5/3/2019 Template copyright 2005 www.brainybetty.com 3
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I Flat Out MISSED It!
• 11 y/o asthmatic male
• Intubated
• PIP in the 80s; ETC02 in the 80s
• NOT sedated, fighting the vent
5/3/2019 Template copyright 2005 www.brainybetty.com 4
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Drug Like A Rock Star
• Immediately sedated with Fentanyl and
Versed
• PIP down to 30s
• I am a ROCK STAR!
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Boogers?
• Without warning, difficult to bag X 3
seconds
• Equal breath sounds
• Resumes easy bagging
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Happy Nappy
• Depart BS, patient sedated, PIP 40’s
• En route: Jason from Halloween
• Sedate and happy nappy
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Who You Calling A DOPE?
• Reassessed for tube placement and lung
sounds
• 2-3 minutes later, difficult to bag
• Equal breath sounds, equal chest rise
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Of Course… 5 Minutes Out
• HR from 120s down to 80s
• ETCo2: 45
• Remains difficult to bag
• Reassess tube placement, lung sounds
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Thank You Mayor Daley
• B/P intermittent r/t crappy Chicago roads
• B/P (finally) 118/89
• Suddenly easy to bag
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Thank You Dr. Brilliant
• Arrive at the “Forefront of
Medicine”
• While off loading the
patient…
• HR ↓ 35
• Resident says “I think it’s
artifact”
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Nope… Not Artifact
• Palpate a weak and thready pulse
• Compressions times TWO
• HR returns to the 70s
• WTH???
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Right Pass The Family
• HR bradys again
• Compressions times FIVE
• HR returns, remains easy to bag
• Auscultate lungs sounds, chest rise
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Nothing Good Happens In The
Elevator
• As the elevator opens to the PICU…
• Brady arrest AGAIN
• Ninja kick to the door plate
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Flight Crew’s Fault…???
• Bilateral needle decompression
• No return of circulation
• Code for 11 minutes before ROSC
• Neurologically devastated (patient and RN)
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Keep Me Up At Night Questions
• BVM vs Vent?
• Paralytics???
• Should we have
needled the chest?
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Lessons Learned
• FEAR the intubated asthmatic kiddo
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Better Living Through Chemistry
• Paralytics and narcotics
are your friend
• Consider chest wall
compliance and lung
sound resonance even in
older kids
• Remember long “E”
time
• Mag; steroid; tincture of
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The BIGGEST Lesson
• Grand Rounds SUCK when your
transport is discussed
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Tummy Turmoil
• 14 months
intussusception
• Abd distended/firm,
painful
• ↓ PO intake, ↓ UOP, No
BM x 2 days
• “Stable” VS
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Narcotic Queen
• Fentanyl given / 20CC/Kg
bolus
• Rock hard abd, LLQ/RLQ
ecchymosis
• BP 76/42, HR 158, RR
28, HGB 8, febrile
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Uh Hello?!!
• Packing kid up / FD and I
discuss ecchymosis
• “Well that’s from the fall!”
• Pt fell from top bunk where he
sleeps
• 14 months? Top bunk bed?
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Trauma Drama Queen
• Now he’s “trauma”…not PICU
• 2nd 20cc/Kg bolus for ↑ HR, ↓ BP
• Request O-Neg 1 unit for flight
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Despite Our Best Efforts…
• ↑ tachycardia / hypotensive
• PRBCs
• Not improving
• Sedated but arousable
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Keep Me Up At Night Questions
• Should I follow my gestalt / jaded RN?
• 3-4 story changes before “Aa Ha!” moment
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Lessons Learned
• Fentanyl will NOT mask
an acute abdomen
• Watch trending vitals
• Thorough history is
important
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Sweet As Sugar-Sick As S@!#
• 14 yr male, 6ft 2 in, 100kg
• PMH Down Syndrome
• New onset IDDM
• DKA
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Prior To Arrival
• ETT for decreased LOC
• Insulin bolus
• Insulin drip
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What The SUGAR Were They
Thinking?
• IVF bolus 2 liters
• D5W !!!!!!!!!!!
• “We knew he needed sugar because we
started insulin”
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How Do We Make This Better?
• Bilateral eye deviation
• CT-profound cerebral edema
• Non responsive to stimuli
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Keep Me Up At Night Questions
• Should I stay or should I go now?
• Should I have been more aggressive in
lowering CO2?
• How fake was my smile?
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Lessons Learned
• Don’t assume “it’s DKA-NBD”
• D5W=FREE WATER
• Controversy adult size / pediatric age
• SLOWWWW Correction
• Enlist PICU Attending
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I Still Have Nightmares!
