preventing perilous pediatric pitfalls · preventing perilous pediatric pitfalls provides six (6)...

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

Head to Toesies

Pediatric Assessment

Teri Campbell

Flight Nurse

University of Chicago Aeromedical Network

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.

Physiologic airway differences

• Neonate: obligatory nose breathers

• BIG tongue

• Ooey, gooey

“Ring around the trachea…”

• Sniffing position

• Shoulder roll

• Anterior / twisting

Do not INHALE the frog!

• FBO

• Infectious obstruction

• Anaphylaxis

Airway obstruction

• Nasal flaring

• ↑ inspiratory effort

• Prolonged “I” phase

• “funny sounds”

Airway “pearls”

• Treat airway FIRST

• Lots of “badness”

• FBO: back blows?

• Position

PLEASE pull my finger!

• Aerophagia

• Diaphragm

• Aspiration

• OGT

Work of breathing

• Chest wall compliance

• Muscles of breathing

• Too fast / too slow

• Paradoxical breathing

I can’t believe I missed it

• Fatigue

• White flag

• Pneumo assessment

Oh thank goodness she stopped…

• Crying…

• Fighting…

• Snoring/wheezing/funny breathing…

Respiratory DISTRESS

• ↑ WOB

• Accessory muscle use

• Requires respiratory assistance

Respiratory Failure

• Inadequate gas exchange

Circulation

• VS “rough guide”, * clinical assessment

• Pulse more reliable than B/P

• Crash and burn

• Skin parameters

• LOC

• Central lines / cutdowns?

Why Are You so SHOCKED?

• Hypovolemia: most common

• Small blood volume

• Acidosis

• ↑ RR, ↑ HR

• ↑ contractility / tone

Given ‘em What They Need

• Only what they need…

• Normovolemia!

• Consequences of flooding

• 20 cc/ kg isotonic

• Blood 10 cc/kg

• Urine output

Disability

• Agitation

• Goofy

• ↓ LOC vs. 0300!

Level of Consciousness

• GCS (modified)

• AVPU

• Assess before NMB

• Pupils

Pain meds / sedation

Exposure

• Strip ‘em and flip ‘em

• Full head to toe

• Hypothermia

• Normothermia

• Controlled hypothermia

• BIG occiput

• Fontanelles

• Don’t forget to palpate!

• FLK

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!

Abdomen

• Abdomen begins at the “nickels”

• Underdeveloped abdominal muscles

• Poor protection of abdominal organs

• Blunt trauma

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

Pelvis / Genitalia

• Pelvic fractures less common

• Less hemorrhage

• Single squeeze

• Straddle injuries

• R/O Abuse

• Most under the age of 3

• 1/3 under 6 months

• S & SX can be subtle

• History and mechanism consistent?

Extemities• Secondary survey! (last)

• Skeletal fractures common

• Incomplete fractures (greenstick)

• Major and minor trauma

• CMS

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

Just Remember

• When kids give you “pucker”

Head to Toesies

Pediatric Assessment

Teri Campbell

Flight Nurse

CONGENTIAL HEART DEFECTS

Teri Campbell RN, BSN, CEN, CFRNKelley Holdren RN, BSN, CFRNUniversity of Chicago Aeromedical Network

NOT our objectives…

• Bedside diagnosis

• Multiple variations

• Surgical repairs

Our REAL objectives…

• Suspect CHD

• Broad classifications

• A → B

• 2 simple truths

• Right side = low pressure

• Left side = high pressure

• High pressure →

• Low pressure

• ASD• VSD• A-V Canal• PDA

• Size DOES matter

• High pressures (LA)→RA→RV

• RV hypertropy, ↑ PA pressures, pulmonary

HTN, CHF

• Pulmonary valve replacement (?)

• Symptoms?

• Pin hole → absence of septum

• Fun factoid: VSD size

• Large defect→ big RV → ↑ PA pressures

(from ↑ volume)

• CHF

• ↓ CO

• Sometimes…

• Turbulent blood flow (pulmonary valve)

• Smaller = louder

• New murmur ?

