.Emergent Interventions (Peds)

Thanks to Dr Dyllon Martini
Estimating vital signs and weight:

Vitals: 
  • HR
    • Rule of 60s (Trevor’s)
      • <1 y/o HR <160, BP >=60, RR < 60
      • >1 y/o HR drops by 10 for 2-5, 6-12. >12 = normal adult
  • SBP (min)
    • 70+ 2*age
  • Weight:
    • Birth wt: 3.5kg


Age/Weight/Color Generalizations:
(credit: image from WikEM: https://wikem.org/wiki/Broselow_color_zones)


Credit: Dr Horeczko’s Pediatric Emergency Medicine Lectures at Harbor-UCLA Resident Conference, from WikEM, from Medscape Drug Reference, UpToDate, UCSF EM Resident Guide.
Equipment:
  • ET tube size = (age/4)+4 uncuffed.  For neonate, -1 for cuff less. 
  • Tube, tape, tap: 
  • NG/OG/Foley =   2x ET
  • Depth (of ET) = 3x ET
  • Chest tube = 4x ET
Blade:
  • 00 premie
  • 0 birth
  • 1 @ 1
  • 2 @ 2
Electricity:
  • Sync 0.5-1 J/g
  • Defib 2 J/kg, 2nd shock 4 J/kg, max 10 J/kg or adult dose
Meds:

Intubation:
  • Succinylcholine: 1.5-2mg/kg (atropine 0.02mg/kg IFF redose)
  • Rocuronium 1.2mg/kg
Sedation:
  • Etomidate 0.3mg/kg
  • Versed 0.1 mg/kg
  • Fentanyl 1-2 mcg/kg
  • Ketamine: 2mg/kg

  • Blue baby -> ketamine (R->L shunt, “needs pinking up”)
  • Pink baby -> etomidate (L->R shunt, “don’t rock the boat”)
Epinephrine
Pulseless Arrest, Bradycardia (symptomatic):
  • 0.01 mg/kg (0.1 mL/kg) 1:10,000 IV/IO q3-5 min (max 1 mg) 
  • 0.1 mg/kg (0.1 mL/kg) 1:1000 ET q3-5 min
Anaphylaxis:
  • 0.01 mg/kg (0.01 mL/kg) 1:1000 IM thigh q15 min prn (max 0.5 mg)
  • Auto-injector 0.3 mg (≥30 kg) IM or JR injector 0.15 mg (10- 30kg) IM
  • 0.01 mg/kg (0.1 mL/kg) 1:10000 IV/IO q3-5 min (max 1mg) if hypotn
  • 0.1 to 1 mcg/kg/min IV/IO infusion if hypotn despite fluids and IM dose
Asthma: 0.01 mg/kg (0.01 mL/kg) 1:1000 SQ q15 min (max 0.5 mg; 0.5 mL)
Croup: 0.25-0.5 mL racemic soln (2.25%) in 3mL NS INH or 3mL 1:1000 INH
Seizure:
  • Lorazepam 0.1mg/kg
  • Versed 0.1mg/kg
  • Fosphenytoin 20 mg/kg (max 1g, rate of 150 mg PE/mim, PE=phenytoin equivalent) OR Phenytoin (dilantin) 20mg/kg (give slow, 1mg/kg/min)
  • Phenobarb 20mg/kg (rate 1mg/kg/min)
  • Keppra 20mg/kg (max 3g) (at 5mg/kg/min
  • Valproate (Depakote) 20mg/kg at 5mg/kg/min
Anti-Arrhythmics 
  • Amiodarone 5mg/kg over 20-60min
  • Procainamide 15mg/kg over 30-60min 
  • Adenosine: 0.2mg/kg

