Category: Resus

ECG placement & mis-LEADing ECG’s

  • V1: 4th intercostal space (ICS), RIGHT margin of the sternum
  • V2: 4th ICS along the LEFT margin of the sternum
  • V4: 5th ICS, mid-clavicular line
  • V3: midway between V2 and V4
  • V5: 5th ICS, anterior axillary line (same level as V4)
  • V7: Left posterior axillary line, in the same horizontal plane as V6.
  • V8: Tip of the left scapula, in the same horizontal plane as V6.
  • V9: Left paraspinal region, in the same horizontal plane as V6.

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Paediatric – Time Critical Transfers (non-trauma)

Definition of a time critical transfer 

Transfer of a patient for life, limb or organ saving treatment when the time taken to provide this treatment is a critical factor in outcome. 

Principles 

  1. Acceptance by the regional centre is NOT dependent on bed availability. 
  2. Time critical transfer should normally be provided by the referring hospital team NOT Embrace. 

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Paediatric Ketamine Sedation

RCEM 2012 Safe sedation in the ED and RCEM Ketamine for paediatric procedural sedation guideline. Please read these documents in full or participate in RCEM learning for further information.

 

Characteristics of ketamine sedation

  • Dissociation – trance-like state with eyes open but not responding
  • Catalepsy – normal or slightly increased muscle tone maintained
  • Analgesia – excellent analgesia is typical
  • Amnesia – usually total
  • Airway reflexes maintained
  • Cardiovascular state – blood pressure and heart rate increase slightly
  • Nystagmus is typical – usually horizontal; eyes remain open and glazed

Who can perform it?

  • Senior medical staff (ST3+)
  • Must have done at least 6 months of anaesthetics/ICU
  • Familiar with giving ketamine, particularly in under 5s
  • Must have at least 3 staff members – someone to perform sedation, someone to perform procedure, someone to monitor the patient
  • Department must be safe – Senior ED Clinician in charge (Consultant of Senior Registrar when Consultant not present in department has final say over if it is appropriate to perform at any given time.

Where should it be performed?

  • ED resus
  • Full monitoring – 3 lead ECG, sats probe, BP cuff, CO2 monitoring

Indications

  • Child >1 years old
  • Procedures such as:
    • Reducing fractures
    • Suturing
    • Removal of foreign body
    • Chest drain placement

Contraindications

  • Any patient who requires to go to theatre for management of their condition
  • Any risk of difficult airway eg. abnormal airway anatomy
  • Allergy/serious adverse reaction to ketamine
  • Reduced GCS
  • Procedure in mouth or throat
  • Significant medical problems including:
    • Active respiratory infection/active acute asthma (high risk of laryngospasm)
    • Obstructive sleep apnoea
    • Moderate to severe gastro-oesophageal reflux disease
    • Psychological problems eg. severe behavioural or cognitive impairment or previous psychosis
    • Poorly controlled epilepsy
    • Significant cardiac disease
    • Pulmonary hypertension
    • Chronic Intracranial pathology
    • Intraocular pathology
    • Bowel obstruction
    • Hyperthyroidism
    • Porphyria

Fasting

  • For an emergency procedure in a child or young person who has not fasted, balance the risks and benefits of the decision to proceed with sedation before fasting criteria are achieved, on the urgency of the procedure and the target depth of sedation. Consider discussing this child with an anaesthetist.
  • Apply the 2-4-6 fasting rule for ketamine sedation in the ED if safe and appropriate for the procedure to wait for this:
    • 2 hours for clear fluids
    • 4 hours for breast milk
    • 6 hours for solids and formula milk

Consent

  • Parent and child (if appropriate) should be consented appropriately
  • Risks and benefits along with potential side effects should be explained
    • Mild side effects
      • Mild agitation (20%)
      • Hypersalivation and lacrimation (<10%)
      • Involuntary movements / ataxia (5%)
      • Vomiting 5-10% of children will vomit in recovery period
        • Can give ondansetron (0.1mg/kg) in intractable vomiting
      • Transient rash 10%
    • More serious complications
      • Apnoea (0.3%) – Give IV ketamine slowly over 1 minute to avoid this
      • Airway misalignment/noisy breathing (<1%) -Basic airway manoeuvres usually enough to resolve this
      • Laryngospasm (0.3%)
        • Basic airway manoeuvres
        • BVM if needed
        • Ask for help early
        • May require RSI (rarely 0.02%)
      • Emergence Phenomena (1.6% <10 years old, commoner as gets older)
          • Calm environment before procedure and as awakening
          • In very severe cases can give benzodiazepines (eg. 0.05-0.1mg/kg midazolam)