• Physio changes at 2-4 weeks of age

• 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

• Open connection between the PA and Ao

• Closes within 10 days of birth

• Preductal O2 sats (Right hand)

• Postductal O2 sats (feet)

• Indomethacin /Ibuprophen

• PGE

• “Won’t eat, just not acting right”

• Assessment: ↑RR, NAD, pink, dehydrated?, dry vs. wet lungs ? CHF

• Sweat during feeding

• Failure to thrive

• ABCs

• IVF bolus : 10cc/kg (titrated)

• Treat CHF (lasix, digoxin,)

• ↓ O2 and glucose requirements

• THESE ARE THE EASY ONES!

• Tetrology of Fallot

• Truncus Arteriosis

• Total Anomalous Pulmonary Venous Return

• Ebsteins

• VSD

• RV hypertrophy

• Pulmonary stenosis: PS

• Overriding aorta

• Variable cyanosis (r/t degree of PS)

• Pink kiddo = minimal PS

• L → R ventricular shunt

• Blue kiddo = moderate / severe PS

• R → L ventricular shunt

• 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

• ↑ irritable, r/t hypoxia

• Hard to bag when hacked off!

• ↑ hypoxia → ↓ LOC

• Easier to bag with ↓ LOC

• SEDATE! (caution w/ Versed).

• One large vessel (truncus)

• Single valve : PA / Ao are one

• VSD

• May have PDA

• Mixing is mandatory!

• Usually presents within 1st week of life

• Murmur

• Hypoxia (as low as 60’s)

• CHF symptoms

• Hepatomegaly

• 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!

• * SAS from birth• Murmur

• Severe respiratory distress r/t ↓ CO

• ↓ pulses

• ↑ capillary refill: mottled, blue, cold

• SPO2: less than 60

• Hypotensive

• Often mistaken for RDS/ Pneumonia/Sepsis

• ECHO confirms diagnosis

• Risk for pneumothorax r/t (US)

• BVM VT!

• 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

• Size does matter

• Symptoms r/t size of ASD

• Cyanosis, ↓ sats (70s)

• Murmur

• WPW and SVT common

• Hypoxic / cyanotic / ↓ SPO2

• CHF

• Murmurs are likely

• Metabolic acidosis

• TAPVR: ↓ B/P / perfusion

• Ebsteins: arrhythmias

• 100% O2 (get better)

• Keep O2 sats ↑ 75

• Sedate (?) TOF

• Treat CHF (lasix)

• Volume and Inotropes as needed (TAPVR)

• Arrhythmias: try ice first

• Transposition of the Great Arteries

• Tricuspid Atresia

• Pulmonary Atresia

• 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

• 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)

• 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

• Cyanotic (worse with PDA closure)

• Murmur (?)

• Sats will be low (60’s)

• Ride sided heart failure

• Left sided heart failure

• 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

• May or may not have a murmur

• R sided / L sided heart failure

• Cyanosis: rapidly deteriorates with PDA closing

• Crash hard, crash fast

• Murmur (?)

• Cyanosis

• Low SPO2

• Tachypnea

• Tachycardia

• R sided / L sided failure

• O2, 100%

• Keep O2 sats 75% or ↑

• *PGE to maintain PDA

• Goal: increase pulmonary blood flow

• No signs of systemic shock

• Coarctation of the Aorta

• Aortic Stenosis

• Interrupted Aortic Arch

• Hypoplastic Left Heart Syndrome

• 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

• Narrowing below/above/at aortic valve

• Bicuspid vs tricuspid valve

• LV hypertrophy/failure

• Mild stenosis: not treated

• Progressive stenosis

• Sudden cardiac arrest

• 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!

• Mitral atresia / stenosis

• Small LV (token LV)

• Aortic atresia /stenosis

• Coarctation of Ao is common

• ASD / PDA mandatory

• Need PGE

• ACTIVELY TRYING TO DIE

• RAPIDLY deteriorating

• Severe cyanosis/hypoxia

• Cardiogenic shock

• Cold, ashen/blue, dead looking kid

• Mimics septic shock

• Murmur (?)

• ETT is a given!

• FIO2 21% !

• O2 sats 75-85%

• PGE !