Other:
  • Atropine 0.02mg/kg
  • Bicarb 1mEq/kg
  • CaCl 20mg/kg
  • Hypertonic saline (3%) 3-10mg/kg, 
  • Mannitol 1g/kg
  • Nalaxone 0.1mg/kg
HR:
  • If narrow and <220 infant or 180 child, suspect sinus tach.
  • If narrow and >220 infant or 180 child, suspect SVT -> adenosine. 
  • ?If wide and regular -> adenosine. 
  • If wide and irregular -> amiodarone OR procainamide.
Fluids:
  • IVF 20 cc/kg bolus (10cc/kg challenge if potential cardiac patient
  • Blood 10cc/kg

Intranasal medications for analgesia (max per nare is 1mL)
  • fentanyl: 1-2mcg/kg repeat q 15 min (max age would be at 40kg, graduate from fentanyl at end of elementary school) 
  • midazolam 0.3 – 0.5 mg/kg repeat q 15 min (max 10mg, which would be 20kg, (graduate midazolam at kindegarten ~ 5/yo) (use the 5mg/ml concentration)

Asthma:
  • Albuterol Nebs: 2.5 mg/dose (<20 kg) or 5 mg/dose (> 20 kg) INH q20 min prn
  • Dexamethasone
  • Croup/Asthma: 0.6 mg/kg PO/IM/IV (max 16 mg) (for asthma, child should return for 2nd dose in 24-36 hours) 
Magnesium for Asthma (refractory status), Torsades de pointes, Hypomagnesemia:
  • 25 to 50 mg/kg IV/IO bolus (pulseless VT)
  • OR over 10 to 20 min (VT with pulses)
  • OR over 15-30 min (status asthmaticus), max 2 g
Methlprednisolone for Asthma (status), Anaphylactic Shock:
  • Load: 2 mg/kg IV/IO/IM (max 80 mg), use acetate salt IM
  • Maintenance: 0.5 mg/kg IV/IO q6hrs (max 120 mg/d)

Glucose (Rule of 50s)
  • Neonate: < 2 mo. 40 gluc -> 5ml/kg D10W
  • Peds 2mo – 8 y/o. < 60 gluc -> 2.5ml/kg D25W (25 @ 2.5 mon old)
  • Adult > 8y/o.  <70 gluc.  50ml (1 amp) OR 1mL/kg D5W
  • Recheck in 5 min.
Procedural Sedation:
  • ketamine 1mg/kg, 0.5-1mg PRN
  • propofol 1mg/kg, then 0.5mg/kg
  • fentanyl 0.1mcg/kg
  • midzolam 50mcg/kg
Post Intubation Sedation:
  • propofol gtt 5-50mcg/kg/min
  • midazolam load 10-50mcg/kg IV, maintenance 20-100mcg/kg/hr
  • fentanyl 2 mcg/kg/hr

Pressors
  • norepinephrine 0.1-0.2mcg/kg/min, titrate
  • epinephrine 0.1 mcg – 1 mcg – 5 mcg /kg/min
Intranasal medications for analgesia (max per nare is 1mL)
  • fentanyl: 1-2mcg/kg repeat q 15 min (max age would be at 40kg, graduate from fentanyl at end of elementary school)
  • midazolam 0.3 – 0.5 mg/kg repeat q 15 min (max 10mg, which would be 20kg, (graduate midazolam at kindegarten ~ 5/yo) (use the 5mg/ml concentration)
Neonatal Resuscitation
Credit: Drs Wu, A. Ogunniyi, R. Pedigo, R. Fleischman on 
OB Sim Day at Harbor-UCLA
Ill-appearing neonate

  • For babies
    born precipitously in ED, always ask: 1) Term? 2) Good tone? 3)
    Breathing or crying?

    • If yes to
      all 3Qs, consider delaying cord clamping and hand baby to mother
      for skin-to-skin contact while keeping baby warm and dry.

      • Clamping of
        cord should be delayed 30-60 sec unless child requires immediate
        resuscitation

      • Associated
        with less IVH, NEC, better BPs and blood volume, but a/w more
        phototherapy requirement

    • If no to any
      of Qs, cut cord and begin resuscitation by:

      • Taking baby
        to warmer (make sure it’s on!, plastic bag from neck
        down) goal temp 36.5-37.5

      • Bulb
        syringe suction to clear secretions,

      • Dry,
        stimulate. Ventilate/oxygenate as needed.