Ketamine dose

  • 1mg/kg – give over 1 minute
  • Supplemental dose (eg. in longer procedure if needed) – 0.5mg/kg
  • Initial dose and potential supplemental dose should be drawn up into separate syringes to minimise error
  • Calculate doses of emergency drugs that may be needed and ensure access to them
  • Speed of action of ketamine
    • Clinical onset (approximately) 1 minute
    • Effective sedation 10-20 minutes
    • Time to discharge (average) 90 minutes

Post sedation care

  • Observe for 1-2 hours until:
    • Conscious and responding appropriately
    • Nystagmus resolved
    • Able to walk unassisted (older children)
    • Vital signs are within normal limits
    • Respiratory status not compromised
    • Pain and discomfort addressed
  • No food or drink for 2 hours after discharge (risk of nausea and vomiting)
  • Supervise child closely for 24 hours (risk of ataxia and falls), no driving for older children
  • Give advice leaflet to parents/carer
  • Ensure that sedation documented on EPR and sign for ketamine in CD book and on EPR

Adult Sedation

This guideline is a brief summary of the RCEM 2012 Safe sedation in the ED and RCEM – Pharmacological Agents for Procedural Sedation and Analgesia in the Emergency Department – March 2019. Please read these documents in full or participate in RCEM learning elearning for further information.

 

Who can perform it?

  • Senior medical staff (ST3+)
  • Must have done at least 6 months of anaesthetics/ICU
  • Must have at least 3 staff members – someone to perform sedation, someone to perform procedure, someone to monitor the patient
  • Department must be safe – Senior ED clinician in department has final say over if it is appropriate to perform at any given time.

Where should it be performed?

  • ED resus
  • Full monitoring – 3 lead ECG, sats probe, BP cuff, CO2 monitoring

Levels of Sedation

  • Analgesia: Relief of pain without intentionally producing a sedated state. Altered mental status may occur as a secondary effect of medications administered for analgesia.
  • Minimal sedation (anxiolysis): The patient responds normally to verbal commands. Cognitive function and coordination may be impaired, but ventilatory and cardiovascular functions are unaffected.
  • Moderate sedation and analgesia: The patient responds purposefully to verbal commands alone or when accompanied by light touch. Protective airway reflexes and adequate ventilation are maintained without intervention. Cardiovascular function remains stable.
  • Deep sedation and analgesia: The patient cannot be easily aroused but responds purposefully to noxious stimulation. Assistance may be needed to ensure the airway is protected and adequate ventilation maintained. Cardiovascular function is usually stable.
  • General anaesthesia: The patient cannot be aroused and often requires assistance to protect the airway and maintain ventilation. Cardiovascular function may be impaired.
  • Dissociative sedation: Dissociative sedation is a trance-like cataleptic state in which the patient experiences profound analgesia and amnesia, but retains airway protective reflexes, spontaneous respirations, and cardiopulmonary stability. Ketamine is the pharmacologic agent used for procedural sedation that produces this state

Indications

  • Any procedure that may cause pain and anxiety
    • Most commonly bone/joint manipulations
    • DC cardioversion

Contraindications

Fasting

  • For an emergency procedure in a patient who has not fasted, balance the risks and benefits of the decision to proceed with sedation before fasting criteria are achieved, on the urgency of the procedure and the target depth of sedation..
  • If safe and appropriate to wait until fully fasted, wait:
    • 2 hours for clear fluids
    • 6 hours for solids

