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One thought is around drug doses - for most drugs it is not as exact a science as paediatric formularies would have you believe - ie if child about 20% / half the size of an adult draw up an adult dose give about 20% / half but round up. They don't (or at least didn't when I worked in OZ both times) have the equivalent of BNF / BNFC you had to use a MIMS book and the childrens hospitals produced their own formularies (presume there are apps now but might be worth checking) As I mentioned before teenagers probably better from a physiological perspective being looked after by adult nurses / docs who recognise the abnormal HR. Paediatric major trauma so rare in UK / Oz that only way to be a specialist in managing paed major trauma is to manage adult major trauma and kids with non trauma emergencies. Neonates - scary even for PEM specialists - if you don't know what is going on treat the treatable stuff (infection / dehydration / jaundice / hypoglycaemia) as not going to do any harm while trying to diagnose rarer stuff like metabolic/cardiac (and even in metabolic babies acute episode often precipitated by infection). Worth mentioning that APLS 20ml/kg fluid boluses may be over generous (I go 5ml/kg if they don't look too bad 10ml/kg if they look awful) can always keep giving. FEAST study has introduced debate / doubt about massive fluid volumes in resus for kids. Drawing fluid boluses up in 20ml not 50ml syringes much easier to push in babies. Will let you know if any more gems occur to me. Rachel Really good Simon. It all makes total sense what you've pulled together. I think it's worth re iterating that in kids you see probably a higher proportion of 'well' patients compared to adults. Most of the time I feel in adults you expect to find something, whereas in kids you don't. So when you've seen tons of well kids, the really sick ones pop out at you. If not its so engrained in your head to run through a head-toe examination that you'll pick stuff up if its there. Does that make sense? The other scarey bit with kids for many is all the syndromes and other weird stuff that can change, and get in the way of just seeing the patient in front of you. More common sense needed in kids sometimes. Adult practice gives you way more exposure to practical skills so when you get to do them on kids it's not so scarey apart from their size. They are my thoughts so far. In kids all this week so may be enlightened some more! K
Easy when you are here new hospital all specialities on site dedicated ped all medical and surgical on site does this give me credibility or not?
NOt so easy when you are here EMS get scared parents transport directly secondary transfers in more common most likely to see a non-specialist PEM physician Frequency of critically ill kids distributed in geography and in time
Cliff of physiology
The case. Let’s give you an example of what can and does happen as we see the effect of
Good people Good knowledge Good process but no action. Not an isolated event Still takes place.
Where are we scared? 1. Unfamiliarity 2. High stakes 3. Unhelpful paediatricians
What’s our starting point and why are we talking about this?
Even the World Health Organisation thinks they are not little adults
Because we all know that.........
But this is SMACC2013 & it’s different
Is the approach still going to be the same for the resuscitation of sick and injured kids? So what worries you here?
Is it really just a size issue OR
Perhaps we need to clarify a few things first. First there is a continuum of ages from birth through to adulthood. That’s fine and the differences change at a gradual rate, and change in different ways. Psychologically children extend to an age well in to teens, but physiologically we are pretty much adults from
So what is that we are really that interested in?
Still have lots of similarities A, B, C, Change of mindset. Look for similarities not look for difference. Where is the expertise in the management of the sick and injured child Have worked in lots of different setting where you either get people thinking someone else is the expert or in settings where they think they are the only people with the expertise. In reality it is a mixed picture.
But in the acute and severe setting what we are looking for is the ability to deal with a group of undifferentiated, sick/injured kids for whom the picture is uncertain, where teams are required and where good overall management is needed. In a situation that is stressful for all. So if there was ever a time for the resuscitationist, then this is it & that perhaps more than anything else is what defines expertise in our specialities.
But maybe they are in many ways, but a lot of the differences in EM management are about when children are fairly well. That’s not why we are here. So why does this matter to us?
RSI Ket and Sux - follow up with Midaz and Morphine as propofol not used in children (though many people do) Airways are usually OK in normal kids. Other than that same process for getting out of trouble. Video laryngoscopes - no-one I know using them. Not usually needed. Same rescue process Last place for needle cric - know your kit. force required to open the mouth teeth tumour arthritis jaw opening HOW WILL YOUR APPROACH BE DIFFERENT? Take FB as an example as that is perhaps one of the scarier aspects
What happens when it goes wrong? What would be your strategy for failure be? Need appropiate kit - but..... DL - LMA - Surgical appropriate speciality
6ml/Kg is just fine. Set the vent as you would an adult or squeeze the bag. Use ETCO2 to guide Chest tubes a great example of a very rare event in children where the expertise will lie within the EM adult community.
6ml/Kg is just fine. Set the vent as you would an adult or squeeze the bag. Use ETCO2 to guide
Top area for failure and preventable death, delay in therapy, chicken bombs etc. What are our rules for cannulation? What are our rules for IO? Who administers these rules - the nurses are good with this.
Data on trauma resuscitation models predominantly from young adults. therefore probably applicable to kids as well. TXA used in paed cardiac surgery
End points for resuscitation
Kids are just little adults. SMACC Paediatric Resuscitation
RelaxChildren are just little adults
themesthe critically ill and injured childtaking actionnot APLSnot PEM in general
Pressure control more popularPressure control more popularTidal volume reasonable (5-8 ml/kg)Tidal volume reasonable (5-8 ml/kg)or maybe better to look at chest wall excursion with pressure controlor maybe better to look at chest wall excursion with pressure controlAim for lower FiOAim for lower FiO22 albeit with higher PEEPalbeit with higher PEEP4-6 to start4-6 to start6-8 if bad lung disease6-8 if bad lung disease8-10 if wet lungs8-10 if wet lungsSpO2 = 88-96%SpO2 = 88-96%Chest tubesChest tubes
• Fluids• APLS 20ml/Kg in sepsis• APLS 10ml/Kg in trauma
Fluid requirements• Sepsis -• Adequate volume important within 1-2 hours• Reduced mortality• less persistent hypovolaemia• no increase in ARDS• each additional hour of shock doubles odds of death.• reduced PICU stayRole of early fluid resuscitation in pediatric shock. Carcillo JA, Davis AL, Zaritsky A. JAMA 1991;266: 1242-1245.Early reversal of Pediatric - Neonatal septic shock by Community Physicians is associated with improved outcome. HanYY, Carcillo JA, Dragotta M et al. Peds 2003;112: 793-799.
In severe sepsislikely requirement for volume is200-360ml/Kg in first 24 hours
FEAST trialHigher mortality in kids with large fluid boluses
Question?Is 20ml/Kg too muchDose/response may be better in 5ml/Kg aliquots
Fluid choice?• Little evidence• Saline causes hyperchloraemic acidosis• Colloids (albumin) after 40-60ml/Kg• Plasmalyte coming into practice
Tranexamic acid15mg/Kg over 1 hour2mg/Kg/Hr for 8 hours
53 patients in 15 monthsNo improvement in mortalityFeasibility proven
Therapeutic end points• Titrate to effect• Normal pulses with no difference central/peripheral• Warm extremities• Return of Urine output (>0.5-1ml/Kg/Hr), HR, Cap refill,LOC• SVC or mixed venous gas• Normalising base deficit and lactate
Today...•Fire up the simulator• Kids & Adults in the past• Kids & Adults in the future