      • Note time,
        document APGAR.

  • Cutaneous
    temp monitor on liver – largest organ provides most consistent
    measurement. Hypothermia increases risk of intraventricular
    hemorrhage, respiratory issues, hypoglycemia, and late onset sepsis.

  • Meconium
    aspiration no longer empirically intubated, treat similar to other
    babies with stimulation, suctioning, PPV as needed. Immediate
    intubation thought to delay resuscitation

Resuscitating a neonate: HR, RR, Pox

  • HR:
    Detecting HR difficult, 3 lead ECG best, umbilical cord stethoscope
    alternate but not as accurate

    • If
      bradycardic HR <60, start chest compressions, thumb encircling
      chest wall, 3:1.

    • If not
      already done, intubate baby

    • Epi 1:10,000
      concentration, dose 0.01 mg to 0.03 mg/kg IV, or 0.05 to 0.1 mg/kg
      via ETT

  • RR/Pulse
    ox     – low oxygen sat is normal in first few minutes of life.
    Increases by 5% every minute of life. Place monitor on R palm/wrist
    for pre-ductal measurement, reflects blood that is going to the
    brain.

    • Normal
      preductal (right hand) O2 Sat

    • Resuscitation
      with room air (FiO2 21%) initially

    • Give
      supplemental O2 – increase FiO2 if not achieving normal saturation
      or has a HR<100.

    • PPV using
      BVM to RR 40-60 for 30 sec, CPAP

    • If need for
      CPR, then intubated baby

  • Intubation:

ETT = [age/4+4]

Laryngoscope blade

<28 wks 2.5

Pre-term 0

28-34 wks 3.0

Term 1

34-38 wks 3.5

>38 wks 3.5 to 4

PEEP 5

Depth 3xETT size to lip


  • Why does baby
    need resuscitation?

    • Shock? Blood
      or volume? Give transfusion or IVF bolus as indicated, 10ml/kg,
      repeat prn

    • Uterine
      rupture or abruption?

    • Accident
      with umbilical cord?

    • Hypoglycemic?
      2ml/kg of D10 as initial bolus, then D10W maintenance IVF at
      80ml/kg per day.
  • •

APGAR 

0 

1 

2 

Activity (tone)

None

Arms/legs flexed

Active movement

Pulse

None

< 100

≥ 100

Grimace (reflex irritability)

None

Grimace

Sneeze/cough/pull away

Appearance (skin)

Central cyanosis

Acrocyanosis

NI

Respiration

None

Slow, irregular

NI, crying

*Check at 1,5,±10min. Normal: 7-10, full neonatal resus if ≤ 3 

ET tube size = (age/4)+4 for uncuffed.  Minus 1 for cuffed. Only used cuffless for neonate.
Tube, tape, tap: NG/OG/Foley =       



Coach Horeczcko’s Pediatric Playbook Words of Wisdom:
“Remember this: 2, 3, 4 – Tube, Tape, Tap

The NG/OG/Foley is 2 x the ETT – tube

The ETT should be secured at a depth of 3 x the ETT size – tape

A chest tube size 4 x the ETT – tap”

 Intubation  (From WikEM):
 
    • Atropine 0.02 mg/kg (min 0.1mg; max 1mg; Always for pts <5yrs or=”” before=”” 2nd=”” dose=”” of=”” succinylcholine)<=”” li=””> 
    • Lidocaine 1 mg/kg (blunts increase in ICP) 
    • Succinylcholine 1.5-2 mg/kg (avoid in incr K, renal failure, h/o neuromuscular disorder or Malignant Hyperthermia) 
    • Rocuronium 1.2 mg/kg (onset 1min, lasts 30min) 
    • Etomidate 0.3 mg/kg (less hypotension than other sedatives) 
    • Versed 0.05-0.1 mg/kg (decreases BP,HR,RR) 
    • Fentanyl 2-5 mcg/kg (can cause chest wall rigidity if given rapidly) 
    • Ketamine 2 mg/kg (preferred in Asthma) 