• 5 month old male, ex-36 wk premie
• URI for few days
• Hypoxic, poor respiration / ventilations
• ETT NOW
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Chaos In The Bay
• Arrive 25-30 mins after initial PICU call
• “Oh UCAN thank God, get in there we
have no airway and it’s been 45 mins!”
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12 People And 2 Crash Carts
• Gray/blue/cold limp baby
• Unresponsive
• Agonal breathing around
ETT
• HR 72/ NO-BP/ NO-POX
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Why Is This Not Better?
• ETT NOT IN!
• “Discussion” with
referring MD
• “Well, now it’s out!”
• Resumed BVM
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HOLY EDEMA!
• How many attempts?
• Finally..bottom tip of cords!
• Place ETT right before cords
takes a sharp left!
• Premie = floppy/crappy airway
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Reassess
• HR 120-130 with BVM/agonal breathing
• POX -all over the place
• FD recon ETT
• RSI
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Take TWO
• Atropine
• Versed
• Succinylcholine
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Stark Realization!
• Chest wall is
not moving /
can’t BVM
• Can’t intubate
• OH CRAP!
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What The?????
• Tried different ambu bag / repositioning
• Vecuronium 0.5mg IVP-No effect
• Tried LMA
• Cric???
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More Chaos!
• Referring MD yelling!
• Ask for Anesthesia
• “Yeah that’s me”
• Attempts = 11
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No Oxygen?
• Progressive bradycardia
• Full arrest
• PALS
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Transport Or Call IT
• BVM/oral airway/CPR
• Lights/sirens = ED door in 7 minutes!
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Airway IS Important!
• ETT with much difficulty
• Immediate ROSC
• BP 123/62, 135, 96%
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Keep Me Up At Night Questions
• OMG! Did I kill that baby?
• Paralytics?
• History?
• Should we have called it?
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Lessons Learned
• It’s only a matter of time…difficult
pediatric airways
• BVM IS an airway
• Edematous airway + paralytics = Bad JU JU
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Out Of Flippin Nowhere!
• Angry bee hive of gang bangers
• “Sucks to be in the ED right now!”
• Laugh’s on me
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Check His ID!
• 16 ½ yr old male
• GSW R chest and mid R abdomen
• Of Course he’s not in a gang!
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“I Gotcha Baby….It’s All Good”
• Stabilized in ED
• CPD at bedside / RN consult
• Police confirm scene is secure
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Nomex VS Kevlar
• Depart bedside
• ED: 2 Officers, Kevlar vest, weapons
accessible
• Nomex flight suit and an EZ IO
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Mother Of The Year Award
• Shadows in the
dark…scene NOT safe!
• “Distraught” mom on
scene
• “All you MFs keep your
mouth shut!”
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Life Choices
• En route
• “Mom” lecture on life
choices
• Tailgating…..
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Transfer Of Terror
• Acute anxiety
• Primary assessment:
medical
• Secondary assessment:
OMG I’m a target
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Defensive Reaction
• Lights out / crouching tiger
• DLABOOH!
• Arrive at destination in 3 mins
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Keep Me Up At Night Questions
• How do YOU define scene safety?
• Should I have called CPD en route?
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Lessons Learned
• Call for police escort
• Call destination hospital
• Hold judgment
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Where The Heck Did That Come
From?
• 9 yr old male, 150 lbs
• Electrocution / V-Fib Arrest
• Defibrillated X 1 en route to OSH
• NSR/unresponsive/ETT
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Twilight
• Started to stir….
• Propofol gtt
• Fentanyl given
• Paralytics?
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No Go…Just Snow
• Med Control / FD decide no paralytics
• Referring MD also against paralytics
• Medicate, pack-up, depart
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How ‘Bout That Blood Pressure?
• Patient snowed
• Hypotensive
• FD orders to ↓
propofol gtt
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5 Minutes Later!
• Legs are moving, arms
are starting to move
• ↑ Propofol gtt back to 50
mcg/kg/min
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Too Late!
• Incredible HULK
• Pt pulls out both PIV
• Pt pulls out ETT
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Aircraft Set Up
• Possessed patient
• What straps?
• Jettison handle
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Shut Down!
• Kid is still crazy and STRONG
• IM drugs are starting to work
• 5 big Firemen, FN, FD, Pilot
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Nite, Nite!
• Sedated
• BVM / ETT
• Transport completed by GROUND
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Keep Me Up At Night Questions
• What if he got to the jettison handles?
• Should they have handled the sedation
differently?
• Physical restraints?
• Should the FN have stood her ground and
insisted on paralytics?
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In Conclusion
• YES, it really could happen to you
• NO, we really don’t stink as nurses
• Culture change
• Learn from US
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The End
Teri Campbell BSN, CEN, CFRN
University of Chicago : UCAN
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