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.

5/3/2019 Template copyright 2005 www.brainybetty.com 2

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

http://images.google.com/imgres?imgurl=http://www.owlnet.rice.edu/~psyc351/Images/DilatedPupil.jpg&imgrefurl=http://woxy.com/boards/showthread.php?t=53249&usg=__gd9Wc-fOClPmOJvTl-gxtQZqjxQ=&h=701&w=600&sz=85&hl=en&start=1&tbnid=d-8RDkK4oC-FdM:&tbnh=140&tbnw=120&prev=/images?q=dilated+pupils&gbv=2&hl=en

Pain meds / sedation

Exposure

• Strip ‘em and flip ‘em

• Full head to toe

• Hypothermia

• Normothermia

• Controlled hypothermia

Head

• 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


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”

5/3/2019Template copyright 2005 www.brainybetty.com

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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)

arms

legs

• 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: [email protected] Holdren: [email protected] of Chicago Aeromedical Network

Trials And Tribulations Of

Terrible Tot Transports And

Their Take-Away Tidbits

Teri Campbell RN, BSN, CEN, CFRN


[email protected]


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???


H

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”

time

• Mag; steroid; tincture of

TIME5/3/2019 Template copyright 2005 www.brainybetty.com 18

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


http://mail.aol.com/32679-311/aol-1/en-us/mail/get-attachment.aspx?uid=1.28216791&folder=NewMail&partId=4

Narcotic Queen

• Fentanyl given / 20CC/Kg

bolus

• 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

ETT

• 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


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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!”


Life Choices

• En route

• “Mom” lecture on life

choices

• Tailgating…..

• Understatement!5/3/2019 Template copyright 2005 www.brainybetty.com 53

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

From?

• 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


http://mail.aol.com/32679-311/aol-1/en-us/mail/get-attachment.aspx?uid=1.28247114&folder=NewMail&partId=4

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

[email protected]

University of Chicago : UCAN

312-720-08355/3/2019 Template copyright 2005 www.brainybetty.com

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PREVENTING PERILOUS PEDIATRIC PITFALLS · PREVENTING PERILOUS PEDIATRIC PITFALLS PROVIDES SIX (6)...

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