Cards

 

    • Epinephrine 0.01mg/kg which is 0.1 cc/kg of 1:10,000
    • Atropine 0.02 mg/kg (min 0.1mg; max 1mg; may repeat once after 5min) 
    • Adenosine 0.1-0.2 mg/kg (max 1mg; may repeat x2 at 0.2 mg/kg) 
    • Defib 2J/4J/4J per kg 

AMS/SZ

 

    • D25W 2 cc/kg (repeat as needed) 
    • Lorazepam 0.05-0.1 mg/kg (may repeat 1-2 times) 
    • Fosphenytoin 18-20 mg PE/kg (rate 150mg PE/min; PE=Phenytoin equivalent) 
    • Phenytoin 18-20 mg/kg (give SLOW, max rate 1mg/kg/min, 2nd choice after Fosphenytoin) 
    • Phenobarb 10-20 mg/kg (rate 1mg/kg/min slow) 
    • Valium rectal 0.5 mg/kg 
    • Mannitol 1 gm/kg 

Tubes

 

    • Endotracheal tube (ETT) = (age-in-years/4) + 4 (uncuffed) OR (Age/4)+3 (cuffed)’ 
    • ETT depth at the lips = ETT size x 3 
    • OG/NG/Foley = ETT size x 2) 
    • Chest Tube = ETT size x 4 
    • Pediatric Central Line 

See Also

 

Authors 
Felipe A. Sanchez, Ross Donaldson, Maxim Ben-Yakov, Hanno Davel, Jordan Swartz 

 
 


Peds Emergent Interventions from the Coach (Courtesy of Dr Horeczko’s Pediatric Emergency Playbook)
    • Meds:
      • fentanyl 1-2mcg/min IV, 2mcg/kg IN (comes in 50mcg/kg) max age 40kg), 
      • midazolam 0.05-0.1mg/kg IV, 0.2-0.5 mg/kg (works up to 20kg),  (lower range when child is older)
      • ketamine 0.3mg/kg IV pain control, 1mg/kg IN pain control (works up to 70kg)
        • “PEM Playbook:” there is no contraindication to ketamine except for known hydrocephalus. It is safe in head trauma.”
          Read more at http://pemplaybook.libsyn.com/adventures-in-rsi#fI2bh14dHlwxO6J8.99
    • Blue baby -> ketamine
    • Pink baby -> etomidate

    • Remember this: 2, 3, 4 – Tube, Tape, Tap. Tube = (age+4 )/4

      • The NG/OG/Foley is 2 x the ETT – tube
      • The ETT should be taped at a depth of 3 x the ETT size – tape
      • A chest tube size 4 x the ETT – tap

    • Read more at http://pemplaybook.libsyn.com/adventures-in-rsi#fI2bh14dHlwxO6J8.99
    • Here’s an easy tip: use the sterile flushes in your IV cart and push in 20, 40, or 60 mL/kg NS.  Just keep track of the number of syringes you use – it is the fastest way to get a meaningful bolus in a small child. Alternatively, if you put a 3-way stop-cock in the IV line and attach a 30 mL syringe, you can turn the stop cock, draw up stream from the IV bag into the syringe, turn te stop cock, and push the fluid in the IV.
      Read more at http://pemplaybook.libsyn.com/adventures-in-rsi#acF1ZlR70IYxQd7k.99

 
(Credit to Dr Lin with ALiEM)
Pediatric Weight-Based Resuscitation Reference 
Michelle Lin, MD 

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*This information is intended for educational purposes only and not intended for use in patient care (which requires a trained credentialed attending physician and individualization of the medical care plan to the specific patient).

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