• Sedation (for us and them)

• Volume and inotropes

• 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

CONGENTIAL HEART DEFECTS

Teri Campbell: tlcsoup@aol.comKelley Holdren: kelley.holdren@uhchospitals.eduUniversity of Chicago Aeromedical Network

Trials And Tribulations Of

Terrible Tot Transports And

Their Take-Away Tidbits

Teri Campbell RN, BSN, CEN, CFRN

TLCMEDED@OUTLOOK.COM

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

Now… For Our REAL Objectives

• Participants will forgive all offensive and

unprofessional humor

• Participants will laugh heartily and write

EXCELLENT speaker evaluations

I Flat Out MISSED It!

• 11 y/o asthmatic male

• Intubated

• PIP in the 80s; ETC02 in the 80s

• NOT sedated, fighting the vent

Drug Like A Rock Star

• Immediately sedated with Fentanyl and

Versed

• PIP down to 30s

• I am a ROCK STAR!

Boogers?

• Without warning, difficult to bag X 3

seconds

• Equal breath sounds

• Resumes easy bagging

Happy Nappy

• Depart BS, patient sedated, PIP 40’s

• En route: Jason from Halloween

• Sedate and happy nappy

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

Of Course… 5 Minutes Out

• HR from 120s down to 80s

• ETCo2: 45

• Remains difficult to bag

• Reassess tube placement, lung sounds

Thank You Mayor Daley

• B/P intermittent r/t crappy Chicago roads

• B/P (finally) 118/89

• Suddenly easy to bag

Thank You Dr. Brilliant

• Arrive at the “Forefront of

Medicine”

• While off loading the

patient…

• HR ↓ 35

• Resident says “I think it’s

artifact”

Nope… Not Artifact

• Palpate a weak and thready pulse

• Compressions times TWO

• HR returns to the 70s

• WTH???

Right Pass The Family

• HR bradys again

• Compressions times FIVE

• HR returns, remains easy to bag

• Auscultate lungs sounds, chest rise

Nothing Good Happens In The

Elevator

• As the elevator opens to the PICU…

• Brady arrest AGAIN

• Ninja kick to the door plate

Flight Crew’s Fault…???

• Bilateral needle decompression

• No return of circulation

• Code for 11 minutes before ROSC

• Neurologically devastated (patient and RN)

Keep Me Up At Night Questions

• BVM vs Vent?

• Paralytics???

• Should we have

needled the chest?

Lessons Learned

• FEAR the intubated asthmatic kiddo

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”

• Mag; steroid; tincture of

The BIGGEST Lesson

• Grand Rounds SUCK when your

transport is discussed

Tummy Turmoil

• 14 months

intussusception

• Abd distended/firm,

painful

• ↓ PO intake, ↓ UOP, No

BM x 2 days

• “Stable” VS

Narcotic Queen

• Fentanyl given / 20CC/Kg

• Rock hard abd, LLQ/RLQ

ecchymosis

• BP 76/42, HR 158, RR

28, HGB 8, febrile

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?

Trauma Drama Queen

• Now he’s “trauma”…not PICU

• 2nd 20cc/Kg bolus for ↑ HR, ↓ BP

• Request O-Neg 1 unit for flight

Despite Our Best Efforts…

• ↑ tachycardia / hypotensive

• PRBCs

• Not improving

• Sedated but arousable

• Should I follow my gestalt / jaded RN?

• 3-4 story changes before “Aa Ha!” moment

Lessons Learned

• Fentanyl will NOT mask

an acute abdomen

• Watch trending vitals

• Thorough history is

important

Sweet As Sugar-Sick As S@!#

• 14 yr male, 6ft 2 in, 100kg

• PMH Down Syndrome

• New onset IDDM

• DKA

Prior To Arrival

• ETT for decreased LOC

• Insulin bolus

• Insulin drip

What The SUGAR Were They

Thinking?

• IVF bolus 2 liters

• D5W !!!!!!!!!!!

• “We knew he needed sugar because we

started insulin”

How Do We Make This Better?

• Bilateral eye deviation

• CT-profound cerebral edema

• Non responsive to stimuli

• Should I stay or should I go now?

• Should I have been more aggressive in

lowering CO2?

• How fake was my smile?

Lessons Learned

• Don’t assume “it’s DKA-NBD”

• D5W=FREE WATER

• Controversy adult size / pediatric age

• SLOWWWW Correction

• Enlist PICU Attending

I Still Have Nightmares!

• 5 month old male, ex-36 wk premie

• URI for few days

• Hypoxic, poor respiration / ventilations

• ETT NOW

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!”