Consent

Medications

DRUGROLEROUTEINITIAL DOSE (elderly)REPEAT DOSE (elderly)INITIAL DOSE (adult)REPEAT DOSE (adult)ONSET (min)PEAK EFFECT (min)
PropofolSedation/AmnesiaIV10-20mg (slowly)10-20mg (slowly)0.5-1mg/kg0.5mg/kg every 3-5min0.5-11-2
MidazolamSedation/AmnesiaIV (over 1-2 min)0.5mg0.5mg1-2mg (max 2.5mg as single dose)After 2-5min1-23-4
KetamineSedation/Amnesia/AnalgesiaIV (give over 30-60sec)10-30mg1mg/kg0.25-0.5mg/kg every 5-10 min0.5-11-2
KetamineSedation/Amnesia/AnalgesiaIM4-5mg/kg2-2.5mg/kg every 5-10min0.5-11-2
KetamineAnalgesia (sub-dissociative)IV0.3mg/kg0.5-11-2
FentanylAnalgesia (with other sedation)IVup to 0.5µg/kgup to 0.5µg/kg (every 2min)1-23-5
FentanylSedation/AmnesiaIVup to 0.5-1.0µg/kg up to 0.5-1.0µg/kg (every 2min)1-23-5
KetofolSedation/Amnesia/AnalgesiaIV0.5-0.75mg/kg (of both agents)0.5-11-2

RCEM – Pharmacological Agents for Procedural Sedation and Analgesia in the Emergency Department – March 2019 – see this document for the references numbered in the table. Only use medications that you are familiar with unless supervised by an experienced colleague.

Post sedation care

  • Patient must be observed in a safe place until:
    • Observations returned to normal
    • The patient is fully awake with intact airway reflexes
    • Nausea, vomiting and pain have been fully addressed
  • Patient must be advised not to drive for 24 hours.
  • Advice leaflet should be given. – HERE
  • Fill in adhoc form on EPR – this covers pre sedation airway assessment, drugs given and any complications
  • Ensure any drugs used are prescribed and signed for. Controlled drugs should also be signed in the CD book by whoever administered them.

Emergency Tracheostomy/Laryngectomy Management

Occasionally patients with Tracheostomy or Laryngectomy present with difficulty breathing due to problem. As this is rare for us in ED, this situation can be very difficult for all of us. However the protocols below can help.

 

Tracheostomy

Tracheostomy is simply a passage from the neck into the trachea. In most cases the trachea will still be connected to the nose and mouth (so can breath though their mouth too).

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COVID-19 (Paediatric multisystem inflammatory syndrome)

AKA: Paediatric Inflammatory Multi-system Syndrome – Temporally associated with SARS-CoV 2 

Although COVID-19 seems a benign disease in almost all children there are increasing evidence (however rare) of a “Paediatric multisystem inflammatory syndrome”. This is a RARE and newly emerging condition and there are many questions still e.g. It is currently unclear if it is directly related to the COVID-19 pandemic.

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COVID-19 (Awake Self-Proning)

There is increasing evidence that Awake Self-Proning of our Covid-19 patients can improve oxygenation. Proning the patient can has several effects which can dramatically improve their SaO2

  • Improves Ventilation to back of the lung (the back of the lung contains more alveoli than the anterior lung)
  • Improves Perfusion – as blood supply to the back of the lung is always better than the front
  • Improves Clearance of secretions
  • Be patient can take 15-20min

Contraindications (all seem obvious)

Absolute contraindications:

  • Respiratory distress (RR ≥ 35, PaCO2 ≥ 6.5, accessory muscle use) 
  • Immediate need for intubation 
  • Haemodynamic instability (SBP < 90mmHg) or arrhythmia 
  • Agitation or altered mental status 
  • Unstable spine/thoracic injury/recent abdominal surgery 

Relative Contraindications: 

  • Facial injury 
  • Neurological issues (e.g. frequent seizures) 
  • Morbid obesity 
  • Pregnancy (2/3rd trimesters) 
  • Pressure sores / ulcers 

 

COVID-19 (Respiratory Flow Chart)

As we know COVID-19 is putan incredible burden on resources, especially for higher level respiratory support. It is important to target those resources in the most effect way. Currently we are targeting SaO2 >94% in those without type 2 respiratory failure(however, in the case of high demand this may reduce to 92% at short notice in the future)

 HRICRH
CPAP/NIVHDU/ICUHDU/ICU
Oxygen ONLY (FOR Escalation)Acute FloorRespiratory/Acute Floor
Oxygen ONLY (NOT FOR Escalation)Acute Floor/Ward 17Respiratory/Acute Floor/Ward 6CD
PalliativeWard 6Ward 6AB

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