12 People And 2 Crash Carts

• Gray/blue/cold limp baby

• Unresponsive

• Agonal breathing around

• HR 72/ NO-BP/ NO-POX

Why Is This Not Better?

• ETT NOT IN!

• “Discussion” with

referring MD

• “Well, now it’s out!”

• Resumed BVM

HOLY EDEMA!

• How many attempts?

• Finally..bottom tip of cords!

• Place ETT right before cords

takes a sharp left!

• Premie = floppy/crappy airway

Reassess

• HR 120-130 with BVM/agonal breathing

• POX -all over the place

• FD recon ETT

• RSI

Take TWO

• Atropine

• Versed

• Succinylcholine

Stark Realization!

• Chest wall is

not moving /

can’t BVM

• Can’t intubate

• OH CRAP!

What The?????

• Tried different ambu bag / repositioning

• Vecuronium 0.5mg IVP-No effect

• Tried LMA

• Cric???

More Chaos!

• Referring MD yelling!

• Ask for Anesthesia

• “Yeah that’s me”

• Attempts = 11

No Oxygen?

• Progressive bradycardia

• Full arrest

• PALS

Transport Or Call IT

• BVM/oral airway/CPR

• Lights/sirens = ED door in 7 minutes!

Airway IS Important!

• ETT with much difficulty

• Immediate ROSC

• BP 123/62, 135, 96%

• OMG! Did I kill that baby?

• Paralytics?

• History?

• Should we have called it?

Lessons Learned

• It’s only a matter of time…difficult

pediatric airways

• BVM IS an airway

• Edematous airway + paralytics = Bad JU JU

Out Of Flippin Nowhere!

• Angry bee hive of gang bangers

• “Sucks to be in the ED right now!”

• Laugh’s on me

Check His ID!

• 16 ½ yr old male

• GSW R chest and mid R abdomen

• Of Course he’s not in a gang!

“I Gotcha Baby….It’s All Good”

• Stabilized in ED

• CPD at bedside / RN consult

• Police confirm scene is secure

Nomex VS Kevlar

• Depart bedside

• ED: 2 Officers, Kevlar vest, weapons

accessible

• Nomex flight suit and an EZ IO

Mother Of The Year Award

• Shadows in the

dark…scene NOT safe!

• “Distraught” mom on

• “All you MFs keep your

mouth shut!”

Life Choices

• En route

• “Mom” lecture on life

choices

• Tailgating…..

Transfer Of Terror

• Acute anxiety

• Primary assessment:

medical

• Secondary assessment:

OMG I’m a target

Defensive Reaction

• Lights out / crouching tiger

• DLABOOH!

• Arrive at destination in 3 mins

• How do YOU define scene safety?

• Should I have called CPD en route?

Lessons Learned

• Call for police escort

• Call destination hospital

• Hold judgment

Where The Heck Did That Come

• 9 yr old male, 150 lbs

• Electrocution / V-Fib Arrest

• Defibrillated X 1 en route to OSH

• NSR/unresponsive/ETT

Twilight

• Started to stir….

• Propofol gtt

• Fentanyl given

• Paralytics?

No Go…Just Snow

• Med Control / FD decide no paralytics

• Referring MD also against paralytics

• Medicate, pack-up, depart

How ‘Bout That Blood Pressure?

• Patient snowed

• Hypotensive

• FD orders to ↓

propofol gtt

5 Minutes Later!

• Legs are moving, arms

are starting to move

• ↑ Propofol gtt back to 50

mcg/kg/min

Too Late!

• Incredible HULK

• Pt pulls out both PIV

• Pt pulls out ETT

Aircraft Set Up

• Possessed patient

• What straps?

• Jettison handle

Shut Down!

• Kid is still crazy and STRONG

• IM drugs are starting to work

• 5 big Firemen, FN, FD, Pilot

Nite, Nite!

• Sedated

• BVM / ETT

• Transport completed by GROUND

• 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?

In Conclusion

• YES, it really could happen to you

• NO, we really don’t stink as nurses

• Culture change

• Learn from US

The End

Teri Campbell BSN, CEN, CFRN

tlcmeded@outlook.com

University of Chicago : UCAN

preventing perilous pediatric pitfalls · preventing perilous pediatric pitfalls provides six (6)...

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